Post traumatic stress disorder

Generalized Social Anxiety Disorder, Maintenance Phase Treatment. 

There has been little formal study of maintenance therapy for social anxiety disorder. Limited data indicates that continued pharmacotherapy provides significant prophylactic protection against relapse. Furthermore, growing evidence indicates that patients with social anxiety disorder experience a high rate of relapse after treatment discontinuation. CBT, however, may afford continued prophylactic benefit long after conclusion of the therapy, though the data to support this contention is limited. 

The conventional recommendation is to continue pharmacotherapy for at least 9-12 months after achieving remission. Medication might then be tapered slowly over several weeks, if not months. In the event of relapse after discontinuation of maintenance therapy, long-term therapy is advised. 

Natural disasters, catastrophic illnesses, incest, rape, and assault are but a few common life experiences that can unleash a wave of intense emotional stress. Acute stress reactions or traumatic neuroses were first addressed in the clinical literature during World War I, as thousands of soldiers returned from the front suffering from severe anxiety, insomnia, and nightmares attributed to shell shock. The understanding of acute stress reactions was furthered by the pioneering work of Eric Lindeman. 

In 1976, psychiatrist Mardi Horowitz published a book entitled Stress Response Syndromes. In this landmark publication. Dr. Horowitz carved out a very useful model for understanding what appears to be a common pattern of human emotional 

Let s take a look at the stress response syndrome (see figure 10-A). The full stress response syndrome is seen most clearly in situations where the stressful event is sudden and intense. Although a host of events may trigger this reaction. Each of the boxes in the figure represents a state of mind or emotion. The stress response reaction begins with awareness of some painful event. 

The first phase is Outcry. In a sense, a state of outcry is simultaneously an eruption of intense, unpleasant emotion (sadness, fear, and so on) and denial ( I can t believe it... it can t be true ). The person is in a state of shock and may be engulfed by very strong emotions. This phase of the reaction can last for a few minutes, a few hours, or a few days. Rather quickly, the person moves into phase two, which may be either a state of intrusion or a state of denial. 

Phase two includes a stage of Denial. Denial may occur directly following Outcry or may come on the heels of a period of intrusion. As noted earlier, denial is a state of emotional numbness people often feel nothing. Other symptoms during the 

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Indeed, 5-HT is also a substrate for the 5-HT transporter, itself an important player in the treatment of depression, and more recently for the whole range of anxiety disorders spectrum (GAD, OCD, social and other phobias, panic and post-traumatic stress disorders). It is the target for SSRIs (selective serotonin reuptake inhibitors) such as fluoxetine, paroxetine, fluvoxamine, and citalopram or the more recent dual reuptake inhibitors (for 5-HT and noradrenaline, also known as SNRIs) such as venlafaxine. Currently, there are efforts to develop triple uptake inhibitors (5-HT, NE, and DA). Further combinations are possible, e.g. SB-649915, a combined 5-HTia, 5-HT1b, 5-HT1d inhibitor/selective serotonin reuptake inhibitor (SSRI), is investigated for the treatment of major depressive disorder. 

OCD, panic disorder, general anxiety disorder, social anxiety disorder, post-traumatic stress syndrome Depression, OCD, panic disorders, post-traumatic stress disorder... 

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Post-traumatic stress disorder (PTSD) is a severe condition with a lifetime prevalence of about 12.5% in women and 6.2% in men (Pigott, 1999). About one in four individuals exposed to trauma develop the syndrome. Drug treatments are still being developed, mostly using antidepressants. Few systematic data are available on the pharmacoeconomics of the condition. 

McCrone P, Knapp M, Cawkill P (2001). Post-traumatic stress disorder (PTSD) in the UK Armed Forces health economic consideration. In press. 

Bandelow B, Zohar J, Hollander E, et al. Guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders. World J Biol Psychiatry 2002 3 171-199. 

Parry-Jones, B. and Parry-Jones, W., Post-traumatic stress disorder Supportive evidence from an eighteenth century natural disaster. Psychological Medicine 24(1), 15-27, 1994. 

Kramer, T., Lindy, J., Green, B., Grace, M. and Leonard, A., The lombordity of post traumatic stress disorder and suicidality in Vietnam veterans. Suicide and Life Threatening Behaviors 24(1), 58, 1994. 

Spiro, A., Schnurr, P. and Aldwin, C., Combat related post traumatic stress disorder symptoms in older men. Psychology and Aging 9(1), 17-26, 1994. 

A prospective, randomized, placebo-controlled trial of paroxetine in adults with chronic post-traumatic stress disorder (PTSD) was recently conducted (Marshall etal., 2007). The subjects were New Yorkers, predominantly female (67%) and Hispanic (65.4%). Seventy subjects entered the study and after a one week placebo lead-in, 52 subjects were randomized to placebo or paroxetine for ten weeks. The subjects were treated with a flexible dosage design (mean dosage, 40.4 mg/day). Dropout rates were 32% for paroxetine and 51.9% for placebo. There were no differences in rates of adverse effects between treatment arms. Paroxetine was superior to placebo in ameliorating the primary symptoms of PTSD (56% vs. 22.2%). 

