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Anxiety Disorders By Dr seddigh HUMS Anxiety Disorders Disorders to be discussed: –Panic disorder –Phobias –Obssessive compulsive disorder –Post-traumatic.

Jan 13, 2016

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  • Anxiety Disorders

    By Dr seddighHUMS

  • Anxiety DisordersDisorders to be discussed:Panic disorderPhobiasObssessive compulsive disorderPost-traumatic stress disorderGeneralized anxiety disorders

  • Panic Disorder introductionAgoraphobia EtiologyPanic & MVP

  • Panic AttackEssential feature: a discrete period of intense fear or discomfort in the absence of real danger that is accompanied by at least four of 13 somatic or cognitive symptoms

  • Panic AttackSomatic or cognitive symptomsPalpitationsSweating Feeling of choking Chest pain or discomfort Nausea or abdominal distress Dizziness or lightheadedness Derealization or depersonalization

  • Fear of losing control or going crazy Fear of dying Paresthesias Chills or hot flushes Trembling/shaking Shortness of breath

    Panic AttackSomatic and Cognitive Symptoms (cont):

  • Panic DisorderThree types of panic attacks:UncuedCued Situationally predisposed

  • Panic DisorderSudden onsetSense of imminent danger, doom, urge to escapeVariability in frequency/severity of attackConcern for implications

  • Panic DisorderAge of onsetMedian is 25 yrs, rare before age 15/after 40

    Gender/Genetics75-80% femaleRelatives

    Life course

  • Panic DisorderDifferential diagnosis

  • Panic DisorderPrevalenceLifetime 1.5-5%Clinical10% in mental health setting10-30% in vestibular, respiratory, neurology setting60% in cardiology

  • Panic DisorderTreatment Behavior therapyCognitive therapyMedicationTricyclic antidepresssants, SSRIs, MAOIs, BenzodiazepinesEducation

  • Serteraline,paroxetine, alprazolamSSRIBZDTCAMAOCARMAMAZEPIN,VALPORATE NaCa.C.BBUSPIRONE

  • PhobiasSpecific PhobiaSocial Phobia

  • PhobiasEpidemiologyPrevalence Spicific phobia 11 % social 3-13%AgeGenerally begins in childhoodSpecific ph 5-9 y or 25-26 ySocial ph 12-15 yGenderFemale: Male 2:1

  • PhobiasSpecific PhobiaDiagnostic feature: Marked and persistent fear of clearly discernible objects or situationsExposure evokes responsePatient avoids or endures stimulusDiagnosis appropriate if interferes with routine life/patient stressedNo other mental disorder is present

  • PhobiasSpecific PhobiaSubtypesAnimal typeNatural environment typeBlood-Injection-Injury typeSituational typeOther type

  • PhobiasSpecific Phobia Acrophobia Agoraphobia Ailurophobia Hydrophobia Claustrophobia PyrophobiaXenophobiaZoophobia

  • PhobiasEpidemiologyPrevalence Spicific phobia 11 % social 3-13%AgeGenerally begins in childhoodSpecific ph 5-9 y or 25-26 ySocial ph 12-15 yGenderFemale: Male 2:1

  • PhobiasSpecific Phobia-associated features and disorders: restricted lifestyle and social lifeMay co-occur with other anxiety/mood/substance disorders

  • PhobiasSocial PhobiaFears of social/performance situation in which embarrassment may occurDiagnose if interferes with functioning, no other mental disorder present

  • PhobiasSocial Phobia FeaturesHypersensitivity to criticism, rejection, low self-esteemPoor social skillsUnderachieverPossible suicidal ideation

  • PhobiasProgressionMay increase in severity, debilitation2 peakcontinius

  • PhobiasTreatment BenzodiazepinesBegin low dosage, raise until symptoms goneAbstain from alcoholPatient may develop tolerance/dependenceGenerally prescribed short-termBeta Blockers

  • Social phobia SSRI BZD VENLAFAXINE BUSPIRONE MAO INH BETA BLOCKERS

  • Obsessive-Compulsive DisorderPrevalence: 2-3 % fourth dxGender: M=FAge of Onset: 20 Y

