Anxiety Disorders

 

 Course Objectives

 

By completing this course the healthcare professional will be able to:                       

1.       Define and distinguish between the various categories of anxiety disorders

2.       Identify triggers to anxiety reactions

3.       Describe symptoms associated with anxiety disorders

4.       Identify the treatments available for those who suffer from the anxiety disorders

5.      Learn effective methods of communication when working with anxiety patients

 

Anxiety Disorders

The anxiety disorders are the most common, or frequently occurring, mental disorders. They encompass a group of conditions that share extreme or pathological anxiety as the principal disturbance of mood or emotional tone. Anxiety, which may be understood as the pathological counterpart of normal fear, is manifest by disturbances of mood, as well as of thinking, behavior, and physiological activity.

Types of Anxiety Disorders 

The anxiety disorders include panic disorder (with and without a history of agoraphobia), agoraphobia (with and without a history of panic disorder), generalized anxiety disorder, specific phobia, social phobia, obsessive-compulsive disorder, acute stress disorder, and post-traumatic stress disorder (DSM-IV). In addition, there are adjustment disorders with anxious features, anxiety disorders due to general medical conditions, substance-induced anxiety disorders, and the residual category of anxiety disorder not otherwise specified (DSM-IV).

 

In the United States, 1-year prevalence for all anxiety disorders among adults ages 18 to 54 exceeds 16 percent and there is significant overlap or comorbidity with mood and substance abuse disorders.  The longitudinal course of these disorders is characterized by relatively early ages of onset, chronicity, relapsing or recurrent episodes of illness, and periods of disability. Panic disorder and agoraphobia, particularly, are associated with increased risks of attempted suicide.

Panic Attacks and Panic Disorder

A panic attack is a discrete period of intense fear or discomfort that is associated with numerous somatic and cognitive symptoms (DSM-IV). These symptoms include palpitations, sweating, trembling, shortness of breath, sensations of choking or smothering, chest pain, nausea or gastrointestinal distress, dizziness or lightheadedness, tingling sensations, and chills or blushing and “hot flashes.” The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes.

Most people report a fear of dying, “going crazy,” or losing control of emotions or behavior. The experiences generally provoke a strong urge to escape or flee the place where the attack begins and, when associated with chest pain or shortness of breath, frequently results in seeking aid from a hospital emergency room or other type of urgent assistance. Yet an attack rarely lasts longer than 30 minutes.

Current diagnostic practice specifies that a panic attack must be characterized by at least four of the associated somatic and cognitive symptoms described above. The panic attack is distinguished from other forms of anxiety by its intensity and its sudden, episodic nature. Panic attacks may be further characterized by the relationship between the onset of the attack and the presence or absence of situational factors. For example, a panic attack may be described as unexpected, situationally bound, or situationally predisposed (usually, but not invariably occurring in a particular situation). There are also attenuated or “limited symptom” forms of panic attacks.

Panic attacks are not always indicative of a mental disorder, and up to 10 percent of otherwise healthy people experience an isolated panic attack per year. Panic attacks also are not limited to panic disorder. They commonly occur in the course of social phobia, generalized anxiety disorder, and major depressive disorder (DSM-IV).

Panic disorder is diagnosed when a person has experienced at least two unexpected panic attacks and develops persistent concern or worry about having further attacks or changes his or her behavior to avoid or minimize such attacks. Whereas the number and severity of the attacks varies widely, the concern and avoidance behavior are essential features. The diagnosis is inapplicable when the attacks are presumed to be caused by a drug or medication or a general medical disorder, such as hyperthyroidism.

Lifetime rates of panic disorder of 2 to 4 percent and 1-year rates of about 2 percent are documented consistently in epidemiological studies. Panic disorder is frequently complicated by major depressive disorder and alcoholism and substance abuse disorders. Panic disorder is also concomitantly diagnosed, or co-occurs, with other specific anxiety disorders, including social phobia (up to 30 percent), generalized anxiety disorder (up to 25 percent), specific phobia (up to 20 percent), and obsessive-compulsive disorder (up to 10 percent) (DSM-IV). As discussed subsequently, approximately one-half of people with panic disorder at some point develop such severe avoidance as to warrant a separate description, panic disorder with agoraphobia.

