Private Practice Psychology

Resilience is something that most people need to bounce back from whatever life throws at them. Everyone experiences difficulties in life, and some people will even experience traumatic events that create an upheaval in their lives. Resilience is the process by which people adapt to changes or crises, like death, divorce, tragedy, the loss of a job, or financial problems. Resilience is not a character trait - it can be learned by anyone, but learning resilience does require time and effort.

Several factors involved in resilience include having a loving support system, the ability to make plans and follow through with them, communication and problem-solving skills, having a positive view of yourself and your abilities, and the capability to manage your feelings and impulses. Building resilience is a different process for everyone, and what works for one person may not work for another. Each person should determine what works for them and do that.

It may be helpful to imagine resilience as a mountain climb to Mount Kinabalu for example. It is best to take that trip with someone else, particularly someone you love and trust. Having a plan in mind for how to navigate the trail is a good idea. Trusting your own instincts and abilities will help guide you along the way. Lastly, stopping along the trail to rest can be a great idea, but you will have to get back on and continue your journey in order to finish the trip.

Building resilience can be a challenging process. Here are a few tips for developing and strengthening resilience:

*Maintain good relationships with your family and friends, and accept their help in times of stress. Also, getting involved in community groups or faith-based organizations may help give you social support when you need it.

*Try to look at the big picture of life, and avoid viewing difficult times as insurmountable. Take small steps toward your goals and take one day at a time.

*Accept that change is a part of life and learn to embrace the circumstances that you cannot change.

*Keep working toward your goals every day, and ask yourself “What can I do today to move in the direction I need to go?”

*Keep a positive view of yourself and your ability to solve issues and challenges.

*Maintain a positive view of life and visualize what you want.

*Notice how you have changed after a tragedy or crisis. Many people report having more confidence in themselves after a crisis and some even have a deeper appreciation for life. Get what you can out of these tough times.

*Take care of yourself! Get enough food, sleep, and exercise to keep yourself healthy. This is especially important during times of stress.

*Lastly, seek professional help if you feel that the situation is too hard for you to handle on your own. A licensed mental health professional, such as a counselor or psychologist, can help you develop a strategy for moving forward in your life.

Definition
Just as the field of treatment for substance use and mental disorders has evolved to become more precise, so too has the terminology used to describe people with both substance use and mental disorders. The term co-occurring disorders replaces the terms dual disorder or dual diagnosis. These latter terms, though used commonly to refer to the combination of substance use and mental disorders, are confusing in that they also refer to other combinations of disorders (such as mental disorders and mental retardation).

Furthermore, the terms suggest that there are only two disorders occurring at the same time, when in fact there may be more. Clients with co-occurring disorders (COD) have one or more disorders relating to the use of alcohol and/or other drugs of abuse as well as one or more mental disorders. A diagnosis of co-occurring disorders occurs when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from the one disorder.

Although co-occurring disorder is the most current term used professionally, for the purposes of this article, dual disorders will be used interchangeably.

The acronym MICA, which represents the phrase Mentally Ill Chemical Abusers, is occasionally used to designate people who have a COD and a markedly severe and persistent mental disorder such as schizophrenia or bipolar disorder. A preferred definition is mentally ill chemically affected people, since the word affected better describes their condition and is not pejorative. Other acronyms include: MISA (mentally ill substance abusers), CAMI (chemical abuse and mental illness), SAMI (substance abuse and mental illness), MISU (mentally ill substance using), MICD (mentally ill chemically dependent) and ICOPSD (individuals with co-occurring psychiatric and substance disorders).

Common examples of co-occurring disorders include the combinations of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism and polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse. Although the focus of this is on dual disorders, some patients have more than two disorders. The principles that apply to dual disorders generally apply also to multiple disorders.

The combinations of COD problems and psychiatric disorders vary along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Indeed, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.

Thus, there is no single combination of dual disorders; in fact, there is great variability among them. However, patients with similar combinations of dual disorders are often encountered in certain treatment settings.

More than half of all adults with severe mental illness are further impaired by substance use disorders (abuse or dependence related to alcohol or other drugs).

Compared to patients who have a mental health disorder or a COD use problem alone, patients with dual disorders often experience more severe and chronic medical, social, and emotional problems. Because they have two disorders, they are vulnerable to both COD relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric decompensation, and worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specially designed for patients with dual disorders. Compared with patients who have a single disorder, patients with dual disorders often require longer treatment, have more crises, and progress more gradually in treatment.

Psychiatric disorders most prevalent among dually diagnosed patients include mood disorders, anxiety disorders, personality disorders, and psychotic disorders.

Symptoms The symptoms of co-occurring disorder include those associated with substance abuse along with those of psychiatric disorders mentioned previously.

Substance abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances. Individuals who abuse substances may experience such harmful consequences of substance use as repeated failure to fulfill roles for which they are responsible, legal difficulties, or social and interpersonal problems. It is important to note that the chronic use of an illicit drug still constitutes a significant issue for treatment even when it does not meet the criteria for substance abuse.

For individuals with more severe or disabling mental disorders, as well as for those with developmental disabilities and traumatic brain injuries, even the threshold of substance use that might be harmful (and therefore defined as abuse) may be significantly lower than for individuals without such disorders. Furthermore, the more severe the disability, the lower the amount of substance use that might be harmful.

People with dual disorders are at high risk for many additional problems such as symptomatic relapses, hospitalizations, financial problems, social isolation, family problems, homelessness, suicide, violence, sexual and physical victimization, incarceration, serious medical illnesses, such as HIV and hepatitis B and C, and early death. Any one of these problems complicates the treatment of co-occurring disorder.

Causes The common wisdom among mental health and medical professionals is that both disorders are biologically based and related to the brain. Sometimes the mental problem occurs first. This can lead people to use alcohol or drugs that make them feel better temporarily. Sometimes the substance abuse occurs first. Over time, that can lead to emotional and mental problems.

Mental disorders and addiction are each a dynamic process, with fluctuations in severity, rate of progression, and symptom manifestation and with differences in the speed of onset. Both disorders are greatly influenced by several factors, including genetic susceptibility, environment, and pharmacologic influences. Certain people have a high risk for these disorders (genetic risk); some situations can evoke or help to sustain these disorders (environmental risk); and some drugs are more likely than others to cause psychiatric or substance use disorder problems (pharmacologic risk).

Treatment To provide appropriate treatment for this complex diagnosis, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the US Department of Health and Human Services recommends integrated treatment of people with COD based on current research that supports the efficacy of this treatment. Integrated treatment is a means of coordinating substance abuse and mental health interventions to treat the whole person more effectively in the context of a primary treatment relationship or service setting.

Integrated Dual Disorders Treatment occurs when a person receives combined treatment for mental illness and substance use from the same clinician or treatment team. It helps people develop hope, knowledge, skills, and the support they need to manage their problems and to pursue meaningful life goals. A person is receiving integrated treatment because their clinician or treatment team will do several things at the same time, including:

• Help the person think about the role that alcohol and other drugs play in their life. This should be done confidentially, without any negative consequences. People feel free to discuss these issues when the discussion is confidential, nonjudgmental, and not tied to legal consequences.
• Offer the person a chance to learn more about alcohol and drugs, to learn about how they interact with mental illnesses and with medications, and to discuss their own use of alcohol and drugs.
• Help the person become involved with supported employment and other services that may help the process of recovery.
• Help the person identify and develop recovery goals. If the person decides that the use of alcohol or drugs may be a problem, a counselor trained in integrated dual disorders treatment can help the person identify and develop personalized recovery goals. This process includes learning about steps toward recovery from both illnesses.
• Provide special counseling specifically designed for people with dual disorders. If the person decides that the use of alcohol or drugs may be a problem, a trained counselor can provide special counseling specifically designed for people with dual disorders. This can be done individually, with a group of peers, with family members, or with a combination of these.

Successful strategies with important implications for clients with COD include interventions based on addiction work in contingency management, cognitive-behavioral therapy (CBT), relapse prevention, and motivational interviewing.

The Mental Health System

Most states have an assortment of public mental health centers that have a wide range of services. Mental health services are provided by a variety of mental health professionals including psychiatrists; psychologists; clinical social workers; clinical nurse specialists; certified substance abuse counselors (CSACs); other therapists and counselors including marriage, family, and child counselors; and paraprofessionals.

These mental health personnel work in a variety of settings, using a variety of theories about the treatment of specific psychiatric disorders. Different types of mental health professionals (for example, social workers and MFCCs) have differing perspectives; moreover, practitioners within a given group often use different approaches.