  • Obsessive-Compulsive DisorderA. Either obsessions or compulsions:Obsessions as defined by 1, 2, 3, and 4Recurrent, persistent thoughts, impulses, or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distressThe thoughts, impulses, or images are not simply excessive worries about real-life problemsThe person attempts to ignore or suppress such thoughts, impulses, or images or tries to neutralize them with some other thought or actionThe person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind

  • Typical ObsessionsDoubts (e.g. Did I turn off the stove? Did I lock the door? Did I hurt someone?)Fears that someone else has been hurt or killedFears that one has done something criminalFears that one may accidentally injure someoneWorry that one has become dirty or contaminatedBlasphemous or obscene thoughts

    NOT just excessive worries about real-life problems

  • Obsessive-Compulsive DisorderCompulsions as defined by 1 and 2Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidlyThe compulsions are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

  • Typical CompulsionsCheckingCleaning/washingDoing things a certain number of times in a rowDoing and then undoing thingsDoing things in a certain order, with symmetryMental acts such as praying, counting, etc.

  • Obsessive-Compulsive DisorderB. The person has recognized that the obsessions or compulsions are excessive or unreasonableC. There is significant distress or an impairment in functioning due to the obsessions or compulsionsD. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to the other Axis I disorderE. The disturbance is not due to a GMC or substance

  • Obsessions and Compulsions Two PossibilitiesNo relationship

    Relationship

  • OCD Potential CausesBehavioral PerspectiveCompulsions

    Cognitive PerspectiveObsessions

  • OCD Potential CausesGenetic Perspective35 % 1st degree

    Biological PerspectiveSerotonin dysfunction Abnormal brain functioning Beta hemolytic streptococci

  • OCD - TreatmentCognitive Behavioral TherapiesExposure and Response Prevention (ERP)SYSTEMATIC DESENSITIZATION

    Medications SSRI, CLOMIPRAMINE50 70 % AUGMENTED : Li, VAL , CAR

  • Generalized Anxiety DisorderCriteria:Excessive anxiety and worry for at least 6 monthsDifficult to control the worryFocus is not confined to specific other anxiety disorders, substance abuse or medical condition

  • Generalized Anxiety DisorderSymptomsAnxiety and worry are associated with three (or more) of six symptoms:RestlessnessBeing easily fatiguedDifficulty concentrating or mind going blank

  • Generalized Anxiety DisorderSymptoms (cont)IrritabilityMuscle tensionSleep disturbance

  • Generalized Anxiety DisorderMay also experience:NauseaSweating DiarrheaExaggerated startle response

  • Generalized Anxiety DisorderThe anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning

  • Generalized Anxiety DisorderAssociated disordersMood DisordersAnxiety DisordersOther stress-related conditions

  • Generalized Anxiety DisorderSpecific featuresCultureAgeGenderFamilial pattern

  • Generalized Anxiety DisorderTreatment:Anxiety managementCognitive-behavioral therapyMedication BenzodiazepinesBuspirone [generic]SSRIs, tricyclic anti-depressants & MAOIs

  • Post-Traumatic Stress DisorderClinical DescriptionPathological emotional and behavioral condition than can follow exposure to traumatic stressor severe enough to lie outside range of usual human experienceDirect or witnessed experience of possible death, injury

  • Post-Traumatic Stress DisorderTraumatic Events examplesDirect experiences: Military combat/POW Personal assault Kidnapping Terrorist attack

  • Post-Traumatic Stress DisorderTraumatic Events examplesTorture Natural/man-made disasters Auto accidents Life-threatening illness

  • Post-Traumatic Stress DisorderWitnessed experiences: Observing death/injury/assault

  • Post-Traumatic Stress DisorderClinical DescriptionMay relive trauma/sleep problemsLose interest/irritable/aggressiveGreater in femalesAge non-specificMay be depressed/abuse substances/have other anxiety disorder

