09_Semple_Chap09.indd 373 12/7/2012 3:34:08 PM CHAPTER 9 Anxiety and stress-related disorders 374 or autonomic symptoms \200\224B-blockers (e.g. cardiovascular symptoms atenolol); other licensed treatments pregabalin (start 150mg/day; m ax 600mg/day; in divided doses). Physical: psychosurgery (very rare) \200\224for severe/intractable anxiety. Course Chronic and disabling, prognosis generally poor, remission rates low (730% after 3yr s, with treatment); 6-yr outcome \200\22468% mild residual symptoms, 9% severe persistent i mpairment. Often comorbidity becomes more sig- ni \201 cant (esp. alcohol misuse) and this worsens the prognosis. Box 9.5 Medical conditions associated with anxiety-like symptoms \200 \200 \200 \200 : arrhythmias, IHD, mitral valve disease, cardiac failure. CVS Respiratory Neurological Endocrine phaeochromocytoma. Miscellaneous : asthma, COPD, HVS, PE, hypoxia. : TLE, vestibular nerve disease. : hyperthyroidism, hypoparathyroidism, hypoglycaemia, : anemia, porphyria, SLE, carcinoid tumor, pellagra. Box 9.6 Prescribed medications causing anxiety-like symptoms \200 \200 \200 CVS Respiratory CNS agents, antidepressants, antipsychotics, disul \201 ram reactions, wit hdrawal from BDZs and other sedatives. Miscellaneous : antihypertensives, anti-arrhythmics. : bronchodilators, A 1/B-adrenergic agonists. : anesthetics, anticholinergics, anticonvulsants, anti-Parkinsonian : levothyroxine, NSAIDs, antibiotics, chemotherapy. 09_Semple_Chap09.indd 374 12/7/2012 3:34:08 PM GENERALIZED ANXIETY DISORDER 375 1 Suarez L, Bennett SM, Goldstein CM, et al. (2008) Understanding anxiety disorders from a \200\230 triple vulnerability \200\231 framework. In: Antony MM and Stein MB, eds, Handboo k of anxiety and anxiety disor- ders. New York: Oxford University Press. 2 NICE recommends SSRIs as \201 rst-line treatment (+CBT) and does not recommend BDZs for more than 2 \200 \2234wks. See: M http://www.nice.org.uk/nicemedia/live/13314/52599/52599.pdf 3 Buspirone sh ould be considered as an alternative to BDZs when sedative effects are unwanted (e.g. drive rs of vehicles, pilots, machine operators), in patients with a personal/family history of d rug misuse, or for those already taking other CNS depressants. 09_Semple_Chap09.indd 375 12/7/2012 3:34:09 PM CHAPTER 9 Anxiety and stress-related disorders 376 Obsessive \200\223compulsive disorder (OCD) Essence A common, chronic condition, often asso ciated with marked anxiety and depression, characterized by \200\230obsessions \200\231 (s ee b p. 101) and \200\230compul- sions \200\231 (see b p. 89). Obsessions/compulsions must cause distress or interfere with the person \200\231s social or individual functioning (us ually by wast- ing time), and should not be the result of another psychiatric disorder. At some point in the disorder, the person recognizes the symptoms to be excessive or unreasona ble. Content of obsessions/compulsions Checking (63%), washing (50%), contamination (45%), doubt ing (42%), bodily fears (36%), counting (36%), insistence on symmetry (31%), aggressive tho ughts (28%). Epidemiology Mean age: 20yrs, 70% onset before age 25yrs, 15% after age 35yrs, 5=4, prevale nce: 0.5 \200\2233% of general population. Etiology of OCD \200 Neurochemical: 5-HT1B, or 5-HT/DA interaction. Immunological: e.g. a gainst basal ganglia peptides \200\224as in Sydenham \200\231s chorea. Imaging: CT and MRI: hypermetabolism in orbitofrontal gyrus, basal ganglia (caudate nuclei), and cingulum that \200\230normalizes \200\231 following successful treatment (either pharmacological or psyc hological). Genetic: relatives affected, MZ: 50 \200\22380% DZ: 25%), no candidate genes as yet identi \201 ed, but polymorphisms of 5-HT1BB have been replicated. defective arousal system and/or inability to control Psychological: unpleasant internal states. Obsessions ar e conditioned (neutral) stimuli, associated with an anxiety-provoking event. Compulsions ar e learned (and reinforced) as they are a form of anxiety-reducing avoidance. Psychoanalytic al: to be the result of regression from oedipal stage to pre-genital anal \200\223erotic st age of development as a defense against aggressive or sexual (unconscious) impulses. Associ ated defenses: isolation, undoing, and reaction formation. Symptoms occur when these defens es fail to contain the anxiety. dysregulation of the 5-HT system (possibly involving cell-mediated autoimmune factors may be associated bilateral reduction in caudate size. PET/SPECT: suggested by family and twin studies (3 \200\2237% of \201 rst-degree Freud coined the term \200\230obsessional neurosis \200\231, thought Associations Avoidant, dependent, histrionic traits (740% of cases), anankastic/obses- sive \200\223compulsive traits (5 \200\22315%) prior to disorder. In schizophrenia, 5 \200\2234 5% of patients may present with symptoms of OCD (schizo-obsessives \200\224 poorer prognosi s). Sydenham \200\231s chorea (up to 70% of cases) and other basal ganglia disorders (e.g. Tourette \200\231s syndrome, post-encephalitic Parkinsonism). 09_Semple_Chap09.indd 376 12/7/2012 3:34:09 PM OBSESSIVE \200\223COMPULSIVE DISORDER 377 Comorbidity Depressive disorder (50 \200\22370%), alcohol- and drug-related disorders, soci al phobia, speci \201 c phobia, panic disorder, eating disorder, PTSD, tic disorder ( 40% in juvenile OCD) or Tourette \200\231s syndrome. Differential diagnosis \200\230Normal \200\231 (but recurrent) thoughts, worries, or habit s (do not cause dis- tress or functional impairment); anankastic PD/OCD; schizophrenia; pho - bias; depressive disorder; hypochondriasis; body dysmorphic disorder; trichotillomania. Management1 \200 Psychological CBT \200\224 \200 approach, including exposure and respo nse prevention (ERP). Behavioral therapy \200\224 response prevention useful in ritualistic behavior; thought stopping may help in ruminations; exposure techniques for obsessions. Co gnitive therapy \200\224 Psychotherapy \200\224supportive: of groups); psychoanalytical: no unequivocal evidence of effectiveness (insight-orientated psychotherapy may be useful in s ome patients). recommended by NICE, but essentially takes a behavioral \200 so far not proven effective. valuable (including family members, use Pharmacological: \200 Antidepressants \202 uoxetine (20 \200\22360mg/day), \202 uvoxamine (100 \200\223300mg/ day), sertraline (150mg/day), or paroxetine (40 \200\22360mg/day) should be considered \201 rst-line (no clear superiority of any one agent, high doses usually needed, at least 1 2wks for treatment response, long-term therapy). Clomipramine (e.g. 250 \200\223300mg) has speci \201 c anti-obsessional action (NICE second-line choice). Other (unlicensed) agents include citalopram (20 \200\22360mg/day; NICE recommended alone or in combination with clom ipramine), venlafaxine (225 \200\223300mg). Augmentative strategies: pimozide) \200\224esp. if psychotic features, tics, or schizotypal traits (less evidence for olanzapine, quetiapi ne, aripiprazole); buspirone/short- term clonazepam (not NICE recommended) \200\224if marke d anxiety. SSRIs (licensed): escitalopram (10 \200\22320mg/day), antipsychotic (risperidone, haloperidol, Physical: \200 ECT \200\224 Psychosurgery \200 intractable cases (i.e. treatment-resist ant: 2 antidepressants, 3 combination treatments, ECT, and behavioral therapy), where the p atient can give informed consent \200\224e.g. stereotactic cingulotomy (reported up to 65% success). In theory, disrupts the neuronal loop between the orbitofrontal cortex and the ba sal ganglia. Deep brain stimulation (DBS) (severe refractory cases). consider if patient suicidal or severely incapacitated. may be considered for severe, incap acitating, ef \201 cacy remains to be established Course Often sudden onset (after stressful event, e.g. loss, pregnancy, sexual problem), pr esentation may be delayed by 5 \200\22310yrs due to secrecy, symp- tom intensity may \202 uctuate (contact-related/phasic) or be chronic. 09_Semple_Chap09.indd 377 12/7/2012 3:34:09 PM CHAPTER 9 Anxiety and stress-related disorders 378 Outcome 20 \200\22330% signi \201 cantly improve, 40 \200\22350% show moderate improvement, but 20 \200\22340% have chronic or worsening symptoms. Relapse rates are high after stopping medi cation. Suicide rates increased esp. if there is secondary depression. Prognostic factors \200 Poor prognosis: male, presence of tics, bizarre compulsions, hoarding, symmetry, comorbid d epression, delusional beliefs or over-valued ideas, personality disorder (esp. schizotypal PD). Better prognosis: precipitating event, episodic symptoms, less avoidance. giving in to compulsions, longer duration, early onset, good premorbid social and occupational adjustment, a 