Post-traumatic stress syndrome

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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In addition, many different psychiatric conditions such as schizophrenia, depression and post-traumatic stress syndrome have been associated with changes in the essential fatty acid levels that can easily be measured in erythrocytes or plasma [2, 3]. 

The co-3 fatty acids have numerous important functions, especially in the brain. Accordingly, a deficiency of DHA and EPA may cause dysfunction of the central nervous system and probably also the retina, thereby resulting in impaired vision. In addition, there is a variety of neurological and psychiatric disorders that have been associated with decreased levels of especially DHA and AA, such as, for example, schizophrenia and depression [3], post-traumatic stress syndrome, autism and attention deficit hyperactivity disorder. Since no primary inherited defect of essential fatty acid interconversion has yet been described, no specific explanations for the essential fatty acid concentration changes are readily available. 

Grob extolled the desirability of "using these substances in sanctioned, approved clinical settings." He emphasized that the development of research protocols for the use of psychedelics with individuals suffering from extremely refractory conditions—such as post-traumatic stress syndrome, terminal illness, and severe alcoholism—offers the most likely route toward eventually opening the door to more broadly based research. 

In addition to the acute toxic effects on the eyes, skin, and respiratory tract, both acute and longer-term neuropsychiatric effects (e.g. depression, anxiety, neurasthenia, insomnia, post-traumatic stress syndrome) have been documented for individuals exposed to sulfur mustard (Romano et al, 2008). Many of these effects have been documented for individuals exposed during noncombat (e.g. munitions plant workers) activities and are not always the result of high-level exposure that result in serious overt effects. Longer-term effects such as chronic bronchitis have been associated with occupational exposures that included episodes of acute toxicity, and delayed or recurrent keratitis may occur 8-40 years after a severe vapor exposure. Sulfur mustard-induced immunosuppression resulting in greater susceptibility to infections has also been reported. 

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. 

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. 

Although we are focusing on the primary sleep disorders, sleep disturbance quite often occurs as a symptom of another illness. Depression, anxiety, and substance abuse can impair the quality of sleep, though in the setting of chronic insomnia, other psychiatric disorders account for less than 50% of cases. Nightmares are a frequent complication of post-traumatic stress disorder (PTSD), and pain, endocrine conditions, and a host of medical illnesses can produce sleep problems. Thus, when discussing insomnia or hypersomnia, we are well advised to remember that these can be either a symptom of a psychiatric syndrome, a medical illness, or a sleep disorder. 

The full complement of anxiety syndromes including panic, generalized anxiety, obsessive-compulsiveness, and post-traumatic stress disorder can arise in the after-math of TBI. In fact, anxiety may be the most common neuropsychiatric complication of TBI. Anxiety appears to be most likely to arise when the injury occurs to the right side of the brain. The treatment alternatives for post-TBl anxiety parallel those used when treating anxiety disorders and include serotonin-boosting antidepressants, buspirone (Buspar), and the benzodiazepines (see Table 12.1). 

Pynoos, R.S. and Nader, K. (1993) Issues in the treatment of post-traumatic stress disorder in children and adolescents. In Wilson, J. and Raphael, B., eds. The International Handbook of Traumatic Stress Syndromes Washington, DC American Psychiatric Press, pp. 535-549. 

The selective serotonin reuptake inhibitors (SSRI) have been used in adults for a wide variety of disorders, including major depression, social anxiety (social phobia), generalized anxiety disorder (GAD), eating disorders, premenstrual dysphoric disorder (PMDD), post-traumatic stress disorder (PTSD), panic, obsessive-compulsive disorder (OCD), trichotillomania, and migraine headaches. Some of the specific SSRI agents have an approved indication in adults for some of these disorders, as reviewed later in this chapter. The SSRIs have also been tried in children and in adults for symptomatic treatment of pain syndromes, aggressive or irritable ( short fuse ) behavior, and for self-injurious and repetitive behaviors. This chapter will review general aspects of the SSRIs and discuss their approved indications in children and adolescents. 

Pediatric patients who develop psychiatric syndromes following acute medical illness or injury or invasive procedures (e.g., a child who develops post-traumatic stress disorder [PTSD] following a motor vehicle accident and trauma a child who develops PTSD following stem cell transplantation)... 

Although DSM-IV includes twelve types of anxiety disorders, the list of disorders in this chapter is somewhat more brief. Patients suffering from post-traumatic stress disorder (PTSD) and a related disorder, acute stress disorder often do present with a host of anxiety symptoms however, anxiety is but one aspect of PTSD. This syndrome also often includes symptoms of depression, transient psychosis, and dissociation. Thus, we have chosen not to address it here, but in a separate chapter (see chapter 10). Additionally, although obsessive-compulsive disorder (OCD) is considered to be an anxiety disorder, its pathophysiology and treatment varies enough from the anxiety disorders to warrant a separate chapter (see chapter 8). 