  • Post-Traumatic Stress DisorderSpecifiersAcuteChronicWith delayed onset

  • Post-Traumatic Stress DisorderPrevalence8% of U.S. adult population

    CourseAge non-specific

    Familial pattern

  • Post-Traumatic Stress DisorderClinical intervention

    Treatment

    Referral for psychiatric evaluationImmediate intervention

  • *The following presentation is entitled Anxiety Disorders. Your presenter is Suzanne McGrath, an independent Physician Assistant consultant. *There are numerous anxiety disorders but this lesson will address four: generalized anxiety disorder, panic attacks, phobias, and post-traumatic stress disorder. Of these four, generalized anxiety disorder, panic attacks, and post-traumatic stress disorder are the most frequently encountered anxiety disorders seen in the emergent setting. All of the information in this presentation is obtained from or is consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision.

    *Now lets consider panic disorder. The essential feature of a panic disorder is that it is a discrete period of intense fear or discomfort in the absence of real danger that is accompanied by at least four of thirteen somatic or cognitive symptoms. *Now lets consider panic disorder. The essential feature of a panic disorder is that it is a discrete period of intense fear or discomfort in the absence of real danger that is accompanied by at least four of thirteen somatic or cognitive symptoms. *These 13 symptoms include: palpitations, sweating, feeling of choking, chest pain or discomfort, nausea or abdominal distress, dizziness or lightheadedness, derealization or depersonalization *fear of losing control or going crazy, fear of dying, paresthesias or morbid or perverted sensation or abnormal sensation, chills or hot flushes, trembling or shaking, and shortness of breath.

    *There are three types of panic attacks. The uncued or unexpected panic attacks are defined as those for which the individual does not associate onset with internal or external situational trigger. The cued or situationally bound are defined as those that invariably occur immediately upon exposure to, or in anticipation of, a trigger.The situationally predisposed attacks are similar to the cued attacks but are not always associated with the cue and do not necessarily occur immediately after the exposure. The occurrence of uncued attacks is necessary for the diagnosis of Panic Disorder. Cued and situationally predisposed attacks are frequent in Panic Disorder but may also occur in the context of other anxiety and mental disorders. *The attack has a sudden onset and builds to a peak rapidly and is often accompanied by a sense of imminent danger or impending doom and an urge to escape. A panic attack is differentiated from generalized anxiety by the almost paroxysmal nature, or sudden, uncontrollable expression of emotion and its typically greater severity. Attacks typically last 15 to 20 minutes with a range of one minute to over an hour. There is considerable variability in the frequency and severity of the attacks. Individuals with panic disorder display concerns about the implications or consequences of the panic attacks. Some fear the attacks are indicative of the presence of a yet undiagnosed life-threatening illness, or that they are emotionally weak, or are going crazy. *The median age of onset is 23. It is rare for the disorder to begin before the age of 15 or after the age of 40. It is twice as common in the 25-44 age group as it is in the 45-64 age group. After the age of 65, the prevalence drops to 1/12th that of the 18-45 age group. 75-80% of the victims of panic disorder are women. This appears to be unrelated to educational status, ethnic background or social status. Panic disorder is up to eight times more likely to develop if there is a first degree biological relative with the disorder. Twin studies have indicated a genetic contribution to the development of panic disorder. The life course of panic disorder has a fluctuating course. Some individuals have episodic outbreaks with years of remission in between and others may have continuous severe symptomatology. Approximately 50% of the patients are disabled to some degree and 73-92% are symptomatic when re-evaluated 20 years after the initial diagnosis. Patients with panic disorder have an excess mortality from suicide and among males, from cardiovascular disease when compared with controls matched for age and sex.