Panic disorder is about twice as common among women as men. Age of onset is most common between late adolescence and mid-adult life, with onset relatively uncommon past age 50. There is developmental continuity between the anxiety syndromes of youth, such as separation anxiety disorder. Typically, an early age of onset of panic disorder carries greater risks of comorbidity, chronicity, and impairment.

Required reading:      Who Will Panic?

Panic Disorder Symptoms

Panic disorder is characterized by panic attacks, acute episodes of terror accompanied by a sudden barrage of symptoms, including at least four of the following:

  •     Racing or pounding heartbeat
  •     Chest pains
  •     Dizziness
  •     Nausea
  •     Difficulty breathing
  •     Flushes or chills
  •     Sweating
  •     Tingling or numbness in the hands
  •     Dreamlike sensations or perceptual distortions
  •     Fear of losing control and doing something embarrassing
  •     Fear of dying
  •     Sense of impending doom

Panic attacks typically occur spontaneously, with no apparent trigger. In fact, they can even begin during sleep. Attacks usually last for a few minutes, rarely longer, yet they often feel like an eternity for the patient.

When a person has repeated panic attacks and feels severe anxiety about having another attack, he or she has panic disorder. Panic disorder tends to worsen over time if not effectively treated.

Panic Disorder

Panic disorder is an anxiety disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress. These sensations often mimic symptoms of a heart attack or other life-threatening medical conditions. As a result, the diagnosis of panic disorder is frequently not made until extensive and costly medical procedures fail to provide a correct diagnosis or relief.

 

Many people with panic disorder develop intense anxiety between episodes. It is not unusual for a person with panic disorder to develop phobias about places or situations where panic attacks have occurred, such as in supermarkets or other everyday situations. As the frequency of panic attacks increases, the person often begins to avoid situations where they fear another attack may occur or where help would not be immediately available. This avoidance may eventually develop into agoraphobia, an inability to go beyond known and safe surroundings because of intense fear and anxiety.

Proper Diagnosis Is Critical

The criteria noted above should distinguish panic disorder from everyday anxiety and stress. To help confirm a panic disorder diagnosis, consider the following approach: To differentiate panic disorder from other medically important conditions, the patient should, of course, have a thorough physical examination. Panic disorder symptoms mimic other conditions, such as myocardial infarction, cardiac arrhythmias, hyperthyroidism, and certain types of epilepsy. It is important to probe the emotional components of the patient's symptoms. Patients may focus on only one or two symptoms as they describe the attacks to you, concentrating only on their physical sensations and not on the fears they experience.  By asking patients to describe their feelings about the attacks, you may be able to more quickly identify panic disorder. You will also be more likely to identify depression or other concurrent conditions that should be considered in the treatment plan. It can be constructive to probe for environmental factors that trigger panic attacks in some people. For example, in susceptible persons, attacks may occur during or within 6 months of such stressful life events as the death of a loved one, divorce, geographic relocation, childbirth, or surgery.

Panic attacks can also be triggered by large doses of caffeine, some cold medicines, and cocaine and marijuana. If someone has a substance abuse problem, it will have to be treated before panic disorder can be addressed effectively. Panic Disorders Can Seriously Harm Your PatientsEven though panic attacks do not represent an immediate danger to the life of the patient, panic disorder can have far more harmful consequences than many other serious medical conditions. Many people with panic disorder develop fears about situations they associate with panic attacks and begin to avoid them. Their lives become an ordeal of chronic fear, and they may become greatly restricted in their ability to carry out normal activities like grocery shopping, traveling, and even leaving home, a condition known as agoraphobia. Panic disorder can radically impair family, work, and social relationships. Patients may lose their jobs and independence. People with panic disorder may also suffer from clinical depression, substance abuse, obsessive-compulsive disorder, or irritable bowel syndrome.

Apart from the suffering experienced by the patient, untreated panic disorder is costly to both the patient and the medical system as a whole because of repeated visits to doctors and emergency departments and unnecessary medical tests. Causes of Panic DisorderResearch suggests that panic disorder has both biological and psychological components, which interact. Family and twin studies indicate that panic disorder involves some genetic vulnerability.Recent studies suggest that people with panic disorder have a low tolerance for the body's normal physiological and psychological response to stress; their body's alarm response goes off with little or no provocation. The hypothesis that panic disorder patients may have learned to perceive essentially normal physiological events as being dangerous may help in understanding the lowered stress response threshold, giving rise to a "false alarm.