Panic disorder Agoraphobia with panic disorder Agoraphobia without panic disorder Specific phobia Social phobia Generalised anxiety disorder Mild anxiety and depression disorder Obsessive compulsive disorder Acute stress disorder Post-traumatic stress disorder (PTSD) Adjustment disorder Panic disorder without agoraphobia Panic disorder with agoraphobia Agoraphobia Specific phobia Social phobia (also called social anxiety disorder) Generalised anxiety disorder Obsessive compulsive disorder Acute stress disorder Post-traumatic stress disorder (PTSD)... 

Prozac (Fluoxetine) Depression Obsessive-compulsive disorders Panic Post-traumatic stress disorder 2.9 1.0 1988 - US 1989 - UK Once daily... 

The development of mild forms of anxiety and neuroveg-etative and/or cognitive responses to stress may represent an adaptive evolutionary step against environmentally (external) or self-triggered (internal) threats, but maladaptive reactions have also emerged in human evolution. Thus, anxiety disorders are maladaptive conditions in which disproportionate responses to stress, or even self-evoked responses, are displayed. Anxiety disorders are one of the most frequent psychiatric illnesses, and have a lifetime prevalence of 15- 20% [1, 89]. The most common presentations are generalized anxiety disorder, with a lifetime prevalence rate of close to 5% [1, 89] social anxiety disorder, with very variable lifetime prevalence rates ranging from 2 to 14% [90] panic disorder, with rates from 2 to 4% [1,89] and post-traumatic stress disorder (PTSD), with a prevalence rate close to 8%. Specific phobias, acute stress and obsessive-compulsive behavior are other clinical presentations of anxiety disorders. 

PCPA parachlorophenylalanine PTSD post-traumatic stress disorder... 

In June of 2005, DHEC mailed a follow-up questionnaire to 280 people who were interviewed. Of the 94 respondents 23 percent had been hospitalized, 83 percent still were experiencing symptoms they felt related to the chlorine spill, 52 percent were taking medication for problems they felt were related to chlorine exposure, 51 percent were under a doctor s care for problems they felt were related to chlorine exposure, and 48 percent screened positive for post-traumatic stress disorder. 

There are some people who would look at my situation and think my health problems were the result of a post-traumatic stress disorder, or depression or both. As a child I was abused, and nearly died from anorexia before the age of ten. 

My father became very concerned, and he took me to another hospital where I stayed for four or five days. I met a really good psychiatrist there who worked with me for a year or so after I left the hospital. He specialized in post-traumatic stress disorder. 

In exceptional cases, there may be a risk of individuals developing post-traumatic stress disorder in such circumstances early intervention and professional counselling are essential. 

The mood disorders were once called affective disorders and are grouped into two main categories unipolar and bipolar. The unipolar depressive disorders include major depressive disorder and dysthymic disorder the bipolar disorders include bipolar 1, bipolar II, bipolar not otherwise specified, and cyclothymic disorder. Other mood disorders are substance-induced mood disorders and mood disorders due to a general medical condition. In addition, mood disturbance commonly occurs as a symptom in other psychiatric disorders including dementia, post-traumatic stress disorder, substance abuse disorders, and schizophrenia. 

The differential diagnosis of depression is organized along both symptomatic and causative lines. Symptomatically, major depression is differentiated from other disorders by its clinical presentation or its long-term history. This is, of course, the primary means of distinguishing psychiatric disorders in DSM-1V. The symptomatic differential of major depression includes other mood disorders such as dysthymic disorder and bipolar disorder, other disorders that frequently manifest depressed mood including schizoaffective disorder, schizophrenia, dementia, adjustment disorder, and post-traumatic stress disorder, and, finally, other nonpsychiatric conditions that resemble depression such as bereavement and medical illnesses like cancer or AIDS. 

Panic disorder is characterized by the occurrence of panic attacks that occur spontaneously and lead to persistent worry about subsequent attacks and/or behavioral changes intended to minimize the likelihood of further attacks. Sporadic panic attacks are not limited, however, to those with syndromal panic disorder as they do occur occasionally in normal individuals and in those with other syndromal psychiatric disorders. The hallmark of panic disorder is that the panic attacks occur without warning in an unpredictable variety of settings, whereas panic attacks associated with other disorders typically occur in response to a predictable stimulus. For example, a person with acrophobia might experience a panic attack when on a glass elevator. A patient with obsessive-compulsive disorder (OCD) with contamination fears may have a panic attack when confronted with the sight of refuse, and a combat veteran with post-traumatic stress disorder (PTSD) may experience a panic attack when a helicopter flies overhead or an automobile backfires. 

Post-traumatic Stress Disorder (PTSD). The same distinction holds true for PTSD. Reminders of the tranma (e.g., sexual intimacy for a rape survivor loud noises for a combat veteran) can trigger panic attacks. Furthermore, PTSD is associated with a variety of avoidant behaviors that can resemble agoraphobia. In the case of PTSD, the avoidance is specifically targeted at reminders of the trauma. For example, places or people who in some way cue memories of the traumatic event are avoided. As for agoraphobia, the avoidance tends to be less specific. It is any sitnation from which it would be difficult to escape should a panic attack occur that is avoided. 

Post-traumatic Stress Disorder (PTSD). Persistent anxiety is an invariable feature of both GAD and PTSD. In the case of GAD, the worry relates to a wide array of situations. As for PTSD, the worry relates to a perceived threat that is often directly, or at least indirectly, reminiscent of the previous trauma. 

TABLE 5.10. Diagnostic Criteria for Post-traumatic Stress Disorder... 

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