    *As with other components of medicine, culture and its implications cannot be ignored. Panic Disorder has been found in epidemiological studies all over the world. In some cultures, panic attacks may involve intense fear of witchcraft or magic. It is most helpful in certain cases to assess the influence of the culture of origin with the influence of the host culture. Some cultures will seek the care of adjunct providers in order to ease the symptoms. Some cultural or ethnic groups restrict the participation of women in public life. This must be differentiated from agoraphobia or the intense, irrational fear of public or open spaces. *Lifetime prevalence rates of Panic Disorder with or without agoraphobia, are about 1-2%. However, the prevalence rates of panic disorder are considerably higher in clinical samples. Panic Disorder is diagnosed in approximately 10% of patients referred for mental health conditions, 10-30% in patients seen in vestibular, respiratory, and neurology settings. There is a 60% occurrence in individuals in the cardiology setting. Some studies have shown a higher prevalence of panic disorder in patients with mitral valve prolapse and thyroid disease. The correlation is unclear.*Behavior therapy is usually necessary to reduce phobic avoidance and anticipatory anxiety. Systematic desensitization for agoraphobia is necessary if this is a part of the presentation. If there are psychosocial problems complicating recovery, psychotherapy is indicated but this is not for everyone with Panic Disorder. Medications include tricyclic antidepressants, SSRIs, MAOIs and benzodiazepines. All are effective in the treatment of Panic Disorder. Education is an important component of treatment. Patients and families need to know about the illness and the rationale for treatments used in order to ensure good compliance thus protecting patients against future relapse. *The next topic is phobias. We will discuss specific phobia, social phobia, and agoraphobia.*Consider culture and ethnicity when making the diagnosis of specific phobia. For example, fears of magic and spirits are present in many cultures. Therefore, the diagnosis should only be made if the fear and impairment are excessive for that cultural orientation. The first symptoms of a specific phobia usually occur in childhood or early adolescence and may occur at a younger age for women than men. Also, the mean age at onset varies according to the type of Specific Phobia. Overall, the ratio of women to men is 2:1, even among the elderly. There is some variation across the different types of specific phobias.Predisposing factors to the onset of Specific Phobias include traumatic events, unexpected Panic Attacks in the to-be-feared situation, observation of others undergoing trauma or demonstrating fearfulness and informational transmissions, for example, repeated parental warnings about the dangers of certain animals or media coverage of a plane crash as demonstrated in the 9/11 news coverage. Feared objects or situations tend to involve things that may actually represent a threat or have represented a threat at one time. Phobias resulting from a traumatic event tend to be particularly acute in their development and do not have a characteristic age at onset. Specific Phobias in adolescence increase the chances of persistence of the phobia or the development of additional phobias in early adulthood. Phobias that persist into adulthood remit only infrequently.There is an increased risk for Specific Phobias in family members of those having specific phobias. Also, there is some evidence to suggest that there is a connection with first-degree relatives by the type of phobia. For example, relatives of an individual with Specific Phobia of the Animal type are likely to have animal phobias. Also, fears of blood and injury have particularly strong familial patterns.*The essential feature of Specific Phobia is a marked and persistent fear of clearly discernible, circumscribed objects or situations. Exposure to the phobic stimulus almost always evokes an immediate response. Adults and adolescents recognize that their fear is unfounded or excessive but children do not. Individuals may respond in one of two ways: 1) avoid the phobic stimulus, 2) endure the stimulus with dread. It is usually the first response that is most frequently seen. The diagnosis is only appropriate if the avoidance, fear, or anticipation of encountering the phobic stimulus interferes with the individuals daily routine, occupational functioning, or social life or if the person