"Some researchers theorize that the disturbance in coping mechanisms is a product of repeated life stresses in predisposed individuals, leading eventually to panic disorder. Research also suggests that people with panic disorder may not be able to utilize the body's own naturally produced anxiety-reducing substances. It may be that the neuronal receptors that bind with these substances are abnormal in people with panic disorder.

Studies in animals and humans have focused on pinpointing the specific brain areas and circuits involved in anxiety and fear, which underlie anxiety disorders, such as panic disorder. Fear, an emotion that evolved to deal with danger, causes an automatic, rapid protective response that occurs without the need for conscious thought. It has been found that the body's fear response is coordinated by a small structure deep inside the brain, called the amygdala.

The amygdala, although relatively small, is a very complicated structure, and recent research suggests that anxiety disorders may be associated with abnormal activation in the amygdala. One aim of research is to use such basic scientific knowledge to develop new therapies.

Treatment Methods

Panic disorder can be treated effectively with cognitive-behavioral therapy (CBT), pharmacological therapy, and possibly a combination of CBT and medication. Patients generally begin to respond quickly to appropriate treatment. However, some treatments may work better than others for certain patients. So, it is important to monitor the response to treatment closely and reassess the treatment strategy if there is no improvement after 6 to 8 weeks.

Cognitive-Behavioral Therapy

CBT teaches patients to anticipate the situations and bodily sensations that are associated with their panic attacks. This awareness sets the stage for helping the patient to control the attacks. Specially trained therapists tailor CBT to the specific needs of each patient. The therapy usually includes the following components: Helping patients identify and change patterns of thinking that cause them to misperceive commonplace events or situations as dangerous and to "think the worst." Patients often are unaware of how deeply these anxiety-raising thoughts are ingrained.

Teaching patients exercises to prevent the hyperventilation that often triggers a panic attack. The exercises also help the patient to replace alarmist thoughts such as, "I'm dying," with more appropriate ones, such as, "I'm just hyperventilating--I can handle this."Helping patients become less fearful by safely and gradually exposing them to situations and physical sensations they avoid or find frightening. CBT is a short-term treatment, typically lasting 12 to 15 sessions over several months. Patients with panic disorder who go through CBT are reported to have very few adverse effects and a relatively low relapse rate of panic attacks. CBT requires special training. If you decide to refer your patients for cognitive-behavioral therapy, check to see if the professional has the requisite training and experience in this method of panic disorder treatment. MedicationSeveral classes of medication can reduce or prevent panic attacks and therefore substantially decrease patients' anticipatory anxiety about having attacks.

The medications most often used are:  Antidepressants - including tricyclics, monoamine oxidase inhibitors, and serotonin reuptake inhibitors and certain high-potency benzodiazepines.  Each of these classes of medications works differently and has different side effects. The latest information about the pharmacotherapy of panic and related disorders is available in clinical handbooks of psychotherapeutic medications. For most of these medications, treatment lasts 6 months to a year. With all of them, proper dosing and monitoring is essential. The practitioner who administers medication for panic disorder should be well versed in the clinical use of the relevant psychotherapeutic medications. It is important to start with a low dose and increase it gradually. Build up to the recommended dosage for the particular medication you are prescribing, watching for troublesome side effects as well as for a decrease in panic attacks.

The goal should be to stop the panic attacks. Make sure the patient is maintained on a dose that is in the therapeutic range. When withdrawing medication,  reduce the dosage gradually, and watch for possible relapse. To improve compliance, it is important to educate the patient about the medication and its side effects. Combining CBT and MedicationA combination of CBT and pharmacotherapy may offer rapid relief, high effectiveness, and a low relapse rate. The combination may be particularly helpful for patients with agoraphobia. NIMH is conducting a large study evaluating the effectiveness of combining these treatments. Who Can Treat Panic Disorder?Panic disorder patients can be treated by mental health professionals or by primary health care providers. If you wish to refer your patients to a mental health professional, it is vital that this person have adequate training and experience in treating people with panic disorder.How to Talk To Your Patients about Panic DisorderMany panic disorder patients are reluctant to seek treatment or have been frustrated by previous encounters with health care professionals. You can play a crucial role in motivating these people to get treatment. Here are some suggestions for communicating with anyone who has panic disorder. AcknowledgeIt helps to acknowledge the seriousness of panic disorder.