A major strength of the mental health system is the comprehensive array of services offered, including counseling, case management, partial hospitalization, inpatient treatment, vocational rehabilitation, and a variety of residential programs. The mental health system has a relatively large variety of treatment settings. These settings are designed to provide treatment services for patients with acute, subacute, and long-term symptoms. Acute services are provided by personnel in emergency rooms and hospital units of several types and by crisis—line personnel, outreach teams, and mental health law commitment specialists. Hospitals, day treatment programs, mental health center programs, and several types of individual practitioners provide sub-acute. Long-term settings include mental health centers, residential units, and practitioners’ offices. Clinicians vary with regard to academic degrees, styles, expertise, and training.

The Addiction Treatment System

Individuals with COD are found in all addiction treatment settings, at every level of care. Although some of these individuals have serious mental illness and/or are unstable or disabled, many of them have relatively stable disorders of mild to moderate severity. As substance abuse treatment programs serve the increasing number of clients with COD, the essential program elements required to meet their needs must be defined clearly and set in place.

Essential components of treatment for substance abuse agencies with COD clients:

1. Screening, assessment, and referral
2. Mental and physical health consultation
3. The use of a prescribing onsite psychiatrist
4. Medication and medication monitoring
5. Psychoeducational classes
6. Onsite double trouble groups
7. Offsite dual recovery mutual self-help groups. These elements are applicable in both residential and outpatient programs.

Screening, Assessment, and Referral

All substance abuse treatment programs should have in place appropriate procedures for screening, assessing, and referring clients with COD. It is the responsibility of each provider to identify clients with both mental—and substance—use disorders, and assure that they have access to the care needed for each disorder.

Screening is a formal process of testing to determine whether a client does or does not warrant further attention at the current time in regard to a particular disorder and, in this context, the possibility of a co-occurring substance use or mental disorder. The screening process for COD seeks to answer a “yes” or “no” question: Does the substance abuse (or mental health) client being screened show signs of a possible mental health (or substance abuse) problem?

Assessment is a process for defining the nature of that problem and developing specific treatment recommendations for addressing the problem. A basic assessment consists of gathering key information and engaging in a process with the client that enables the counselor to understand the client’s readiness for change, problem areas, COD diagnoses, disabilities, and strengths. This typically involves a clinical examination of the functioning and well-being of the client and includes a number of tests and written and oral exercises. The COD diagnosis is established by referral to a psychiatrist, clinical psychologist, or other qualified healthcare professional. Assessment of the client with COD is an ongoing process that should be repeated over time to capture the changing nature of the client’s status.

Some intake information includes:

• Background: family, trauma history, history of domestic violence (either as a batterer or as a battered person), marital status, legal involvement and financial situation, health, education, housing status, strengths and resources, and employment.
• Substance use: age of first use, primary drugs used (including alcohol, patterns of drug use, and treatment episodes), and family history of substance use problems.
• Mental health problems: family history of mental health problems, client history of mental health problems including diagnosis, hospitalization and other treatment, current symptoms and mental status, medications, and medication adherence.

A comprehensive assessment serves as the basis for an individualized treatment plan. Appropriate treatment plans and treatment interventions can be quite complex, depending on what might be discovered in each domain. This leads to another fundamental principle: There is no single, correct intervention or program for individuals with COD. Rather, the appropriate treatment plan must be matched to individual needs according to these multiple considerations.

Mental and Physical Health Consultation

A physical and mental health consultation serves individuals with COD by determining the physical and mental health challenges and incorporates the necessary treatment(s) into patient services.

Prescribing an Onsite Psychiatrist

An onsite addiction treatment psychiatrist can improve treatment retention and decrease substance use among patients. The onsite psychiatrist brings diagnostic, medication, and psychiatric counseling services directly to the location clients are based at for the major part of their treatment. This approach often is the most effective way to overcome barriers presented by offsite referral, including distance and travel limitations, the inconvenience of enrolling in another agency and of the separation of clinical services (more “red tape”), fears of being seen as “mentally ill” (if referred to a mental health agency), cost, and the difficulty of becoming comfortable with different staff.

Medication and Medication Monitoring

Many clients with COD require medication to control their psychiatric symptoms and to stabilize their psychiatric status.

Pharmacological advances over the past decade have produced antipsychotic, antidepressant, anticonvulsant, and other medications with greater effectiveness and fewer side effects. With the support available from better medication regimens, many people who once would have been too unstable for substance abuse treatment, or institutionalized with a poor prognosis, have been able to lead more functional lives.

Psychoeducational Classes

Psychoeducational classes on mental and substance use disorders are important elements in basic COD programs. These classes typically focus on the signs and symptoms of mental disorders, medication, and the effects of mental disorders on substance abuse problems. Psychoeducational classes of this kind increase client awareness of their specific problems and do so in a safe and positive context.

Relapse prevention education presents strategies designed to help clients become aware of cues or “triggers” that make them more likely to abuse substances and help them develop alternative coping responses to those cues. Some providers suggest the use of “mood logs” that clients can use to increase their consciousness of the situational factors that underlie the urge to use or drink.

Onsite Double Trouble Groups

Onsite groups such as “Double Trouble” provide a forum for discussion of the interrelated problems of mental disorders and substance abuse, helping participants to identify triggers for relapse. Clients describe their psychiatric symptoms (such as hearing voices) and their urges to use drugs. They are encouraged to discuss, rather than to act on, these impulses. Double Trouble groups also can be used to monitor medication adherence, psychiatric symptoms, substance use, and adherence to scheduled activities. Double Trouble provides a constant framework for assessment, analysis, and planning. Through participation, the individual with COD develops perspective on the interrelated nature of mental disorders and substance abuse and becomes better able to view his or her behavior within this framework.

Dual Recovery Mutual Self-Help Groups (Offsite)

These offsite self-help groups exist in many communities. Substance abuse treatment programs can refer clients to dual recovery mutual self-help groups, which are tailored to the special needs of a variety of people with COD. These groups provide a safe forum for discussion about medication, mental health, and substance abuse issues in an understanding, supportive environment wherein coping skills can be shared.

The dual recovery mutual self-help movement is emerging from two cultures: the 12-Step fellowship recovery movement and, more recently, the culture of the mental health consumer movement. In keeping with traditional 12-Step principles and traditions, dual recovery 12-Step fellowships do not provide specific clinical or counseling interventions, classes on psychiatric symptoms, or any services similar to case management. Dual recovery fellowships maintain a primary purpose of members helping one another achieve and maintain dual recovery, prevent relapse, and carry the message of recovery to others who experience dual disorders. Dual recovery 12-Step members who take turns chairing their meetings are members of their fellowship as a whole.

Substance abuse groups include the 12-step program of Alcoholics Anonymous (AA); Narcotics Anonymous (NA), Cocaine Anonymous (CA), and so on, can provide needed support and encouragement for patients in treatment. More importantly, these services are widespread nationally and internationally. While self-help programs are not considered treatment per se, they are integral adjuncts to professional treatment services.

Outpatient Substance Abuse Treatment Programs for Clients with COD

Treatment for substance abuse occurs most frequently in outpatient settings—a term that includes a wide variety of disparate programs. Some offer several hours of treatment each week, which can include mental health and other support services as well as individual and group counseling for substance abuse; others provide minimal services, such as only one or two brief sessions to give clients information and refer them elsewhere. Some agencies offer intensive outpatient programs that provide services several hours per day and several days per week. Typically, treatment includes individual and group counseling, with referrals to appropriate community services.

Screening and assessment are used to make two essential decisions—about the stability of the individual with COD to remain in an inpatient, outpatient or appropriate alternative treatment setting and the needed mental health services. A centralized intake team is a useful approach to screening and assessment, providing a common point of entry for many clients entering treatment.

Once admitted to treatment, clients need regular reassessment as reductions in acute symptoms of mental distress and substance abuse may precipitate other changes. Periodic assessment will provide measures of client change and enable the provider to adjust service plans as the client progresses through treatment. Then careful assessment will help to identify those clients who require more secure inpatient treatment settings (such as clients who are actively suicidal or homicidal), as well as those who require 24-hour medical monitoring, those who need detoxification, and those with serious substance use disorders who may require a period of abstinence or reduced use before they can engage actively in all treatment components.