09_Semple_Chap09.indd 378 12/7/2012 3:34:09 PM OBSESSIVE \200\223COMPULSIVE DISORDER 379 1 NICE guideline: M http://guidance.nice.org.uk/CG31/NICEGuidance/pdf/English 09_Semple_Chap09.indd 379 12/7/2012 3:34:09 PM CHAPTER 9 Anxiety and stress-related disorders 380 Exceptional stressors and traumatic events ICD-10 de \201 nition \200\230Common-sense \200\231 approach: \200\230a stressful event or situation of an excep- tionally thre atening or catastrophic nature, which is likely to cause pervasive distress in almost anyon e \200\231. Includes traumatic events (e.g. rape, bombing, criminal assault, natural catast rophe), and unusual sudden changes in the social position and/or network of the individual (e.g. domestic \201 re, multiple bereavement). DSM-IV de \201 nition Narrower criteria. Traumatic event must have involved actual or thre at- ened death or serious injury, or threat to the physical integrity of self or others. Th e person \200\231s response to the traumatic event must have involved intense fear, helples sness, or horror (disorganized/agitated behavior in children). Type I and Type II trauma (see Box 9.7) The ICD-10 and DSM-IV de \201 nitions describe wha t has been termed: \200 Type I trauma isolated (often rare) traumatic experiences of sudden, surprising, devastatin g nature, with limited duration. : due to sustained and repeated ordeal stressors Type II t rauma (series of traumatic events or exposure to prolonged trauma); may be variable, multip le, chronic, repeated, and anticipated, usually of intentional human design (e.g. ongoing p hysical or sexual abuse, combat). May lead to \200\230complex PTSD \200\231. Symptoms incl ude: somatization, dissociation, detachment from others, restricted range or dysregulation of affect, emotional lability (poor impulse control, self-destructive behavior, pathologica l patterns of relationships), and emotional numbing. ICD-10 acknowledges this type of react ion with the diagnosis \200\230enduring personality changes after catastrophic experience \200\231, whereas DSM-IV does not currently include the much debated diagnosis \200\230DES NOS \200\231 (disorders of extreme stress not otherwise speci \201 ed). : single, dangerous and overwhelming events comprising How common are these events? Using DSM-IV criteria, up to 80% of men and 75% of women1 expe ri- ence at least one traumatic event in their lifetime (but see cautionary notes in Box 9. 8). Common events include sudden death of a loved one, accidents, \201 re, \202 ood, na tural disasters, or being a witness to severe injury (or murder). 09_Semple_Chap09.indd 380 12/7/2012 3:34:09 PM EXCEPTIONAL STRESSORS AND TRAUMATIC EVENTS 381 Box 9.7 Continued debate \200 Both of the ICD-10 and DSM-IV de \201 nitions fail to address \200\230low- magnitude stre ssors \200\231 (e.g. divorce, job loss, failing exams) even though 0.4% of the population m ay develop \200\230PTSD-like \200\231 symptoms.1 Equally, \200\230common \200\231 events (e.g. RTAs, sexual assault) quite often lead to PTSD-like symptoms. Even perpetrators (albe it \200\230unwilling \200\231) of traumatic events (e.g. war-related crimes, torture) may experience PTSD-like symptoms (associated with feelings of shame or guilt). Emphasis on lif e-threatening events/threats to physical integrity may also be too restrictive. The percept ion of threat to, or loss of, autonomy and mental defeat may actually be more signi \201 c ant than physical assault \200\224seen in studies of victims of sexual/physical assault and political prisoners. Whether diagnosis should be made on the basis of symptom clusters, ra ther that any de \201 nition of what constitutes a \200\230valid \200\231 traumatic event becomes academic when a patient presents with clinically signi \201 cant problems (althou gh it may generate much heat when issues of compensation are involved). 