Often, people trivialize this condition. Your recognition that it is real and serious can persuade patients to seek treatment and begin returning their lives to normalcy. In offering comfort to your patients, it is important to avoid statements that may be interpreted as dismissive, "It's nothing to worry about," or "It's just stress," for example. Patients need to hear words that reflect the gravity of the disorder. Many professionals who have treated panic disorder have found patients receptive to the following explanation. "You have a condition that can be treated, it called panic disorder. Without treatment, it can grow worse. You need professional help to overcome it, just as you would for any serious medical illness."Also, many people feel their condition is their own fault.

By telling them that the disorder has both psychological and biological components, you can reassure your patients that they are not to blame for the condition. EducateKnowing more about panic disorder can help people overcome their fear, embarrassment, or skepticism about treatment. For example, your patients may benefit from hearing that millions of people have panic disorder--in fact, one out of 63 people has, or will have, it. Point out that treatment can make a significant difference in their lives--in just weeks or months--and explain the various treatment options. Make the patient an active, fully informed participant in the treatment planning process. If you encounter patients who have been unsuccessfully treated for panic disorder before, you can tell them that even when one treatment fails, another often succeeds. EncourageFinally, encourage your patients to seek more information about panic disorder. You may also want to suggest that your patients join self-help groups.

Facts about Panic Disorder

  • Approximately 2.4 million American adults ages 18 to 54, or about 1.7 percent of people in this age group in a given year, have panic disorder.
  • Panic disorder typically develops in late adolescence or early adulthood and is twice as common in women as in men.
  • Panic disorder may coexist with other disorders, most often depression and substance abuse. Appropriate diagnosis and treatment of other disorders are important to successfully treating panic disorder.

Agoraphobia

The ancient term agoraphobia is translated from Greek as fear of an open marketplace. Agoraphobia today describes severe and pervasive anxiety about being in situations from which escape might be difficult or avoidance of situations such as being alone outside of the home, traveling in a car, bus, or airplane, or being in a crowded area (DSM-IV).

Most people who present to mental health specialists develop agoraphobia after the onset of panic disorder. Agoraphobia is best understood as an adverse behavioral outcome of repeated panic attacks and the subsequent worry, preoccupation, and avoidance. Thus, the formal diagnosis of panic disorder with agoraphobia was established. However, for those people in communities or clinical settings who do not meet full criteria for panic disorder, the formal diagnosis of agoraphobia without history of panic disorder is used (DSM-IV).

Agoraphobia occurs about two times more commonly among women than men. The gender difference may be attributable to social-cultural factors that encourage, or permit, the greater expression of avoidant coping strategies by women (DSM-IV), although other explanations are possible.

Specific Phobias

These common conditions are characterized by marked fear of specific objects or situations (DSM-IV). Exposure to the object of the phobia, either in real life or via imagination or video, invariably elicits intense anxiety, which may include a (situational bound) panic attack. Adults generally recognize that this intense fear is irrational. Nevertheless, they typically avoid the phobic stimulus or endure exposure with great difficulty. The most common specific phobias include the following feared stimuli or situations: animals (especially snakes, rodents, birds, and dogs); insects (especially spiders and bees or hornets); heights; elevators; flying; automobile driving; water; storms; and blood or injections.

Approximately 8 percent of the adult population suffers from one or more specific phobias. Much higher rates would be recorded if less rigorous diagnostic requirements for avoidance or functional impairment were employed. Typically, the specific phobias begin in childhood, although there is a second “peak” of onset in the middle 20s of adulthood (DSM-IV). Most phobias persist for years or even decades, and relatively few remit spontaneously or without treatment.

The specific phobias generally do not result from exposure to a single traumatic event (i.e., being bitten by a dog or nearly drowning). Rather, there is evidence of phobia in other family members and social or vicarious learning of phobias. Spontaneous, unexpected panic attacks also appear to play a role in the development of specific phobia, although the particular pattern of avoidance is much more focal and circumscribed.

