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
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.

Imagine how you might feel in each of the following situations:

• You are stuck in a traffic jam and are about to be late for an important meeting
• You are about to stand up and give a public address to 200 people
• You or your loved one have to go to the hospital for a major and risky surgical procedure
• You are working towards an important deadline and suddenly collapse from fatigue

In this century, stress affects people of all ages. Today, being stuck in traffic could be classified as “stress”. In fact, if you are the kind of person who always expects the worst to happen or you tend to push yourself very hard and have high expectations of yourself, you may be suffering from stress with very little external provocation.

Herein lies one of the major challenges with the concept of stress. It can be caused by almost any event as well as chronic circumstances such as poor work conditions. Stress sometimes seems to be an almost inevitable spin-off of just about all aspects of modern life, yet at the same time there are huge and largely unexplained differences in people’s susceptibility.

Why Manage Stress?

People don’t die from stress. They die from stress related diseases. The wide range of techniques and expertise known and practice today guarantees that our professionals consider all areas of your personality and external factors to customised a stress management programme that works best for you and not against you, leading you to a more stress - free life, better productivity at work and greater relationships.

We have known for some time that stress affects our immune systems. Many studies have shown that stress can suppress the immune system, but other studies have shown boosts in the immune system under stress. A July 2004 meta-analysis of 293 studies conducted over the past 30 years puts the pieces of the puzzle together. Psychologists Suzanne Segerstrom, Ph.D., and Gregory Miller, Ph.D. found the following:

• Stress does indeed affect the immune system in powerful ways.
• Short-term stressors boost the immune system. It seems that the “fight or flight” response prompts the immune system to ready itself for infections resulting from bites, punctures, scrapes or other challenges to the integrity of the body.
• Chronic, long-term stress suppresses the immune system. The longer the stress, the more the immune system shifted from they adaptive changes seen in the “fight or flight” response to more negative changes, first at the cellular level and later in broader immune function. The most chronic stressors – stress that seems beyond a person’s control or seems endless – resulted in the most global suppression of immunity. Almost all measures of immune system function dropped across the board.
• The immune systems of the elderly or those already sick are more subject to stress-related changes.

In reaching these conclusions the authors looked at the effects of the various stressors on different immune responses, such as “natural” and “specific” immunity. They summarized the results of the studies that looked at each of these types of stress:

Natural immunity produces quick-acting, all-purpose cells that can attack many pathogens; they bring fever and inflammation.

The body takes a few days to mount a more specific attack on particular invaders with specific immunity. This response includes lymphocytes (T-cells and B cells). Specific immunity has both cellular responses, which fight pathogens that get inside cells (such as viruses), and humoral responses, which fight pathogens that stay outside cells, such as bacteria and parasites. Segerstrom and Miller were able to assess how different types of immune response correlated with different types of stress because researchers have identified the blood markers of these different immune responses.

They divided stressors into different types:

Acute time-limited stressors: lab challenges such as public speaking or mental math.

Brief naturalistic stressors: real-world challenges such as academic tests.

Stressful event sequences: a focal event such as loss of a spouse or major natural disaster gives rise to a series of related challenges that people know at some point will end.

Chronic stressors: pervasive demands that force people to restructure their identity or social roles, without any clear end point – such as injury resulting in permanent disability, caring for a spouse with severe dementia, or being a refugee forced from one’s native country by war.

Distant stressors: traumatic experiences that occurred in the distant past yet can continue modifying the immune system because of their long-lasting emotional and cognitive consequences, such as child abuse, combat trauma or having been a prisoner of war. Much of their analysis goes on to review the similarities and differences among the 293 studies that they examined. These studies included a total of 18,941 subjects. “Stressful event sequences” appeared to be weakly associated with different immune consequences, depending on the type of event. There appeared to be different patterns for grief than for trauma, for example, but the associations weren’t strong enough for the authors to make new claims. They recommended further study.

The authors did find that the most chronic stressors - those which change people’s identities or social roles, are more beyond their control and seem endless - were associated with the most global suppression of immunity. In such situations almost all measures of immune function dropped across the board. The longer the stress, the more the immune system shifted from potentially adaptive changes (such as those in the acute “fight or flight” response) to potentially detrimental changes, at first in cellular immunity and then in broader immune function. This analysis suggests that stressors that turn a person’s world upside down and appear to offer no hope for the future probably have the greatest psychological and physiological impact.