Discharge planning is important to maintain gains achieved through outpatient care. Clients with COD leaving an outpatient substance abuse treatment program have a number of continuing care options. These options include mutual self-help groups, relapse prevention groups, continued individual counseling, mental health services (especially important for people who will continue to require medication), as well as intensive case management monitoring and supports. A carefully developed discharge plan, produced in collaboration with the person with COD, will identify and match their needs with community resources, providing the supports needed to sustain the progress achieved in outpatient treatment.

Individuals with COD often need a range of services besides substance abuse treatment and mental health services. Generally, prominent needs include housing and case management services to establish access to community health and social services. These can be essential to the successful recovery of the person with COD.

It is imperative that discharge planning for the client with COD ensures continuity of psychiatric assessment and medication management, without which client stability and recovery will be severely compromised. Relapse prevention interventions after outpatient treatment need to be modified so that the client can recognize symptoms of psychiatric or substance abuse relapse on her own and can call on a learned repertoire of symptom management techniques (such as self-monitoring, reporting to a “buddy,” and group monitoring). This also includes the ability to access assessment services rapidly, since the return of psychiatric symptoms can often trigger substance abuse relapse.

The Medical System

Although not substance abuse treatment settings per se, acute care and other medical settings are included here because important substance abuse and mental health treatment do occur in medical units. Acute care refers to short-term care provided in intensive care units, brief hospital stays, and emergency rooms (ERs). Providers in acute care settings usually are not concerned with treating substance use disorders beyond detoxification, stabilization, and/or referral.

In other medical settings, such as primary care offices, providers generally lack the resources to provide any kind of extensive substance abuse treatment, but may be able to provide brief interventions and treatment referrals.

Primary health-care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with psychiatric and COD use disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to psychiatric and substance use disorders. And because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with psychiatric and COD disorders. At that point, the person with COD can be referred for appropriate services in the proper setting.

Sources:

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
• Office for Treatment Improvement, Alcohol, Drug Abuse, and Mental Health Administration
• Substance Abuse and Mental Health Services Administration (2005)
• Hospital and Community Psychiatry
• Dual Diagnosis of Major Mental Illness and Substance Disorder
• Journal of the American Medical Association
• Journal of Addictive Diseases
• Archives of General Psychiatry
• Center for Substance Abuse Treatment
• Charney DA, Paraherakis AM, Gill KJ. Integrated treatment of comorbid depression and substance use disorders. Journal of Clinical Psychiatry. 62((9)):672-677; 2001.
• Saxon AJ, Calsyn DA. Effects of psychiatric care for dual diagnosis patients treated in a drug dependence clinic. American Journal of Drug and Alcohol Abuse. 21((3)):303-313; 1995.
• Etheridge RM, Hubbard RL, Anderson J, Craddock SG, Flynn PM. Treatment structure and program services in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behavior. 11((4)):244-260; 1997.
• Simpson DD, Joe GW, Rowan-Szal GA. Drug abuse treatment retention and process effects on follow-up outcomes. Drug and Alcohol Dependence. 47((3)):227-235; 1997b.

Definition
Antisocial personality disorder is best understood within the context of the broader category of personality disorders.

A personality disorder is an enduring pattern of personal experience and behavior that deviates noticeably from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to personal distress or impairment.

Antisocial personality disorder is characterized by a pattern of disregard for and violation of the rights of others. The diagnosis of antisocial personality disorder is not given to individuals under the age of 18 and is only given if there is a history of some symptoms of conduct disorder before age 15.

The severity of symptoms of antisocial personality disorder can vary in severity. The more egregious, harmful, or dangerous behavior patterns are referred to as sociopathic or psychopathic. There has been much debate as to the distinction between these descriptions. Sociopathy is chiefly characterized as a something severely wrong with one’s conscience; psychopathy is characterized as a complete lack of conscience regarding others. Some professionals describe people with this constellation of symptoms as “stone cold” to the rights of others. Complications of this disorder include imprisonment, drug abuse, and alcoholism.

People with this illness may seem charming, but they are likely to be irritable and aggressive as well as irresponsible. They may have numerous somatic complaints and perhaps attempt suicide. Due to their manipulative tendencies, it is difficult to separate what they say about themselves that is true from what is not.

Symptoms

• Disregard for society’s laws
• Violation of the physical or emotional rights of others
• Lack of stability in job and home life
• Lack of remorse
• Superficial wit and charm
• Recklessness, impulsivity
• A childhood diagnosis (or symptoms consistent with) conduct disorder

Diagnosis is given to those over 18 years of age. Antisocial personality is confirmed by a psychological evaluation. Other disorders should be ruled out first, as this is a serious diagnosis.

People with antisocial personality disorder often use alcohol and other drugs, which can exacerbate symptoms of the disorder. The coexistence of substance abuse and antisocial personality disorder complicates treatment for both.

Causes While the exact causes of this disorder are unknown, environmental and genetic factors have been implicated. Genetic factors are suspected since the incidence of antisocial behavior is higher in people with an antisocial biological parent. Environmental factors are believed to contribute to the development of antisocial personality disorder since a person whose role model had antisocial tendencies is more likely to develop the disorder. About 3 percent of men and about 1 percent of women have antisocial personality disorder, with much higher percentages among the prison population.

Treatment Antisocial personality disorder is one of the most difficult personality disorders to treat. Individuals rarely seek treatment on their own and may only initiate therapy when mandated by a court. There is no known effective treatment for this disorder.

Sources:

• American Psychiatric Association
• Diagnostic and Statistical Manual of Mental Disorders (4th ed.).
• National Institutes of Health, National Library of Medicine, MedlinePlus, 2006. Antisocial Personality Disorder. www.nlm.nih.gov/medlineplus/ency/article/000921.htm
• Stout, M. (2005). The Sociopath Next Door. NY: Broadway.
• Westermeyer, J. and Thuras, P. (2005). Association of Antisocial Personality Disorder and substance disorder morbidity in a clinical sample. American Journal of Drug and Alcohol Abuse.

Definition
Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that may develop after exposure to a terrifying event or ordeal in which severe physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or unnatural disasters, accidents, or military combat.

Those who may experience PTSD include military troops who served in wars; rescue workers for catastrophes like the 2001 terrorist attacks on New York City and Washington, D.C.; survivors of the Oklahoma City bombing; survivors of accidents, rape, physical or sexual abuse, and other crimes; immigrants fleeing violence in their countries; survivors of earthquakes, floods, and hurricanes; and those who witness traumatic events. Family members of victims can develop the disorder as well.

PTSD affects about 7.7 million American adults, but it can occur at any age, including childhood. Women are more likely to develop the disorder than men, and there is some evidence that it may run in families. PTSD is frequently accompanied by depression, substance abuse, or anxiety disorders. When other conditions are appropriately diagnosed and treated, the likelihood of successful treatment increases.

Roughly 30 percent of Vietnam veterans developed PTSD. The disorder also has been detected among veterans of the Gulf War, with some estimates running as high as 8 percent.

Complex PTSD

Complex PTSD, also known as disorder of extreme stress, is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. Research shows that many brain and hormonal changes may occur as a result of early, prolonged trauma, and contribute to troubles with learning, memory, and regulating emotions. Combined with a disruptive, abusive home environment, these brain and hormonal changes may contribute to severe behavioral difficulties such as eating disorders, impulsivity, aggression, inappropriate sexual behavior, alcohol or drug abuse, and other self-destructive actions, as well as emotional regulation (such as intense rage, depression, or panic) and mental difficulties (such as scattered thoughts, dissociation, and amnesia). As adults, these individuals often are diagnosed with depressive disorders, personality disorders, or dissociative disorders. Treatment may progress at a much slower rate, and requires a sensitive and structured program delivered by a trauma specialist.

Symptoms Many people with PTSD tend to re-experience the ordeal that set the disease in motion, 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, sleep disturbances, anxiety, intense guilt, depression, irritability, or outbursts of anger. Most people with PTSD try to avoid any reminders or thoughts of the ordeal. PTSD is diagnosed when symptoms last more than one month.