Social Phobia

Social phobia, also known as social anxiety disorder, describes people with marked and persistent anxiety in social situations, including performances and public speaking. The critical element of the fearfulness is the possibility of embarrassment or ridicule. Like specific phobias, the fear is recognized by adults as excessive or unreasonable, but the dreaded social situation is avoided or is tolerated with great discomfort. Many people with social phobia are preoccupied with concerns that others will see their anxiety symptoms (i.e., trembling, sweating, or blushing); or notice their halting or rapid speech; or judge them to be weak, stupid, or “crazy.” Fears of fainting, losing control of bowel or bladder function, or having one’s mind going blank are also not uncommon. Social phobias generally are associated with significant anticipatory anxiety for days or weeks before the dreaded event, which in turn may further handicap performance and heighten embarrassment.

The 1-year prevalence of social phobia ranges from 2 to 7 percent, although the lower figure probably better captures the number of people who experience significant impairment and distress. Social phobia is more common in women. Social phobia typically begins in childhood or adolescence and for many is associated with the traits of shyness and social inhibition. A public humiliation, severe embarrassment, or other stressful experience may provoke an intensification of difficulties. Once the disorder is established, complete remissions are uncommon without treatment. More commonly, the severity of symptoms and impairments tends to fluctuate in relation to vocational demands and the stability of social relationships.

Generalized Anxiety Disorder

Generalized anxiety disorder is defined by a protracted (> 6 months’ duration) period of anxiety and worry, accompanied by multiple associated symptoms (DSM-IV). These symptoms include muscle tension, easily fatigued, poor concentration, insomnia, and irritability. In youth, the condition is known as overanxious disorder of childhood. In DSM-IV, an essential feature of generalized anxiety disorder is that the anxiety and worry cannot be attributable to the more focal distress of panic disorder, social phobia, obsessive-compulsive disorder, or other conditions. Rather, as implied by the name, the excessive worries often pertain to many areas, including work, relationships, finances, the well-being of one’s family, potential misfortunes, and impending deadlines. Somatic anxiety symptoms are common, as are sporadic panic attacks.

Generalized anxiety disorder occurs more often in women, with a sex ratio of about 2 women to 1 man.  Approximately 50 percent of cases begin in childhood or adolescence. The disorder typically runs a fluctuating course, with periods of increased symptoms usually associated with life stress or impending difficulties.

Obsessive-Compulsive Disorder

Obsessions are recurrent, intrusive thoughts, impulses, or images that are perceived as inappropriate, grotesque, or forbidden (DSM-IV). The obsessions, which elicit anxiety and marked distress, are termed “ego-alien” or “ego-dystonic” because their content is quite unlike the thoughts that the person usually has. Obsessions are perceived as uncontrollable, and the sufferer often fears that he or she will lose control and act upon such thoughts or impulses. Common themes include contamination with germs or body fluids, doubts (i.e., the worry that something important has been overlooked or that the sufferer has unknowingly inflicted harm on someone), order or symmetry, or loss of control of violent or sexual impulses.

Compulsions are repetitive behaviors or mental acts that reduce the anxiety that accompanies an obsession or “prevent” some dreaded event from happening (DSM-IV). Compulsions include both overt behaviors, such as hand washing or checking, and mental acts including counting or praying. Not uncommonly, compulsive rituals take up long periods of time, even hours, to complete. For example, repeated hand washing, intended to remedy anxiety about contamination, is a common cause of contact dermatitis.

Although once thought to be rare, obsessive-compulsive disorder has now been documented to have a 1-year prevalence of 2.4 percent. Obsessive-compulsive disorder is equally common among men and women.

Obsessive-compulsive disorder typically begins in adolescence to young adult life (males) or in young adult life (females) (DSM-IV). For most, the course is fluctuating and, like generalized anxiety disorder, symptom exacerbations are usually associated with life stress. Common comorbidities include major depressive disorder and other anxiety disorders. Approximately 20 to 30 percent of people in clinical samples with obsessive-compulsive disorder report a past history of tics, and about one-quarter of these people meet the full criteria for Tourette’s disorder (DSM-IV). Conversely, up to 50 percent of people with Tourette’s disorder develop obsessive-compulsive disorder