1 McNally RJ (2000) Post traumatic stress disorder. In: Millon T, Blaney PH, David RD, eds, Oxford textbook of psychopathology. Oxford: Oxford University Press. XBox 9.8 Recovered and false memories \200 Survivors of traumatic events, esp. child abuse, sometimes claim to have recovered memories after a long period of time. Organizations such as the False Memory Syndrome Foundation (U SA) and the False Memory Society (UK) suggest that many, if not all, of these recovered mem ories are the product of inappropriate therapeutic suggestion. The possibility of false acc usations of supposed perpetrators, disruption of families, and accusations of malpractice a gainst therapists have meant that debate is polarized and subsequently the literature is ve ry dif \201 cult to interpret. Few would disagree with Lindsay & Read \200\231s summary (1 995): reading, the scienti \201 c evidence has clear implications memories recovered via suggestive memory work by people who initially denied any such history should be viewe d with skepticism, but there are few grounds to doubt spontaneously recovered memories of c ommon forms of child sexual abuse or recovered memories of details of never-forgotten abuse . Between these extremes lies a gray area within which the implications of existing scienti \201 c evidence are less clear and experts are likely to disagree. \200\231 1 \200\230In our 1 Lindsay DS and Read JD (1995) \200\230Memory work \200\231 and recovered memories of chi ldhood sexual abuse: scienti \201 c evidence and public, professional and personal issues. Psychol Publ Policy Law 1: 846 \200\223908. 1 Stein MB, Walker JR, Hazen AL, et al. (1997) Full and partial posttraumatic stress disord er: \201 nd- ings from a community survey. Am J Psychol 154: 1114 \200\22319. 09_Semple_Chap09.indd 381 12/7/2012 3:34:09 PM CHAPTER 9 Anxiety and stress-related disorders 382 Acute stress reaction (ICD-10) Essence A transient disorder (lasting hours or days) that ma y occur in an indi- vidual as an immediate (within 1hr) response to exceptional stress (e.g . natural catastrophe, major accident, serious assault, warfare, rape, multiple bereavement , \201 re). The stressor usually involves severe threat to the security or physical integ rity of the individual or of a loved person(s). Symptoms/signs Symptoms tend to be mixed/changeable with an initial state of daze, followed by depression, anxiety (as for GAD, see b p. 372), anger, or despair. Presence of social w ithdrawal, narrowed attention, disorienta- tion, aggression, hopelessness, over-activity, o r excessive grief de \201 nes mild (none of these symptoms present), moderate (2 present), or severe (4 present, or dissociative stupor) forms. Epidemiology Incidence variable acros s studies, but estimated around 15 \200\22320% of indi- viduals following exceptional stres s. Etiology No speci \201 c theories, as it is a transient disorder. Risk factors Physical exhaustion, presence of other organic factors, elderly. Differential diagnosis PTSD ( \200\230exceptional trauma \200\231, delayed or persistent sy mptoms, re-experi- encing of the traumatic event), adjustment disorder (not necessarily exc ep- tional stressor, wider range of symptoms), concussion/mild brain injury (neuropsycholog ical testing cannot always distinguish), brief psychotic dis- order, dissociative disorders (no clear stressor), substance misuse. Management By de \201 nition, no speci \201 c tre atment needed. Ensure other needs are addressed, i.e. safety, security, practical assistanc e, social supports. Outcome \200 Once the stressor is removed, symptoms resolve (usually) within a few hours. If the stress continues, the symptoms tend to diminish after 24 \200\22348hrs and are minimal within abou t 3 days. 09_Semple_Chap09.indd 382 12/7/2012 3:34:09 PM This page intentionally left blank CHAPTER 9 Anxiety and stress-related disorders 384 Acute stress disorder (DSM-IV) Essence Clear overlap with \200\230acute stress reaction \200\231 (symptoms of dissociation, anxiety, hyperarousal), but greater emphasis on dissoci ative symptoms, onset within 4wks, lasting 2 days to 4wks (after which diagnosis changes to PTSD). Symptoms/signs As for PTSD \200\224re-experiencing of events, avoidance, and hyperarousal ( but lasting no more than 4wks). Epidemiology Incidence depends on trauma: e.g. 13 \200\22314% in RTA survivors, 19% in vict ims of assault, 33% in victims of mass shooting. Etiology Similar to PTSD. \200 \200\230re-experiencing symptoms \200\231. Fear response to harmless Psychological: situations associated with original trauma, perhaps due to emoti onal memories (i.e. having personal signi \201 cance). Remodeling underlying schemas requi res holding trauma experiences in \200\230active \200\231 memory until the process is comp lete (working through). Dissociation \200\224a mechanism of avoiding overwhelming