Symptoms associated with reliving the traumatic event:

• Having bad dreams about the event or something similar
• Behaving or feeling as if the event were actually happening all over again (known as flashbacks)
• Having a lot of emotional feelings when reminded of the event
• Having a lot of physical sensations when reminded of the event (heart pounds or misses a beat, sweating, difficulty breathing, feeling faint, feeling a loss of control)

Symptoms related to avoidance of reminders of the traumatic event:

• Avoiding thoughts, conversations, or feelings about the event
• Avoiding people, activities, or places associated with the event
• Having difficulty remembering an important part of the original trauma

Changes frequently made after the event:

• Loss of interest in things previously considered important
• Feeling detached from people
• Feeling emotionally numb and finds it hard to have loving feelings even toward those who are close
• Difficulty falling or staying asleep
• Irritability and anger
• Difficulty concentrating
• Feeling that one is not going to live long and there is no reason to plan for the future
• Feeling easily startled
• Always on guard

Medical or emotional issues:

• Stomach problems
• Intestinal problems
• Gynecological problems
• Weight gain or loss
• Chronic pain (back, neck, pelvic area in women)
• Problems getting to sleep
• Problems staying asleep
• Headaches
• Skin rashes and other problems
• Irritability, quick temper, other anger problems
• Nightmares
• Depression
• Lack of energy, chronic fatigue
• Alcoholism and other substance use problems
• General anxiety
• Panic attacks

Causes People who have suffered childhood abuse or other previous traumatic experiences are more likely to develop the disorder. And people who experience emotional distancing may be more prone to PTSD.

Studies in animals and humans have pinpointed the brain areas 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 the body. The fear response is coordinated by a small structure deep inside the brain, called the amygdala. The amygdala, is a complicated structure, and research suggests that posttraumatic stress disorder may be associated with abnormal activation of the amygdala.

Once fear is conditioned in the amygdala, it is hard to change. However, the neural pathways from the amygdala to the hippocampus and to cortical regions such as the frontal lobes allow its suppression until triggered. Fear quickly returns when the individual is re-exposed. An increase in stressors seems to affect the fear-inducing and the fear-inhibiting pathways. High stress levels decrease the capacity to suppress fear, while increasing the ability to induce it. Thus, the fear induced by re-exposure to traumatic material indicates a failure of inhibition on the part of the hippocampus, and is evidence that the traumatic episode is not integrated as a narrative, spatio-temporal event in autobiographical memory. Furthermore, the heightened sensitivity of exposure of PTSD patients to trauma-related material results in an increase in fearfulness in response to stimuli that are not truly life threatening.

Studies using MRI in PTSD have measured volume of the hippocampus, a brain structure involved in learning and memory. Patients with combat-related PTSD had an 8 percent decrease in right hippocampal volume when compared with controls. A decrease of 12 percent in left hippocampal volume was found in patients with a history of PTSD related to severe childhood physical and sexual abuse. Reduced hippocampal volume was associated with dissociative symptoms in women who had a history of childhood sexual abuse.

People with PTSD tend to have abnormally high levels of key hormones involved in response to stress. A person in danger produces 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, which might 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 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.

Treatment Treatment for PTSD typically begins with a detailed evaluation, and development of a treatment plan that meets the unique needs of the survivor. PTSD-specific-treatment begins only when the survivor is safely removed from the crisis situation. Other strategies for treatment include:

• Educating trauma survivors and their families about how persons get PTSD, how PTSD affects survivors and their loved ones, and other problems commonly associated with PTSD symptoms. Understanding that PTSD is a medically recognized anxiety disorder is essential for effective treatment.
• Exposure to the event via imagery allows the survivor to re-experience the event in a safe, controlled environment. A professional can carefully examine reactions and beliefs in relation to that event.
• Examining and resolving strong feelings such as shame, anger, or guilt, which are common among survivors of trauma.
• Teaching the survivor to cope with post-traumatic memories, reminders, reactions, and feelings without becoming overwhelmed or emotionally numb. Trauma memories usually do not go away entirely as a result of therapy, but new coping skills can make them more manageable.

Medications

A number of medications that were originally approved for depression have been found effective in healing post-traumatic stress disorder. If an antidepressant is prescribed, it will need to be taken for several weeks before symptoms start to fade. It is important not to get discouraged and stop taking these medications before they’ve had a chance to work.

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. These medications act in the brain on a chemical messenger called serotonin. SSRIs tend to have fewer side effects than older antidepressants. While some patients report feeling slightly nauseated or jittery when taking SSRIs, symptoms disappear with time. Some people also experience sexual dysfunction when using some of these medications. An adjustment in dosage or a switch to another SSRI will usually correct problems. It is important to discuss side effects with your doctor.

Fluoxetine, sertraline, fluvoxamine, paroxetine, and citalopram are among the SSRIs commonly prescribed for PTSD. These medications are given at a low dose and gradually increased until they reach a therapeutic level.

Similarly, antidepressant medications called tricyclics are given at low doses and gradually increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating anxiety disorders. They are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics sometimes cause dizziness, dry mouth, drowsiness, and weight gain.

Psychotherapy

Cognitive-behavioral therapy (CBT) works to change emotions, thoughts, and behaviors. Exposure therapy is one form of CBT unique to trauma treatment—this uses careful, repeated, detailed imagining of the trauma in a safe, controlled context. In some cases, trauma memories or reminders can be confronted all at once (flooding). And in other cases, it is preferable to work gradually up to the most severe trauma by using relaxation techniques and by taking the trauma one piece at a time (desensitization).

Along with exposure, CBT includes learning skills for coping with anxiety (for example, breathing retraining or biofeedback) and negative thoughts (cognitive restructuring), managing anger, preparing for stress reactions (stress innoculation), handling future trauma symptoms, as well as addressing urges to use alcohol or drugs (relapse prevention), and communicating and relating effectively with people (social skills or marital therapy).

Eye movement desensitization and reprocessing (EMDR) is a relatively new treatment of traumatic memories that involves elements of exposure therapy and cognitive behavioral therapy, combined with techniques (sounds, eye movements, hand taps) that create an alteration of attention. There is some evidence that the therapeutic element unique to EMDR, attentional alteration, may be helpful in accessing and processing traumatic material.

Group treatment is an ideal therapeutic setting because trauma survivors are able to risk sharing traumatic material in a safe environment. As group members achieve greater understanding and resolution of their trauma, they often feel more confident and able to trust. As they discuss and share trauma-related shame, guilt, fear, rage, doubt, and self-condemnation, they prepare themselves to focus on the present rather than the past. Telling one’s story and directly facing the grief, guilt, and anxiety related to trauma enables many survivors to cope with their symptoms, memories, and other aspects of life.

Brief psychodynamic psychotherapy focuses on the emotional conflicts caused by the traumatic event, particularly in relation to early life experiences. Through the retelling of the traumatic event to a calm and empathic counselor, the survivor achieves a greater sense of self-esteem, develops effective ways of thinking and coping, and more successfully deals with the intense emotions that emerge during therapy. The therapist helps the survivor identify current life situations that set off traumatic memories and worsen PTSD symptoms.

Definition
Acute stress disorder develops within one month after an individual experiences or sees an event involving a threat or actual death, serious injury, or physical violation to the individual or others, and responded to this event with strong feelings of fear, helplessness or horror. The diagnosis was established to identify those individuals who would eventually develop post-traumatic stress disorder. As far back as World War I this condition was referred to as “shell shock,” in which there are similarities between reactions of soldiers who suffered concussions caused by exploding bombs or shells and those who suffered blows to their central nervous systems. Civilians may also suffer from it. More recently, ASD was brought to light as it became clear that for a short period, people might exhibit PTSD-like symptoms immediately after a trauma.

Trauma has both a medical and a psychiatric definition. Medically, trauma refers to a serious or critical bodily injury, wound or shock. This definition is often associated with trauma medicine practiced in emergency rooms and represents a popular view of the term. Psychiatrically, trauma has assumed a different meaning and refers to an experience that is emotionally painful, distressful or shocking, which often results in lasting mental and physical effects.

Psychiatric trauma, or emotional harm, is essentially a normal response to an extreme event. It involves the creation of emotional memories about the distressful event that are stored deep within the brain. In general, it is believed that the more direct the exposure to the traumatic event, the higher the risk for emotional harm. Thus in a school shooting, for example, the student who is injured probably will be most severely affected emotionally; and the student who sees a classmate shot or killed is likely to be more emotionally affected than the student who was in another part of the school when the violence occurred. But even secondhand exposure to violence can be traumatic. For this reason, all children and adolescents exposed to violence or a disaster, even if only through graphic media reports, should be watched for signs of emotional distress.

Symptoms For a diagnosis of acute stress disorder, symptoms must persist for a minimum of two days to up to four weeks within a month of the trauma.

A person may be described as having acute stress disorder if other mental disorders or medical conditions do not provide a better explanation for the person’s symptoms. If symptoms persist after a month, the diagnosis becomes post-traumatic stress disorder.