Obsessive-compulsive disorder has a clear familial pattern and somewhat greater familial specificity than most other anxiety disorders. Furthermore, there is an increased risk of obsessive-compulsive disorder among first-degree relatives with Tourette’s disorder. Other mental disorders that may fall within the spectrum of obsessive-compulsive disorder include trichotillomania (compulsive hair pulling), compulsive shoplifting, gambling, and sexual behavior disorders. The latter conditions are somewhat discrepant because the compulsive behaviors are less ritualistic and yield some outcomes that are pleasurable or gratifying. Body dysmorphic disorder is a more circumscribed condition in which the compulsive and obsessive behavior centers around a preoccupation with one’s appearance (i.e., the syndrome of imagined ugliness)

Facts about OCD

  • Approximately 3.3 million American adults ages 18 to 54, or about 2.3 percent of people in this age group in a given year, have OCD. 
  • The first symptoms of OCD often begin during childhood or adolescence. 
  • OCD is equally common in males and females. 
  • OCD is sometimes accompanied by depression, eating disorders, substance abuse, or other anxiety disorders. Symptoms of OCD can also coexist and may even be part of a spectrum of other brain disorders, such as Tourette's syndrome.  Appropriate diagnosis and treatment of other co-occurring disorders are important to successful treatment of OCD.

Treatments for OCD

Treatments for OCD include medications and behavioral therapy, a specific type of psychotherapy. The combination of these treatments is often most effective. 

Several medications have been proven helpful for people with OCD: clomipramine, fluoxetine, fluvoxamine, sertraline, and paroxetine. If one drug does not work, others should be tried. A number of additional medications are currently being studied.

A type of behavioral therapy known as "exposure and response prevention" is very useful for treating OCD. In this approach, a person is deliberately and voluntarily exposed to whatever triggers the obsessive thoughts, and then is taught techniques to avoid performing the compulsive rituals and to deal with the anxiety.

Required Reading:  Drugs May Help!

Acute and Post-Traumatic Stress Disorders

Acute stress disorder refers to the anxiety and behavioral disturbances that develop within the first month after exposure to an extreme trauma. Generally, the symptoms of an acute stress disorder begin during or shortly following the trauma. Such extreme traumatic events include rape or other severe physical assault, near-death experiences in accidents, witnessing a murder, and combat. The symptom of dissociation, which reflects a perceived detachment of the mind from the emotional state or even the body, is a critical feature. Dissociation also is characterized by a sense of the world as a dreamlike or unreal place and may be accompanied by poor memory of the specific events, which in severe form is known as dissociative amnesia. Other features of an acute stress disorder include symptoms of generalized anxiety and hyperarousal, avoidance of situations or stimuli that elicit memories of the trauma, and persistent, intrusive recollections of the event via flashbacks, dreams, or recurrent thoughts or visual images.

If the symptoms and behavioral disturbances of the acute stress disorder persist for more than 1 month, and if these features are associated with functional impairment or significant distress to the sufferer, the diagnosis is changed to post-traumatic stress disorder. Post-traumatic stress disorder is further defined in DSM-IV as having three subforms: acute (< 3 months’ duration), chronic (> 3 months’ duration), and delayed onset (symptoms began at least 6 months after exposure to the trauma).

By virtue of the more sustained nature of post-traumatic stress disorder (relative to acute stress disorder), a number of changes, including decreased self-esteem, loss of sustained beliefs about people or society, hopelessness, a sense of being permanently damaged, and difficulties in previously established relationships, are typically observed. Substance abuse often develops,  especially involving alcohol, marijuana, and sedative-hypnotic drugs.

About 50 percent of cases of post-traumatic stress disorder remit within 6 months. For the remainder, the disorder typically persists for years and can dominate the sufferer’s life. A longitudinal study of Vietnam veterans, for example, found 15 percent of veterans to be suffering from post-traumatic stress disorder 19 years after combat. In the general population, the 1-year prevalence is about 3.6 percent, with women having almost twice the prevalence of men. The highest rates of post-traumatic stress disorder are found among women who are victims of crime, especially rape, as well as among torture and concentration camp survivors. Overall, among those exposed to extreme trauma, about 9 percent develop post-traumatic stress disorder

Many people with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event can also trigger symptoms. People with PTSD also experience emotional numbness and sleep disturbances, depression, anxiety, and irritability or outbursts of anger. Feelings of intense guilt are also common. Most people with PTSD try to avoid any reminders or thoughts of the ordeal. PTSD is diagnosed when symptoms last more than 1 month.