is markedly stressed about having the phobia. The anxiety, panic attacks or phobic avoidance are not better accounted for by another mental disorder. In children, it is very common to find fears of certain objects or situations. However, in many cases, the impairment is not great enough to warrant the diagnosis. Keep in mind that if the phobia is not great enough to impair the persons functioning or cause marked stress, the diagnosis cannot be made. *Anxiety is almost invariably felt immediately upon confronting the phobic stimulus. The level of anxiety or fear will usually vary with the proximity of the stimulus and the degree to which the escape from the stimulus is limited. There are five subtypes that may be specified to indicate the focus of fear or avoidance in Specific Phobia. Lets consider the first three. The first one is animal type. This sub-type should be specified if the fear is cued by animals or insects. This subtype usually has a childhood onset.Another Specific Phobia subtype is natural environment type. This subtype should be specified if the fear is cued by objects in the natural environment such as storms, heights, or water. This also usually has a childhood onset.The Blood-Injection-Injury subtype should be specified if the fear is cued by seeing blood or an injury or by seeing an injection or other invasive medical procedure. This subtype is highly familial and is often characterized by a strong vasovagal response. *The last two subtypes are situational and other. The situational subtype should be specified if the fear is cued by a specific situation such as public transportation, tunnels, bridges, elevators, flying, driving or enclosed spaces. The other subtype should be specified if the fear is cued by other stimuli. This might include the fear of choking, vomiting, contracting an illness, or a space phobia, in which the person is afraid of falling down if they step away from a wall or other means of physical support. Children may fear loud sounds or costumed characters. *Consider culture and ethnicity when making the diagnosis of specific phobia. For example, fears of magic and spirits are present in many cultures. Therefore, the diagnosis should only be made if the fear and impairment are excessive for that cultural orientation. The first symptoms of a specific phobia usually occur in childhood or early adolescence and may occur at a younger age for women than men. Also, the mean age at onset varies according to the type of Specific Phobia. Overall, the ratio of women to men is 2:1, even among the elderly. There is some variation across the different types of specific phobias.Predisposing factors to the onset of Specific Phobias include traumatic events, unexpected Panic Attacks in the to-be-feared situation, observation of others undergoing trauma or demonstrating fearfulness and informational transmissions, for example, repeated parental warnings about the dangers of certain animals or media coverage of a plane crash as demonstrated in the 9/11 news coverage. Feared objects or situations tend to involve things that may actually represent a threat or have represented a threat at one time. Phobias resulting from a traumatic event tend to be particularly acute in their development and do not have a characteristic age at onset. Specific Phobias in adolescence increase the chances of persistence of the phobia or the development of additional phobias in early adulthood. Phobias that persist into adulthood remit only infrequently.There is an increased risk for Specific Phobias in family members of those having specific phobias. Also, there is some evidence to suggest that there is a connection with first-degree relatives by the type of phobia. For example, relatives of an individual with Specific Phobia of the Animal type are likely to have animal phobias. Also, fears of blood and injury have particularly strong familial patterns.*Specific phobias may result in a restricted lifestyle or interfere with certain occupations. For example, an occupation may be jeopardized if there is a fear of traveling. Social activities may be restricted if there is a fear of crowds or being in closed in places. Phobias frequently co-occur with other anxiety, mood and substance disorders. Rates of co-occurrence range from 50% to 80%. In the clinical setting, only 12% to 20% seek help for Specific Phobias. The co-morbid diagnosis is the focus of clinical attention. So, even though phobias are common in the general population, they rarely cause enough impairment or distress to warrant a diagnosis.