emotion ( i.e. \200\230thinking without feeling \200\231), which, if persistent, delays the process of integration. Biological: changes as a result of the effects of chronic stress or persist ent re-experiencing of the stressful event. Neurotransmitters implicated \200\224 cathechol amines, 5-HT, GABA, opioids, and glucocorticoids. neurophysiological changes leading to permanent neuronal Risk factors Previous history of psychiatric disorder, previous traumatic event(s), pre- mo rbid depression, or dissociative symptoms. Comorbidity Similar to PTSD (i.e. depression, substance misuse). Differential diagnosis PTSD (timeframe >4wks duration), adjustment disorder (doesn \200\231 t meet criteria for \200\230traumatic \200\231 event \200\224see b p. 380; wider range of symptoms), concussion/mild brain injury (neuropsychological testing cannot always distingui sh), brief psychotic disorder, dissociative disorders (no clear stres- sor), substance misu se. Management \200 Simple practical measures: procedures, insurance claims, dealing with the media, course and prognosis, may be all that is required. Psychological: Debrie \201 ng \200\224may be use ful for certain individuals (needing supportive \200 therapy), but reviews suggest there is little positive bene \201 t of single session debrie \201 ng and may worsen outcome!1 e.g. support, advice regarding police 09_Semple_Chap09.indd 384 12/7/2012 3:34:10 PM ACUTE STRESS DISORDER (DSM-IV) 385 CBT exposure, and cognitive restructuring) may reduce development of chronic problems/PTSD (not immediate, but 72wks after the event appears best). Pharmacological: signi \201 cant symptoms (evidence lacking). \200\224brief interventions (education, relaxation, graded in vivo TCAs, SSRIs, and BDZs may be useful for clinically Outcome By de \201 nition, either self-limiting or continues into PTSD. 1 Rose SC, Bisson J, Churchill R and Wessely S (2002) Psychological debrie \201 ng for pre venting post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews: CD0 00560. 09_Semple_Chap09.indd 385 12/7/2012 3:34:10 PM CHAPTER 9 Anxiety and stress-related disorders 386 Adjustment disorders Adjustment disorders sit uneasily between what are regarded as normal or just \200\230problematic \200\231 dif \201 culties and the major psychiatric diagnoses . They must occur within 1 (ICD-10) or 3mths (DSM-IV) of a particular psycho- social stress or, and should not persist for longer than 6mths after the stressor (or its consequences) i s removed (except in the case of \200\230pro- longed depressive reaction \200\231 in ICD-1 0). Symptoms are \200\230clinically signi \201 cant \200\231 due to marked distress, or i mpairment of normal functioning, and may be \200\230subthreshold \200\231 (due to symptom or duration criteria) manifestations of mood disorders, anxiety disorders, stress-related d isorders, somatoform disorders, or conduct disorders. Subclassi \201 cation \200 ICD-10: brief depressive reaction (>1mth), prolonged depressive reaction (>6mths, but <2yrs ), mixed anxiety and depressive reaction, predominant disturbance of other emotions, predom inant disturbance of conduct, mixed disturbance of emotion and conduct, and other speci \201 ed predominant symptoms. Allows inclusion of bereavement/ grief reactions. DSM-IV: dep ressed mood, anxious mood, mixed anxious and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspeci \201 ed. Speci \201 cally excludes berea vement reactions (see b p. 388). \200\230Acute \200\231 disorders <6mths; \200\230chronic \200\231 disorders >6mths. Epidemiology Prevalence in inpatient/outpatient psychiatric populations is conservatively e stimated at around 5%. In general hospital settings it may be as high as 20% (physical illn ess being the primary stressor for up to 70% of these cases). Etiology By de \201 nition the problems are caused by an identi \201 able stressor. Indiv idual predisposition plays a greater role than in other conditions, but symptoms would not have arisen without the stressor. Comorbidity Possibly higher incidence of alcohol-related problems than the general populati on, but no different from other psychiatric disorders. Differential diagnosis Diagnostic uncertainty may arise if debate surrounds whether the str es- sor is suf \201 ciently severe to be labeled \200\230exceptional \200\231 or \200 \230traumatic \200\231 (acute stress reaction/disorder or PTSD may be considered). Equally, it may be dif \201 cult to determine whether symptoms (e.g. low mood, anxiety, sleep dist urbance, anorexia, lack of energy) are attributable to a medical disor- der or are primaril y psychiatric in nature. Use of alcohol and drugs (illicit and prescribed) may complicate t he picture. 