Symptoms include:

• Lack of emotional responsiveness, a sense of numbing or detachment
• A reduced sense of surroundings
• A sense of not being real
• Depersonalization or a sense of being dissociated from self
• An inability to remember parts of the trauma, “dissociative amnesia”
• Increased state of anxiety and arousal such as a difficulty staying awake or falling asleep
• Trouble experiencing pleasure
• Repeatedly re-experiencing the event through recurring images and/or thoughts, dreams, illusions, flashbacks
• Purposeful avoidance of exposure to thoughts, emotions, conversations, places or people that remind them of the trauma
• Feelings of stress interfering with functioning; social and occupational skills are impaired affecting the patient’s ability to function, pursue required tasks and seek treatment

Causes When a fearful or threatening event is perceived, humans react innately to survive: They either are ready for battle or run away (hence the term “fight-or-flight response”). The nature of the acute stress response is all too familiar. Its hallmarks are an almost instantaneous surge in heart rate, blood pressure, sweating, breathing and metabolism, and a tensing of muscles. Enhanced cardiac output and accelerated metabolism are essential to mobilizing for fast action. This explanation is thought to be in part a cause for anxiety disorders. Yet over the past decade, the limitations of the acute stress response as a model for understanding anxiety have become more apparent. The first and most obvious limitation is that the acute stress response relates to arousal rather than anxiety. Anxiety differs from arousal in several ways: First, with anxiety, the concern about the stressor is out of proportion to the realistic threat. Second, anxiety is often associated with elaborate mental and behavioral activities designed to avoid the unpleasant symptoms of a full-blown anxiety or panic attack. Third, anxiety is usually longer lived than arousal. Fourth, anxiety can occur without exposure to an external stressor. Cognitive factors, especially the way people interpret or think about stressful events, play a critical role in the etiology of anxiety. A decisive factor is the individual’s perception, which can intensify or dampen the response. One of the most salient negative cognitions in anxiety is the sense of uncontrollability. It is typified by a state of helplessness due to a perceived inability to predict, control or obtain desired results. These are among the factors considered as causes of anxiety disorders such as acute stress disorder.

Treatment Cognitive behavioral therapy is the treatment that has met with the most success in combating ASD. It has two main components: First, it aims to change cognitions, patterns of thought surrounding the traumatic incident. Second, it tries to alter behaviors in anxiety-provoking situations.

Cognitive behavioral therapy not only ameliorates the symptoms of ASD, but also it seems to prevent people from developing post-traumatic stress disorder. The chance that a person diagnosed with acute stress disorder will develop PSTD is about 80 percent; the chance that they will develop PTSD after cognitive-behavioral therapy is only about 20 percent.

Psychological debriefing and anxiety management groups are two other types of therapy that have been examined for the treatment of ASD. Psychological debriefing involves an intense therapeutic invention immediately after the trauma, so that traumatized individuals can “talk it all out.” In anxiety management groups, people share coping strategies and learn to combat stress together. However, both types of therapy have proven to be largely ineffectual for the treatment of ASD.

The Internet is unlike anything we have ever seen before. It is a socially connecting device that is socially isolating at the same time. With the increasing number of users and the social problems that people are finger pointing at, it is not surprising that there is an uprising concern about the use of Internet.

However, no research has yet established that there is a disorder of Internet addiction that is separable from problems such as loneliness or pathological gambling, or that a passion for using the Internet is long-lasting.

Much of the original research was based upon the weakest type of research methodology, namely exploratory surveys with no clear hypothesis or rationale backing them. Therefore, we cannot establish causal relationships between specific behaviors and their cause.

Years have gone by and there are more than a few studies out there looking at Internet addiction. Yet none of them agree on a single definition for this problem, and all of them vary widely in their reported results of how much time an “addict” spends online. If they cannot even get these basics down, it is not surprising the research quality still suffers.

For now, this and other questions about Internet use will remain unanswered until more controlled studies are done.

Do some people have problems spending too much time online?

Sure they do. Some people also spend too much time reading, watching television, and working, and ignore family, friendships, and social activities. That does not suggest they have a TV addiction disorder, book addiction, and work addiction that is legitimate mental disorders in the same category as schizophrenia and depression. It is the tendency of some mental health professionals and researchers to want to label everything they see as potentially harmful with a new diagnostic category. Unfortunately, this causes more harm than it helps people.

Some people online who think they are addicted could possibly be suffering from desires not to want to deal with other problems in their lives. These problems could include a mental disorder (depression, anxiety, etc.), a serious health problem or disability, or a relationship problem. In this case, it is no different than turning on the TV so you won’t have to talk to your spouse, or going “out with the boys” for a few drinks so you don’t have to spend time at home. Nothing is different except the modality.

On the other hand, some people who spend time online without any other problems present may suffer from compulsive over-use. Compulsive behaviours, however, are already covered by existing diagnostic categories and treatment would be similar. It is not the technology (whether it be the Internet, a book, the telephone, or the television) that is important or addicting – it is the behavior. And behaviors are easily treatable by cognitive-behavioural techniques in psychotherapy.

Is it possible for people to become addicted to chat rooms?

As explained above, I will now use the word addiction in a different manner.

Time alone cannot be an indicator of being addicted or engaging in compulsive behavior. Time must be taken in context with other factors, such as whether you are a college student (who, as a whole, proportionally spend a greater amount of time online), whether it is a part of your job, whether you have any pre-existing conditions (such as another mental disorder), whether you have problems or issues in your life which may be causing you to spend more time online (e.g., using it to “get away” from life’s problems, a bad marriage, difficult social relations), etc. So talking about whether you spend too much time online without this important context is useless.

There are evidence that suggests that the time people spend chatting online is phasic and can be explained in terms of three phases:

Stage I: Enchantment (Obsession)
Stage II: Disillusionment (Avoidance)
Stage III: Balance (Normal)

That is to say that people first are enchanted by the activity (characterized by some as obsession) especially when they are new users, followed by disillusionment with chatting and a decline in usage, and then a balance was reached where the level of chat activity normalized.

What can lead to such an addiction?

How do people get caught up in the Internet? For one thing, human beings are curious. People like to see more and do more. People like to feel competent and in control. Online, they can act in ways that are exciting and they can do so without leaving their chair of being with a real person. Especially in chat rooms and a virtual society - accountability, supervision and social consequences are almost non-existent.

People also like to feel better and they don’t like to feel bad. We like to do things that feel good and avoid things that feel worse. We especially like doing pleasurable things more and more.

On the Internet, people do not have to go out and find real people and have an honest relationship. They can stay in their own chair and explore endless activities. They can walk away and come right back. There is always something happening.

People will even miss you and ask you to come back.

The seduction and addictive nature of the chat rooms can be understood primarily in terms of a behavior modification process called a variable reinforcement schedule. That means you don’t know how much of a reward you will get and when for your behavior (ie. praises, expressions of longing, admiration, intimacy, true friendships, etc). And a variable reinforcement schedule is the most addictive reward system.

Being on the Internet is not necessarily about having a good time. Being on-line might make you feel better but it might just change how you feel. It can be an escape from reality that isn’t necessarily better for you.

Prolonged chats on-line and mouse clicking on the Internet will produce a dissociative state whereby Internet users can separate from reality and enter cyber reality. Anyone with children has seen how children can watch television for countless hours. Children and even adults watching television long enough will enter a “hypnotic trance.” They “meld” into the television and disconnect from reality.

People can disappear into a good book or a movie, but there is always an end to a book or a movie. The Internet is especially addictive because it is endless, interactive, social and exploding with never ending images and information. The Internet offers exciting relationships 24 hours a day all over the world.

Limited use is a form or healthy recreation or escape. Prolonged and repeated use can create problems.

What do you think is the pull or the attraction for many young people today to communicate and express themselves and make friends via chat rooms as opposed to meeting people the old fashioned way?

Nearly 20% of the people going on-line will encounter one or more of the following problems.

    * Personal neglect
* Social anxiety
* Lack self esteem and self confidence
* Compulsive checking and “clicking”
* Isolation and avoidance from people
* Depression
* Relationship problems
* Academic failure

Apart from that, meeting real people and developing friendships takes a longer time and much more effort and in this century, I see young people having heavier schedules than the average adult! Piano lessons, tuition classes for all subjects, competitive sports, you name it.

Meeting people online also seems to be more convenient and cost effective for young people. They don’t have to negotiate with their parents for money, transportation and curfew time.

To a certain extend, meeting real people means taking a risk. A risk of getting hurt, embarrassed, humiliated and many more. And if that happens online, you can just change your name, age and marital status and just start over.