The authors also found that age and disease status affected a person’s vulnerability to stress-related decreases in immune function. It seems that illness and age make it harder for the body to regulate itself.

This is a ground-breaking meta-analysis that helps us understand the complex relationship between stress and the immune system. It should lead to new treatments and to better stress management programs, especially for patients with HIV or other disorders that compromise immunity.

Reference: Segerstrom & Miller, 2004. Psychological Stress and the Human Immune System: A Meta-Analytic Study of 30 Years of Inquiry Psychological Bulletin, 130, 4.

We all feel sad sometimes. Sadness is a normal emotion that can make life more interesting. Much art and poetry is inspired by sadness and melancholy. Sadness almost always accompanies loss. When we say goodbye to a loved one we usually feel sad. The sadness is even deeper if a close relationship has ended or a loved one has died.

Sadness also helps us appreciate happiness. When our mood eventually changes from sadness toward happiness the sense of contrast adds to the enjoyment of the mood.

Here are some ways to experience normal sadness in a healthy way and to allow this emotion to enrich your life:

• Allow yourself to be sad. Denying such feelings may force them underground, where they can do more damage with time. Cry if you feel like it. Notice if you feel relief after the tears stop.

• If you are feeling sad, plan a sadness day. Plan a day or evening just to be alone, listen to melancholy music, and to observe your thoughts and feelings.
  Planning time to be unhappy can be actually feel good. It can help you ultimately move into a more happy mood.

• Think about the context of the sad feelings. Are they related to a loss or an unhappy event? It is usually not as simple as discovering the “cause” of the sadness, but it may be possible to understand factors involved.

• Sadness can result from a change that you did not expect, or it can signal the need for a change in your life. Change is usually stressful, but it is necessary for growth.

• Know when sadness turns into depression. Get help if this happens rather than getting stuck in it.

Get help if you experience more than a couple of the following symptoms of depression:

• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Decreased energy, fatigue, being “slowed down”
• Difficulty concentrating, remembering, making decisions
• Insomnia, early-morning awakening, or oversleeping
• Appetite and/or weight loss or overeating and weight gain
• Thoughts of death or suicide; suicide attempts
• Restlessness, irritability
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain.

It is the end of our fourth session and Ming gets up and walks to the door. After the customary “see you next week,” she adds:”Thank you so much for these sessions. I really feel a lot better afterward.”

Uh oh.

A common misunderstanding about therapy is that its function is to help us “feel better” each week. Many equate psychotherapy with the day spa where we enter with tension and leave feeling relaxed and refreshed. Sometimes this is the case. But much of the time we leave with a greater understanding of the gravity, severity and prevalence of our issues. We think we have one problem but realize we have five. This does not always feel better; it can feel much worse.

That is why my response to Ming’s comment is “uh oh.” If she is expecting to always feel good after her sessions, she may be setting herself up for disappointment.

In the first few sessions the therapist and client are getting to know one another and explore the issues. If there is a good connection between them, clients often feel relieved, supported and hopeful. The issue they have held inside is finally being addressed, the therapist seems to care and understand without judgment, and there is a real sense that progress can be made. This feels good.

As the work continues, things often get worse before they get better. In his book The Heart of Psychotherapy, psychologist George Weinberg writes:

“In the course of psychotherapy, we help the person see the generality of his problem…As patients see, ‘This problem is more pervasive than I thought,’ they are occasionally disheartened somewhat…And to the extent that the problem was broader than they thought, the gain is greater when it is resolved.” (p. 18)

Ming entered therapy to better understand her difficulty with dating. She describes herself as a “serial monogamist” who dates men until her suspicions lead her to believe he is untrustworthy. In these first three sessions, she has been able to tell her story, vent a bit about her lousy relationships, and feel that I am working to understand and assist her. She truly feels better after the session because she was heard and supported. But our future sessions may go into uncomfortable territory.