Physical symptoms such as headaches, gastrointestinal distress, immune system problems, dizziness, chest pain, or discomfort in other parts of the body are common in people with PTSD. Often, doctors treat these symptoms without being aware that they stem from an anxiety disorder.

Facts about PTSD

  • An estimated 5.2 million American adults ages 18 to 54, or approximately 3.6 percent of people in this   age group in a given year, have PTSD. 
  • About 30 percent of Vietnam veterans developed PTSD at some point after the war. 2 The disorder also has been detected among veterans of the Persian Gulf War, with some estimates running as high as 8 percent. 
  • More than twice as many women as men experience PTSD following exposure to trauma. 
  • Depression, alcohol or other substance abuse, or other anxiety disorders frequently co-occur with PTSD.  The likelihood of treatment success is increased when these other conditions are appropriately diagnosed and treated as well.

Treatments for PTSD

PTSD can be extremely debilitating. Studies have demonstrated the efficacy of cognitive-behavioral therapy, group therapy, and exposure therapy, in which the person gradually and repeatedly re-lives the frightening experience under controlled conditions to help him or her work through the trauma.  Studies also have found that several types of medication, particularly the selective serotonin reuptake inhibitors and other antidepressants, can help relieve the symptoms of PTSD. 

Other research shows that giving people an opportunity to talk about their experiences very soon after a catastrophic event may reduce some of the symptoms of PTSD. A study of 12,000 schoolchildren who lived through a hurricane in Hawaii found that those who got counseling early on were doing much better 2 years later than those who did not. 

Research Findings

Research is continuing to reveal factors that may lead to PTSD. People who have been abused as children or who have had other previous traumatic experiences are more likely to develop the disorder.  In addition, it used to be believed that people who tend to be emotionally numb after a trauma were showing a healthy response; but now some researchers suspect that people who experience this emotional distancing may be more prone to PTSD.

Studies in animals and humans have focused on pinpointing the specific brain areas and circuits involved in anxiety and fear, which are important for understanding anxiety disorders such as PTSD.  Fear, an emotion that evolved to deal with danger, causes an automatic, rapid protective response in many systems of the body. It has been found that the fear response is coordinated by a small structure deep inside the brain, called the amygdala. The amygdala, although relatively small, is a very complicated structure, and recent research suggests that different anxiety disorders may be associated with abnormal activation of the amygdala.

People with PTSD tend to have abnormal levels of key hormones involved in response to stress.  When people are in danger, they produce high levels of natural opiates, which can temporarily mask pain. Scientists have found that people with PTSD continue to produce those higher levels even after the danger has passed; this may lead to the blunted emotions associated with the condition.

Some studies have shown that cortisol levels are lower than normal and epinephrine and norepinephrine are higher than normal. Norepinephrine is a neurotransmitter released during stress, and one of its functions is to activate the hippocampus, the brain structure involved with organizing and storing information for long-term memory.

This action of norepinephrine is thought to be one reason why people generally can remember emotionally arousing events better than other situations. Under the extreme stress of trauma, norepinephrine may act longer or more intensely on the hippocampus, leading to the formation of abnormally strong memories that are then experienced as flashbacks or intrusions. Since cortisol normally limits norepinephrine activation, low cortisol levels may represent a significant risk factor for developing PTSD.

Research to understand these neurotransmitter systems involved in memories of emotionally charged events may lead to the discovery of drugs or psychosocial interventions that, if given early, could block the development of PTSD symptoms.

Anxiety disorders are the most prevalent mental disorders in adults. The anxiety disorders affect twice as many women as men. Underlying this heterogeneous group of disorders is a state of heightened arousal or fear in relation to stressful events or feelings. The biological manifestations of anxiety, which are grounded in the “fight-or-flight” response, are unmistakable: they include surge in heart rate, sweating, and tensing of muscles. But this is certainly not the whole picture. Although the full array of biological causes and correlates of anxiety are not yet known, numerous effective treatments for anxiety disorders exist now. Treatment draws on an assortment of psychosocial and pharmacological approaches, administered alone or in combination.

Please read the following:   Children and Panic Disorders

Home |FAQs |Accreditations |Contact Us |Login| Course Catalog| Nursing CEUs