The reasons why young people choose online chat rooms instead of real life interactions are varied and endless.

Furthermore, some people do have serious challenges in real life social interactions such as social anxiety disorders, depression, shyness, lack self esteem and many more. The most important to bear in mind is to seek professional treatment for it. Help is readily available without needing to create all these hoopla about a new diagnosis.

Nearly any well-trained mental health professional will be able to help to slowly curve the time spent online, and address the problems or concerns that may have contributed to online overuse.

Finally, prevention is more likely to be assured if you maintain balance in your life. People go on-line looking for something missing in their life or they become involved in content and relationships on-line that begin to interfere with important routines, responsibilities and relationships. Making a conscious effort and commitment to a balanced life in crucial.

Definition
Anorexia nervosa is an eating disorder characterized by refusal to stay at even the minimum body weight considered normal for the person’s age and height. Other symptoms of the disorder include distorted body image and an intense fear of weight gain. Inadequate eating or excessive exercising results in severe weight loss. Eating disorders frequently develop during adolescence or early adulthood, but some reports indicate their onset can occur during childhood or later in adulthood. Anorexia nervosa is one of the two major types of eating disorders; the other is bulimia.

People with anorexia see themselves as overweight even though they are dangerously thin. The process of eating becomes an obsession to them. Unusual eating habits develop, such as avoiding what they perceive as high caloric food and meals, picking out a few foods and eating only these in small quantities, or carefully weighing and portioning food. People with anorexia may repeatedly check their body weight and many engage in other techniques to control their weight, such as intense and compulsive exercise or purging by means of vomiting and abuse of laxatives, enemas, and diuretics. Girls with anorexia often experience a delayed onset of their first menstrual period.

Eating disorders frequently co-occur with other psychiatric disorders, such as depression, substance abuse, and anxiety disorders. In addition, people who suffer from eating disorders can experience a wide range of physical health complications, including serious heart conditions and kidney failure, that may lead to death. Recognition of eating disorders as real and treatable diseases, therefore, is critically important.

Symptoms An estimated 0.5 percent to 3.7 percent of females and 0.1 percent to 0.2 percent of males suffer from anorexia nervosa in their lifetime. Symptoms of anorexia nervosa include:

• Refusal to maintaining body weight at or above a minimally normal weight for one’s age and height
• Intense fear of gaining weight or becoming fat, even though one is underweight
• Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of low body weight
• Infrequent or absent menstrual periods (in females who have reached puberty)

Causes Eating disorders are not due to a failure of will or behavior; rather, they are real, treatable medical illnesses in which certain maladaptive patterns of eating take on a life of their own.

Dieting to a body weight leaner than required for health is highly promoted by current fashion trends, by sales campaigns for special foods, and in some activities and professions. Researchers are investigating how and why initially voluntary behaviors, such as eating smaller or larger amounts of food than usual, move beyond control for some people and develop into eating disorders.

Studies on the basic biology of appetite control and its alteration by prolonged overeating or starvation have uncovered enormous complexity; in time, their findings may to lead to new pharmacologic treatments for eating disorders. Scientists suspect that multiple genes may interact with environmental and other factors to increase the risk of developing these illnesses.

Treatment Eating disorders can be treated, and a healthy weight can be restored. The sooner these disorders are diagnosed and treated, the better the outcome is likely to be. Because of their complexity, eating disorders require a comprehensive treatment plan involving medical care and monitoring, psychosocial interventions, nutritional counseling, and, when appropriate, medication management. At the time of diagnosis, the clinician must determine whether the person is in immediate danger and requires hospitalization.

Treatment of anorexia calls for a specific program that involves three main phases: (1) restoring weight lost to severe dieting and purging, (2) treating psychological disturbances such as distortion of body image, low self-esteem, and interpersonal conflicts, and (3) achieving either long-term remission and rehabilitation or full recovery. Early diagnosis and treatment increases the treatment success rate. Use of psychotropic medication in people with anorexia should be considered only after weight gain has been established. Certain selective serotonin reuptake inhibitors (SSRIs) have been shown to be helpful for weight maintenance and for resolving mood and anxiety symptoms associated with anorexia.

The acute management of severe weight loss is usually provided in an inpatient hospital setting, where feeding plans address the person’s medical and nutritional needs. In some cases intravenous feeding is recommended. Once malnutrition has been corrected and weight gain has begun, psychotherapy (often cognitive-behavioral or interpersonal psychotherapy) can help people with anorexia overcome low self-esteem and address distorted thought and behavior patterns. Families are sometimes included in the therapeutic process.

People with eating disorders often do not recognize or admit that they are ill. As a result, they may strongly resist getting into and staying in treatment. Family members or other trusted individuals can be helpful in ensuring that the person with an eating disorder receives needed care and rehabilitation. For some people, treatment may be long-term.

Sources:

• American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised. Washington, D.C.: American Psychiatric Association, 2000.
• American Psychiatric Association Work Group on Eating Disorders (APAWG). Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, 2000; 157(1 Suppl): 1-39.
• Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. New England Journal of MedicineAmerican Journal of Psychiatry, 1999; 340(14): 1092-8.
• National Institutes of Health, National Library of Medicine, MedlinePlus, 2006. Anorexia nervosa. http://www.nlm.nih.gov/medlineplus/ency/article/000362.htm
• The National Institute of Mental Health

Separation anxiety refers to a developmental stage in which a child experiences anxiety due to separation from the primary care giver (usually the mother). This phase is fairly standard at around 8 months of age and can last until the child is 14 months old. In young children, unwillingness to leave a parent or a caregiver is a sign that attachments have developed between the caregiver and child. The child is beginning to understand that each object (including people) in the environment is different and permanent. Young children do not yet understand time, therefore they do not know when or even if a parent will ever come back. Children at this stage struggle between the desire to strike out on their own and the need to stay safe by a parent or caregiver’s side.

While separation anxieties are normal among infants and toddlers, they are inappropriate for older children and may indicate separation anxiety disorder. To be diagnosed as such, the symptoms must cause distress or affect social, academic, or job functioning and must last at least 1 month.

Infants experience various emotions as they develop, usually in a relatively predictable sequence. Before 8 months, they are so new to the world that they cannot easily gauge what is ordinary and what may be dangerous, so new situations or experiences seem usual, not frightening.

In normal development, this early period involves establishing familiarity with the home environment, and feeling safe when parents or other known caretakers are present. After this time, lack of familiarity often produces fear as the infant recognizes that something unusual is going on.

Children recognize their parents as familiar and safe. When separated from parents, particularly when away from home, they feel threatened and unsafe. This is particularly strong when the child is between 8 and 14 months.

Separation anxiety is a normal stage in an infant’s development. It helped keep our ancestors alive and helps children learn how to master their environment. It usually ends at around age 2, when toddlers begin to understand that a parent may be out of sight right now, but they will return later. At this age, a child also tends to want to test their autonomy.

Symptoms

• Excessive distress when separated from the primary caregiver
• Worry about losing or harm coming to the primary caregiver
• Recurrent reluctance to go anywhere because of fear of separation
• Reluctance to go to sleep without the significant adult nearby
• Nightmares
• Repeated physical complaints
• Symptoms last four weeks or longer
• Symptoms begin before 18 years of age
• Impairment of school, social, or personal functioning as a result of anxiety

Causes Though the cause of separation anxiety disorder is unknown, some risk factors have been identified. Affected children tend to come from families that are very close-knit. The disorder might develop after a stress such as moving or a death in the family, or in certain, cases, a trauma (such as physical or sexual assault) might bring on the disorder. It sometimes runs in families, but the precise role of genetic and environmental factors has not been established.

To resolve the feelings of separation anxiety, a child must develop an adequate sense of safety in the environment, as well as trust in people other than their parents, and trust in the parent’s return.

Even after children have successfully mastered this developmental stage, separation anxiety may return during periods of stress. Most children will experience some degree of separation anxiety when in unfamiliar situations, for example if the child is in a hospital without parents, these symptoms are likely to return.

Treatment It is helpful for a parent to accompany the child during medical examinations or treatments whenever possible. When a parent is not available, prior exposure to the situation, such as visiting the doctor’s office before a test, will be helpful for the child. In these situations, many physicians will recommend the child taking a sedating medication. Otherwise, the child may display severe anxiety by begging, crying, screaming, and resisting treatment.

Some hospitals provide Child Life specialists who explain procedures and medical conditions to children of all ages. If your child is particularly anxious and needs significant medical care, you may consider asking your health care provider about such services.