We might discover that her suspicions have cost her many friendships as well. We could find that painful events in her childhood made trust very difficult to maintain. We might even find that her issues extend to herself - that she has a hard time trusting her own thoughts and feelings, and she projects this onto other people. These harsh realisations will not leave her with a spring in her step. This is the “disheartened” feeling Weinberg mentions.

I have seen many clients get to this point in therapy and decide to stop. We have opened several cans of worms and they simply feel overwhelmed. I do not blame them for feeling this way, but encourage them to stick with it. This is the pain we endure to achieve the gain. I equate this process with a person organizing a long-forgotten basement or closet - when you start pulling stuff out it is easy to feel overwhelmed by the clutter and sheer volume of material.

Leave it now, and you are stuck with a big mess on your hands. But push through and you will see gradual progress and eventually a more organised space.

I believe the goal of psychotherapy is to help each client grow in awareness, understanding, responsibility and acceptance. Rather than helping her “feel better” an hour a week, I hope therapy helps Ming know who she is, why she does what she does and feels how she feels. I hope it helps her realistically appraise her strengths and limitations, giving her the freedom to choose relationships, jobs and activities that bring her joy, accomplishment and contentment.

Recent research has linked lack of sleep to a wide range of ailments, including memory problems and obesity. Learn more about some of the top reasons why you should get a good night’s sleep.

Sleep May Help You Learn More Effectively

Researchers have long believed that sleep plays an important role in memory, but recent evidence suggests that getting a good night’s sleep can improve learning. In one study, researchers found that depriving students of sleep after learning a new skill significantly decreased memory of that skill up to three days later (Winerman, 2006). Known as the memory consolidation theory of sleep, this notion proposes that sleep serves to process and retain information learned earlier while awake. While there is research both for and against the theory, many studies have shown that sleep can play an important role in certain types of memory.

Research Suggests Sleep Deprivation May Contribute to Obesity

In addition to affecting memory and learning, lack of sleep has been linked to body weight. In one 2005 study published in the Archives of Internal Medicine, overweight participants were found to sleep less than participants of a normal weight (Vorona et al., 2005). Brandon Peters, About.com’s Guide to Sleep Disorders, reports that poor sleep at age 30 months can predict obesity at age seven. While researchers do not yet understand exactly how sleep disruption impacts appetite and metabolism, getting a good night’s sleep certainly can’t hurt your weight loss or weight maintenance efforts.

Sleep is Important for Managing Stress

According to many experts, most people need between seven and eight hours of sleep each night. What happens when you don’t get enough sleep? Symptoms such as moodiness, anxiety, aggression and increased stress levels can result. About.com’s Guide to Stress Management, Elizabeth Scott, suggests taking “power naps” to combat drowsiness, reduce stress and increase productivity. While sleeping more certainly won’t eliminate all stress, it can help increase your readiness to cope with the stress of day-to-day life.

Sleep Can Help You Make Better Decisions

Have you ever found yourself struggling to make relatively simple decisions after a night of poor sleep? In addition to reducing such things as response time and accuracy, lack of sleep has also been linked to difficulty making good decisions. In one study published in the journal Sleep, researchers found that sleepiness has a serious impact on the ability to make effective decisions (Roehrs, 2004). Another study suggested that sleep impairs decision-making when gambling by increasing expectations of potential gains while minimizing losses. If you’re facing a challenging decision, make sure that you are well rested so that you will be at your best.

References

_{American Academy of Sleep Medicine (2007, May 5). Sleep Deprivation Can Threaten Competent Decision-making. ScienceDaily. National Sleep Foundation. (2008). Longer Work Days Leave Americans Nodding Off On the Job.}

_{Peters, B. (2008). Why so fat and tired?}

_{Roehrs, T., Greenwald, M., Roth T. (2004). Risk-taking behavior: effects of ethanol, caffeine, and basal sleepiness. Sleep, 27(5), 887-93.}

_{Vorona, R. et al. (2005, Jan. 10). Overweight and Obese Patients in a Primary Care Population Report Less Sleep Than Patients With a Normal Body Mass Index. Archives of Internal Medicine, 165, 25-30.}

_{Winerman, L. (2006). Let’s sleep on it: A good night’s sleep may be the key to effective learning, says recent research. Monitor on Psychology.}