    *The essential feature of Social Phobia is a marked and persistent fear of social or performance situations in which embarrassment may occur. Most often, the social situation is avoided. Sometimes it is endured with severe dread. Again, the diagnosis is only appropriate if the fear and anxiety cause interference with the social life, occupational functioning or the persons daily routine or if the person is markedly stressed by the phobia and the condition is not better accounted for by another mental disorder. The social phobic has a desire to function in society whereas a schizoid personality does not desire social interaction.*Associated features include hypersensitivity to criticism, negative evaluation or rejection, difficulty being assertive and low self- esteem. Patients may exhibit poor social skills, fear taking a test, show signs of anxiety and often underachieve in academic settings. In severe cases, individuals may drop out of school, have no friends, refrain from dating, or remain with their family of origin. Social Phobia may be associated with suicidal ideation especially when there are co-morbid disorders. Clinical presentations may differ across cultures. In certain cultures such as in Japan and Korea, individuals with Social Phobia may develop fears of being offensive.

    *There is evidence to suggest that Specific Phobia, Social Phobia and agoraphobia lie along a continuum of increasing severity and debilitation. The disorders can be distinguished along cognitive dimensions as well. Specific Phobia is primarily concerned with the nature of the fear response. Social Phobia regards the evaluation of others. Finally, agoraphobia is primarily concerned with the implications regarding personal control and confidence. *Anti-anxiety medications include the benzodiazepines, which can relieve symptoms within a short time. They have relatively few side effects: drowsiness and loss of coordination are most common; fatigue and mental slowing or confusion can also occur. These effects make it dangerous for people taking benzodiazepines to drive or operate some machinery. Other side effects are rare.Benzodiazepines vary in duration of action in different people; they may be taken two or three times a day, sometimes only once a day, or just on an "as-needed" basis. Dosage is generally started at a low level and gradually raised until symptoms are diminished or removed. The dosage will vary a great deal depending on the symptoms and the individual's body chemistry.It is wise to abstain from alcohol when taking benzodiazepines, because the interaction between benzodiazepines and alcohol can lead to serious and possibly life-threatening complications. People taking benzodiazepines for weeks or months may develop tolerance for and dependence on these drugs. Abuse and withdrawal reactions are also possible. For these reasons, the medications are generally prescribed for brief periods of time, such as days or weeks and sometimes just for stressful situations or anxiety attacks. However, some patients may need long-term treatment.*With a generalized anxiety disorder, the client reports excessive anxiety and worry occurring more days than not for at least six months. The anxiety and worry are about a number of events or activities such as work or school.The patient finds it difficult to control the worry. Also, the intensity, duration, or frequency of the anxiety or worry is far out of proportion to the actual likelihood or impact of the feared event. In general, adults often worry about finances, work responsibilities, family health, the well-being of their children or minor matters such as chores or being late for appointments.The worry is not confined to other specific disorders. For example, the person is not worried about having a panic attack or being contaminated, such as is seen in obsessive-compulsive disorder, or gaining weight as in Anorexia Nervosa. The worry also needs to be distinguished from the anxiety caused by a substance such as drug abuse, a medication or exposure to a toxin. For example, severe anxiety that occurs only in the context of heavy caffeine consumption would be considered Caffeine-Induced Anxiety Disorder. The focus is also not confined to a medical condition.*The anxiety and worry are accompanied by at least three other symptoms in a list of six that include restlessness, being easily fatigued, and difficulty concentrating or the mind going blank.*Others of the six possible symptoms are irritability, muscle tension and disturbed sleep. It is important to note that only one of these additional symptoms is required in children. Associated with muscle tension, there may be trembling, twitching, feeling shaky, and muscle aches or soreness. Sleep disturbance is also prevalent.*Many patients with generalized anxiety disorder also experience somatic symptoms such as nausea, sweating, diarrhea and an exaggerated startle response.

    *Because of the prevalence of anxiety, the associated features and the co-occurrence of mood disorders, there is a co-existing of impairment of important areas of functioning. *Generalized anxiety disorders very frequently co-occur with mood disorders such as Major Depressive Disorder or Dysthymic Disorder and with other Anxiety Disorders, such as Panic Disorder, Social Phobia, Specific Phobia and with Substance-Related Disorders. Other conditions that may be associated with stress frequently accompany Generalized Anxiety Disorder. These may include irritable bowel syndrome and headaches.

    *There is considerable cultural variation in the expression of anxiety. Some cultures express anxiety with somatic complaints. In other cultures, intense expression of anxiety is a cultural form of grief. Therefore it is important to evaluate the cultural context when assessing whether the anxiety in certain situations is excessive.In children and adolescents with generalized anxiety disorder (GAD), the anxieties are often related to the quality of their performance or competence even when their performance is not being evaluated. They may worry excessively about punctuality. They may worry about catastrophic events, or more currently, terrorism or the impact of war. Children with this disorder may be overly conforming, perfectionistic, and unsure of themselves. Tasks may be redone due to dissatisfaction with their performance. Typically, they are overzealous in seeking approval and require excessive reassurance about their worries.The diagnosis of GAD is made more frequently in females than in males in the clinical setting. In epidemiological studies, two-thirds are female. There is a familial association with anxiety as a trait. Recent studies suggest a genetic contribution to the development of this disorder. However, further studies are needed to determine the extent to which GAD is familial or heritable. There may also be genetic factors influencing risk of GAD closely related to those for Major Depressive Disorder.