Explain the situation and experience to the child and assure him or her that a parent is waiting, and specifically, explain WHERE the parent is waiting.

For older children, effective treatments may include counseling for the parents and child, changes in parenting techniques, and anti-anxiety medications.

Treatment for certain cases may involve individual psychotherapy, family education, and family therapy.

For younger children, there are courses of action a parent or caregiver can take:

• Try to schedule departures after naps and mealtimes since your child will be more susceptible to separation anxiety when tired, hungry, or sick.
• Prepare your child before the separation occurs by reassuring him that you will return. Treat the anxiety seriously and react with understanding, patience, and confidence: “I know you don’t want me to go away right now, but I will be back after school.” Do not tease: “You’re so silly to cry about it.” Or sound annoyed: “You make me feel so mad when you cry like that!”
• Stay calm, matter-of-fact and, sympathetic: “I know you are upset that I have to go into the kitchen, but I need to cook the chicken for dinner.” Go into the kitchen with the child on your leg if necessary.
• Create feelings of security for your toddler by giving lots of love and attention. Young children learn faster when they receive necessary attention and affection than by the parent’s taking a “learn the hard way” attitude.
• Practice short-term separations around the house. As you go into the next room out of sight, talk to your child: “Where did mommy go?” When you return, let her know: “Here I am!” These repeated separations might help your child learn that your disappearance is only temporary.
• Do not sneak away from your child. While tempting, this approach will only lead to more difficulty the next time you leave.
• Maintain control over your own anxieties. If your child senses or sees your distress at leaving, that will tell him that there must be something wrong.

Sources:

• American Academy of Pediatrics
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised
• Brazelton, T. Berry. Touchpoints: Your Child’s Emotional and Behavioral Development
• Eisenberg, Arlene, Murkoff, Heidi, & Hathaway, Sandee. What to Expect the Toddler Years
• Goenjian, A. K., Pynoos, R. S., Steinberg, A. M., et al. Psychiatric comorbidity in children after the 1988 earthquake in Armenia
• Morrison, James, DSM-IV Made Easy: The Clinician’s Guide to Diagnosis
• National Institutes of Health - National Library of Medicine

Definition
A person with panic disorder experiences sudden and repeated episodes of intense fear accompanied by physical symptoms such as chest pain, heart palpitations, breathlessness, vertigo or abdominal distress. Because these symptoms are so similar to those of a heart attack or other life-threatening medical conditions, panic disorder may not be diagnosed until extensive and expensive medical tests have ruled out other serious illnesses.

Even between panic attacks, it is common for sufferers to be extremely anxious. These people often develop phobias about places such as shopping malls—where previous episodes have occurred. They also develop fears about experiences that have set off an attack, such as an airplane flight. As panic attacks become more frequent, the person may begin to shun situations that might trigger another episode. This avoidance may lead to agoraphobia, the inability to leave familiar, safe surroundings because of intense fear and anxiety.

Approximately 2.4 million Americans, or 1.7 percent of the population between the ages of 18 and 54, suffer from panic disorder each year. Women are twice as likely as men to develop the disorder and in about half of all cases, it strikes before age 25.

Symptoms To be formally diagnosed with panic disorder, a patient must have experienced either four panic attacks in four weeks, or one or more attacks followed by at least a month of continual anxiety about having another episode. During one of these attacks, at least four of these symptoms must peak within 10 minutes.

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Shortness of breath or a sensation of smothering
• A choking feeling
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, lightheaded, or faint
• Feeling detached from oneself
• Fear of losing control or of going crazy
• Fear of dying
• Numbness or tingling sensation
• Chills or hot flashes

Causes Heredity, other biological factors, stressful events, and thinking that magnifies normal reactions play a role in the onset of panic disorder. Although the precise causes are still unknown, they are the subject of many scientific studies.

Researchers have conducted both animal and human studies to pinpoint the particular parts of the brain that are involved in anxiety and fear. Because fear evolved to deal with danger, it sets off an immediate protective response without conscious thought. This fear response is believed to be coordinated by the amygdala, a structure deep inside the brain. Although relatively small, the amygdala is quite complex, and recent studies suggest that anxiety disorders may be associated with abnormal activity in the amygdala.

Treatment Panic disorder is treated with medications and cognitive-behavioral therapy, psychotherapy that teaches patients to view their attacks in a different way and demonstrates how to reduce anxiety. Appropriate treatment by an experienced professional can reduce or prevent panic attacks in 70 to 90 percent of people with the disorder. Most patients show significant progress after just a few weeks of therapy. Relapses may occur, but they can be treated effectively.

Antidepressants

Several medications initially approved to treat depression have been found to be effective for relieving panic disorder. These antidepressants must be taken for several weeks before symptoms begin to disappear. Patients must not get discouraged or stop taking their medications, which need time to work.

Among the latest antidepressants are the selective serotonin reuptake inhibitors, or SSRIs. These work in the brain on a chemical messenger called serotonin. SSRIs tend to have fewer side effects than the earlier generation of antidepressants. Patients may be slightly nauseated or jittery when they first take SSRIs, but in time that feeling goes away. Sexual dysfunction may be a side effect of these antidepressants, but an adjustment in dosage or a switch to another SSRI may correct the problem. Patients should discuss all side effects with their doctor so that any needed changes in medication can be made.

SSRIs commonly prescribed for panic disorder in combination with obsessive-compulsive disorder, social phobia, or depression include fluoxetine, sertraline, fluvoxamine, paroxetine and citalopram. An initial low dose of these medications is gradually increased until it reaches a therapeutic level.

The antidepressants known as tricyclics are also taken at low doses, and are slowly increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating panic disorders. They are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics can have side effects such as dizziness, drowsiness, dry mouth, and weight gain. If these problems persist, the patient may request a change in dosage or a switch in medications.

The oldest generation of antidepressant medications is the monoamine oxidase inhibitors, or MAOIs. Phenelzine, the most commonly prescribed MAOI, is helpful for patients with panic disorder. People who take MAOIs must watch their diet because these antidepressants can interact with some foods and beverages, including cheese and red wine, which contain a chemical called tyramine. MAOIs also interact with certain other medications, including SSRIs. These different interactions can cause a dangerous rise in blood pressure and other life-threatening reactions.

Anti-Anxiety Medications

The group of anti-anxiety medications known as benzodiazepines, including alprazolam and lorazepam, may be prescribed for patients with panic disorder. These drugs alleviate symptoms quickly and have few side effects other than drowsiness, but because people can develop a tolerance to them—and would have to increase the dosage to keep getting the same effect—they are generally prescribed only for short time periods. Because of dependency issues, they are not recommended for patients who have abused drugs or alcohol. Reducing the dosage gradually should prevent possible withdrawal symptoms in patients going off benzodiazepines, but their anxiety may return once they stop taking the medication.

Cognitive-Behavioral and Behavioral Therapy

One form of psychotherapy that has been shown to be effective in treating several anxiety disorders, including panic, is cognitive-behavioral therapy (CBT). A major goal of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that trigger panic. It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her attacks are not really heart problems as previously feared; the tendency to put the worst possible interpretation on physical symptoms can be overcome.

The behavioral component of CBT seeks to change people’s reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. The therapist helps the patient to cope with the resultant anxiety. Eventually, after this exercise has been repeated a number of times, anxiety will diminish. If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission. You will work with the therapist to determine how much you can handle and at what pace you can proceed.

To be effective, CBT or behavioral therapy must be directed at the person’s specific anxieties and it is necessary to tailor it to the person’s particular concerns. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign “homework”—specific problems that the patient will need to work on between sessions.

CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder.

Medication may be combined with psychotherapy, and for many people this is the best approach to treatment. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn’t work, the odds are that another one will, so don’t give up.

If you have recovered from an anxiety disorder, and at a later date it recurs, don’t consider yourself a “treatment failure.” Recurrences can be treated effectively, just like an initial episode. In fact, the skills you learned in dealing with the initial episode can be helpful in coping with a setback.

Sources:

• National Institutes of Health - National Library of Medicine
• National Institute of Mental Health
• US Department of Health and Human Services

Definition
Generalized anxiety disorder (GAD) is much more than the normal anxiety people experience day to day. Without provoking, it is chronic and exaggerated worry and tension. This disorder involves anticipating disaster, often worrying excessively about health, money, family or work. Sometimes, though, just the thought of getting through the day brings on anxiety.