PMDD is not the only mental disorder that can be treated with SSRIs. There are many kinds of syndromes that SSRIs have been approved to treat. These syndromes include eating disorders, obsessive-compulsive disorder, post-traumatic stress disorder, panic disorder, and generalized anxiety disorder. Although each SSRI would probably be just as effective in treating these syndromes, the companies that own them have done extensive research to find a niche for their drug. Thus some SSRIs, such as Paxil (paroxetine), are approved for social phobia simply because the company that owns them has done the clinical studies proving it is effective and therefore should be licensed for it. Indeed, there seems to be no end to syndrome niche markets in which SSRIs can be effective. There are now efforts to market some SSRIs as treatments... 

There is also little evidence of central nervous system damage as indicated by objective evidence of neuropsychological deficits (David et al., 2002). Subjective symptoms of cognitive difficulties are, of course, very common, but just as in the literature of chronic fatigue syndrome, these do not relate very well to objective indices of neuropsychological difficulties, but do relate to symptoms of post-traumatic stress disorder or depression (David et al., 2002 Lindem et al., 2003). In conclusion, it is unlikely that the tens of thousands of Gulf War veterans with unexplained health problems are suffering from the results of exposure to neurotoxic chemicals (Spencer et al., 2001). 

Interpretable medical records and accounts only commence from the middle of the 19th Century, but from then onwards the literature does contain clinical descriptions of ex-servicemen (and it is always men) with conditions that do show considerable similarities to the Gulf narratives (Hyams et al, 1996). These condition have received many different labels - Soldier s Heart , later termed Effort Syndrome , owes its provenance to the Crimean and American Civil Wars. Shell shock and neurasthenia dominate the writings of World War I, while Agent Orange Syndrome and Post-Traumatic Stress Disorder emerged after Vietnam. 

Kang HK, Natelson B, Mahan C et al. (2003). Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans a population-based survey of 30 000 veterans. Am J... 

According to the DSM-IV, anxiety syndromes are obsessive-compulsive disorder, panic attacks for no apparent reason, phobias and post-traumatic stress disorder. Anxiety can be associated with depression or psychosis. 

Off-label use Certain psychiatric disorders including bipolar disorders and post-traumatic stress disorder, non-neuritic pain syndromes, restless leg syndrome, management of alcohol, cocaine and benzodiazepine withdrawal, and chorea in children. ... 

Cross-situational anxiety differs from the situation-specific anxiety described in the previous chapter, in that it involves multiple anxieties and worries that affect performance across a wide range of work and non-work-related situations and tasks. Examples of cross-situational anxiety include disorders such as uncued panic attacks, agoraphobia, generalized social phobia and generalized anxiety disorder (American Psychiatric Association [APA] 2000). The treatment of panic attacks and phobias was discussed in the previous chapter. This chapter thus focuses on the formulation and treatment of generalized anxiety disorder (GAD). GAD warrants specific attention since it requires quite a different CBT treatment approach from the other forms of anxiety already mentioned. Two other anxiety syndromes which have been found to be particularly prevalent among health workers, namely post-traumatic stress disorder (PTSD) and health anxiety, are also discussed in this chapter. 

There are two other work-related anxiety syndromes which have been found to be particularly prevalent among health workers. These are post-traumatic stress disorder and health anxiety. The rest of this chapter looks at the cognitive behavioural treatment of these two anxiety syndromes. 

CBT treatments for PTSD have been widely researched and experimentally validated (Foa et al. 1991 Follete et al. 1999 Horowitz 1986 Keane 1997 Kulka et al. 1990 Resick and Schnicke 1992 Resick et al 1981). Behavioural approaches emphasize the central role of anxious arousal and phobic avoidance in the PTSD syndrome. For example, the two-factor theory (Kilpatrick et al 1982) proposed that anxiety is conditioned to previously neutral cues at the time of the traumatic event. These cues then serve as subsequent triggers to the post-traumatic stress reaction. Avoidance develops in response to the anxiety and is reinforced by reduction in arousal associated with the avoidance. 

Post-traumatic stress disorder is a term that is bandied about fairly indiscriminately, and a word of caution is needed about its use. Properly conceived, it is a formal psychiatric diagnosis with strict, specific criteria. We have no idea how many people suffer from the full syndrome after medical treatment but the number is probably small. However, the incidence of some of the symptoms is probably very much greater. Many injured patients suffer from nightmares about their treatment and time in hospital, from persistent and intrusive recollections of their care and other problems, but nevertheless not from the full constellation of symptoms that makes up post-traumatic stress disorder. Depression appears to be a more common long-term response to the chronic problems of medical injury (Vincent and Coulter, 2002), although there is little research in this area. Whether people actually become depressed and to what degree will depend on the severity of their injury, the support they have from family, friends and health professionals and a variety of other faaors (Kessler, 1997). 

The five classes of drugs described above are prescribed widely to control not just depression, but a whole range of mood and mental disorders, including ADHD, anxiety, post-traumatic stress disorder, anorexia and bulimia, Tourette s syndrome, narcolepsy, insomnia, smoking cessation. .. and even chronic hiccups ... 

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