    *In the past 15 years, there have been specific psychological treatments developed. These include the two broad categories of anxiety management and cognitive and behavioral therapy. In GAD, patients frequently have fears of losing control, being unable to cope, or being publicly embarrassed. Anxiety management involves strategies aimed at teaching ways of coping with anxiety- related to these fears. Cognitive-behavioral therapies involve the examination of and change of patients anxiety related cognitions and behavior.Pharmaceutical interventions include benzodiazepines, buspirone and selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs). Benzodiazepines are effective in the acute treatment of GAD with rapid relief of symptoms, but carry the caution of short term use, only up to several months, due to potential for dependence and withdrawal symptoms. Benzodiazepines are best avoided in patients with a history of alcohol or other substance abuse. Buspirone appears comparable to benzodiazepines and its apparent lack of sedation, psychomotor effects, dependence and withdrawal symptoms make it an attractive alternative. SSRIs, tricyclic antidepressants and MAOIs may be useful in selected patients.*The last disorder we will discuss is Post-traumatic Stress Disorder. This disorder describes the pathological emotional and behavioral condition that can follow exposure to a traumatic stressor severe enough to be outside the range of usual human experience. The experience may be direct or witnessed and involves actual or threatened death, serious injury, or other threat to ones physical integrity. *Traumatic events that are experienced directly may include, but are not limited to: military combat or being a POW, violent personal assault, being kidnapped, terrorist attack *torture, natural or man-made disasters, automobile accidents, or being diagnosed with a life-threatening illness.*Witnessed events may include but are not limited to observing serious injury or death or violent assault of another, or learning of a sudden, unexpected death of someone close. The disorder may be especially severe or long lasting if the stressor is of human design, for example torture or rape.*Whatever the source of the problem, some people with post-traumatic stress disorder (PTSD) repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They may also experience other sleep problems, feel detached or numb, or be easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Things that remind them of the trauma may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the traumatic event are often very difficult. They may describe painful guilt feelings about surviving when others did not or what they had to do to survive.PTSD affects about 5.2 million adult Americans. Women are more likely than men to develop PTSD. It can occur at any age, including childhood, and there is some evidence that susceptibility to PTSD may run in families. The disorder is often accompanied by depression, substance abuse, or one or more other anxiety disorders. In severe cases, the person may have trouble working or socializing. In general, the symptoms seem to be worse if the event that triggered them was deliberately initiated by a personsuch as a rape or kidnapping.Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, may lose touch with reality and believe that the traumatic event is happening all over again.*Certain terms may be used to specify onset and duration of the symptoms of PTSD. The term acute should be used when the duration of symptoms is less than three months. Chronic is used when the symptoms last three months or longer. Delayed onset indicates that at least six months have passed between the traumatic event and the onset of symptoms.*The prevalence of PTSD in the United States, gleaned from communitybased studies is 8% of the adult population. Information on other countries is not available. Studies of at-risk populations yield variable findings. The highest rates, ranging between 1/3 and more than one-half of those exposed, are found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.The course of PTSD is age non-specific. It can occur at any age, including childhood. Symptoms usually begin within the first three months after the trauma, although there may be a delay of months or even years, before the symptoms appear. Diagnostically, there is increased autonomic arousal such as galvonic skin response, electromyogram, heart rate and blood pressure.There is evidence of a heritable component to the transmission of PTSD. Furthermore, a history of depression in a first-degree relative has been related to an increased vulnerability to developing PTSD. *Drug therapy calls for caution in the use of benzodiazepines for mild sedation due to the potential for abuse. Antidepressants are often useful in those with and without co-morbid depression. However, do not rely on medication as the primary treatment modality. Referral for psychiatric evaluation is indicated. Intervention as soon as possible after the trauma has considerable advantage over delayed intervention. Patients vary in their response to ventilation and cognitive-behavioral approaches. Support groups and family intervention are important to others. It is important to treat any co-existing disorders such as depression or substance abuse.

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