People with GAD can’t shake their concerns, even though they usually realize that much of their anxiety is unwarranted. People with GAD also seem unable to relax and often have trouble falling or staying asleep. Their worries are accompanied by physical symptoms, especially trembling, twitching, muscle tension, headaches, irritability, sweating, hot flashes and feeling lightheaded or out of breath.

Many individuals with GAD startle more easily than other people. They tend to feel tired, have trouble concentrating and may suffer from depression. GAD may involve nausea, frequent trips to the bathroom or feeling like there is a lump in the throat.

GAD affects about 4 million adult Americans and about twice as many women as men. The disorder comes on gradually and can begin at any time, though the risk is highest between childhood and middle age. It is diagnosed when someone spends at least six months worrying excessively about a number of everyday problems, and it is commonly treated with medications. Evidence shows that genes play a modest role in GAD.

GAD rarely occurs alone; it is usually accompanied by another anxiety disorder, depression or substance abuse. These other conditions must be treated along with GAD.

Symptoms Generalized anxiety disorder (GAD) is characterized by six months or more of chronic, exaggerated worry and tension that is unfounded or much more severe than the normal anxiety most people experience. People with this disorder usually:

• Expect the worst
• Worry excessively about money, health, family or work, when there are no signs of trouble
• Are unable to relax
• Are irritable
• Suffer from insomnia
• Have physical symptoms, such as fatigue, trembling, muscle tension, headaches, irritability or hot flashes

Causes Like heart disease and diabetes, anxiety disorders are complex and probably result from a combination of genetic, behavioral, developmental and other factors.

Using brain imaging technologies and neurochemical techniques, scientists are finding that a network of interacting structures is responsible for these emotions. Much research centers on the amygdala, an almond-shaped structure deep within the brain. The amygdala is believed to serve as a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret them. It can signal that a threat is present, thus triggering a fear response (anxiety). It appears that emotional memories stored in the central part of the amygdala may play a role in disorders involving very distinct fears, like phobias, while different parts may be involved in other forms of anxiety.

By learning more about brain circuitry involved in fear and anxiety, scientists may be able to devise more specific treatments for anxiety disorders. It someday may be possible to increase the influence of the thinking parts of the brain on the amygdala, thus placing the fear and anxiety response under conscious control. In addition, with new findings about neurogenesis (birth of new brain cells) throughout life, perhaps a method will be found to stimulate growth of new neurons in the hippocampus in people with severe anxiety.

Studies of twins and families suggest that genes play a role in the origin of anxiety disorders. However, experience also plays a part. In PTSD, for example, while trauma triggers the anxiety disorder, genetic factors may explain why only certain individuals exposed to similar traumatic events develop full-blown PTSD. Researchers are attempting to learn how genetics and experience interact in each of the anxiety disorders — information they hope will yield clues to prevention and treatment.

Treatment Medication and specific types of psychotherapy are the recommended treatments for this disorder. The choice of one or the other, or both, depends on the patient’s and the doctor’s preference, and also on the particular anxiety disorder.

Before treatment can begin, the doctor must conduct a careful diagnostic evaluation to determine whether your symptoms are due to an anxiety disorder, which anxiety disorder(s) you may have, and what coexisting conditions may be present. Anxiety disorders are not all treated the same, and it is important to determine the specific problem before embarking on a course of treatment. Sometimes alcoholism or some other coexisting condition will have such an impact that it is necessary to treat it at the same time or before treating the anxiety disorder.

If you have been treated previously for an anxiety disorder, be prepared to tell the doctor what treatment you tried. If it was a medication, what was the dosage, was it gradually increased and how long did you take it? If you had psychotherapy, what kind was it, and how often did you attend sessions? Oftentimes people believe they have “failed” at treatment, or that the treatment has failed them, when in fact it was never given an adequate trial.

When you undergo treatment for an anxiety disorder, you and your doctor or therapist will be working together as a team. Together, you will attempt to find the approach that is best for you. If one treatment doesn’t work, the odds are good that another one will. And new treatments are continually being developed through research.

Antidepressants

A number of medications that were originally approved for treating depression have been found to be effective for anxiety disorders. These must be taken for several weeks before symptoms start to fade, so it is important not to get discouraged and stop taking these medications before they’ve had a chance to work.

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. These medications act on a chemical messenger in the brain called serotonin. SSRIs tend to have fewer side effects than older antidepressants. People do sometimes report feeling slightly nauseated or jittery when they first start taking SSRIs, but that usually disappears with time. Some people also experience sexual dysfunction when taking some of these medications. An adjustment in dosage or a switch to another SSRI will usually correct bothersome problems. It is important to discuss side effects with your doctor so that he or she will know when there is a need for a change in medication. Venlafaxine, a drug closely related to the SSRIs, is useful for treating GAD.

Similarly, antidepressant medications called tricyclics are started at low doses and gradually increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating anxiety disorders. For anxiety disorders other than OCD, they are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics sometimes cause dizziness, drowsiness, dry mouth, and weight gain. When these problems persist or are bothersome, a change in dosage or a switch in medications may be needed. Tricyclics are useful in treating people with co-occurring anxiety disorders and depression. Imipramine, prescribed for panic disorder and GAD, is an example of such a tricyclic.

Antianxiety Medications

High-potency benzodiazepines relieve symptoms quickly and have few side effects, although drowsiness can be a problem. Because people can develop a tolerance to them — and would have to continue increasing the dosage to get the same effect — benzodiazepines are generally prescribed for short periods of time. People who have had problems with drug or alcohol abuse are not usually good candidates for these medications because they may become dependent.

Some people experience withdrawal symptoms when they stop taking benzodiazepines, although reducing the dosage gradually can diminish those symptoms. In certain instances, the symptoms of anxiety can rebound after stopping medication. Potential problems with benzodiazepines have led some physicians to shy away from using them, or to use them in inadequate doses, even when they are of potential benefit to the patient. Alprazolam is a benzodiazepine that is helpful for panic disorder and GAD.

Buspirone, a member of a class of drugs called azipirones, is a newer antianxiety medication that is used to treat GAD. Possible side effects include dizziness, headaches and nausea. Unlike the benzodiazepines, buspirone must be taken consistently for at least two weeks to achieve an antianxiety effect.

Other Medications

Beta-blockers, such as propanolol, are often used to treat heart conditions but have also been found to be helpful in certain anxiety disorders, particularly in social phobia. When a feared situation, such as giving an oral presentation, can be predicted in advance, your doctor may prescribe a beta-blocker to keep your heart from pounding, your hands from shaking and other physical symptoms from developing.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker or counselor to learn how to deal with problems like anxiety disorders.

Cognitive-Behavioral and Behavioral Therapy

Research has shown that cognitive-behavioral therapy (CBT), a form of psychotherapy, is effective for several anxiety disorders, particularly panic disorder and social phobia. It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her panic attacks are not really heart attacks; the tendency to put the worst possible interpretation on physical symptoms can be overcome. Similarly, a person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him or her.

The behavioral component of CBT seeks to change people’s reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. Another behavioral technique is to teach the patient deep breathing as a relaxation aid.

Behavioral therapy alone, without a strong cognitive component, has long been used effectively to treat specific phobias. Here also, therapy involves exposure. The person is gradually exposed to the object or situation that is feared. At first, the exposure may be only through pictures or audiotapes. Later, if possible, the person actually confronts the feared object or situation. Often the therapist will accompany him or her to provide support and guidance.

If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission, and you will work with the therapist to determine how much you can handle and at what pace you can proceed.

A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless. Similarly, performance of compulsive rituals in OCD gives some relief from anxiety and prevents the person from testing rational thoughts about danger, contamination, and so forth.

To be effective, CBT or behavioral therapy must be directed at the person’s specific anxieties. An approach that is effective for a person with a specific phobia about dogs is not going to help a person with OCD who has intrusive thoughts of harming loved ones. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign homework — specific problems that the patient will need to work on between sessions.

CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Group therapy is particularly effective for people with social phobia. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder; the same may be true for OCD, PTSD and social phobia.

For many people, the best approach to treatment is medication combined with therapy. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn’t work, the odds are that another one will.

If you have recovered from an anxiety disorder, and at a later date it recurs, don’t consider yourself a treatment failure. Recurrences can be treated effectively, just like an initial episode. The skills you learned in dealing with the initial episode can be helpful in coping with a setback.

Sources:

• Archives of General Psychiatry
• National Institute of Mental Health Anxiety Disorders
• British Journal of Psychiatry Supplement
• Psychiatric disorders in America: the Epidemiologic Catchment Area Study