09_Semple_Chap09.indd 386 12/7/2012 3:34:10 PM ADJUSTMENT DISORDERS 387 Management \200 Psychological: the mainstay of management is essentially supportive psych otherapy to enhance the capacity to cope with a stressor that cannot be reduced or removed, and to establish suf \201 cient support (esp. practical help, e.g. provision of carers/ch ildcare, \201 nancial support and bene \201 ts, occupational therapy [OT] assessment, co ntact with speci \201 c support groups) to maximize adaption. Ventilation/ verbalization o f feelings may be useful in preventing maladaptive behaviors (e.g. social isolation, destru ctive behaviors, suicidal acts) and understanding the \200\230meaning \200\231 of the stre ssor to the individual may help correct cognitive distortions. the use of antidepressants o r anxiolytics/hypnotics Pharmacological: may be appropriate where symptoms are persistent a nd distressing (e.g. prolonged depression/dysphoria), or where psychological interventions have proved unsuccessful. Outcome \200 770% (adolescents: 740%), 5-yr follow-up suggests recovery in intervening problems in 710% (adolescents: 715%), and d evelopment of major psychiatric problems in 720% (adolescents: 745%). In adults, further ps ychiatric problems are usually depression/anxiety or alcohol-related problems. 1 There is a very real risk of suicide and self-harm (esp. in younger popu- lations). Addit ional risk factors include poor psychosocial functioning, pre- vious psychiatric problems, personality disorder, substance misuse, and mixed mood/behavioral symptoms. Do not ignore. 09_Semple_Chap09.indd 387 12/7/2012 3:34:10 PM CHAPTER 9 Anxiety and stress-related disorders 388 Normal and abnormal grief reactions Controversy surrounds how we should regard normal/abnor mal grief, and whether they are distinct from depression or other stress-related disor- der s.1 It is very common for those suffering bereavement to have depres- sive symptoms. Howeve r, it is less common for people to experience a clear depressive episode that requires trea tment.2 Normal grief is variable in its intensity and duration. Some commentators regard be reavement as just another stressor and argue that, depending on the phenomenology, grief ma y be regarded as an acute stress reaction/disorder, an adjustment disorder, or even a form of PTSD ( \200\230traumatic grief \200\231). Just as the former reactive/endogenous debate surrounding depression has led to recom- mendations that \200\230clinical \200\231 symptom s should be treated, a bereaved person should not be denied effective treatment on the basi s of \200\230understandability \200\231, nor should arbitrary timeframes (e.g. less than 4 wks [ICD-10], less than 2mths [DSM-IV]) become more important than assessment of clinical n eed. De \201 nitions \200 \200 Bereavement Grief \200 : any loss event, usually the death of someone. : feelings, thoughts, and behavior associat ed with bereavement. \200\224typical symptoms experienced after bereavement \200\230Normal \200\231 include: disbelief, shock, numbness, and feelings of unreality; an ger; feelings of guilt; sadness and tearfulness; preoccupation with the deceased; disturbed sleep and appetite and, occasionally, weight loss; seeing or hearing the voice of the dece ased. Usually these symptoms gradually reduce in intensity, with acceptance of the loss and readjustment. A typical \200\230grief reaction \200\231 lasts up to 12mths (mean 6mths), but cultural differences exist. Intensity of grief is usually greatest for the loss of a ch ild, then spouse or partner, then parent. grief reaction that is \200\230Abnormal (patholo gical/morbid/complicated) \200\231 \200\224 very intense, prolonged, delayed (or absent), o r where symptoms outside normal range are seen, e.g. preoccupation with feelings of worthle ssness, thoughts of death, excessive guilt, marked slowing of thoughts and movements, a pro longed period of not being able to function normally, hallucinatory experiences (other than the image or voice of the deceased)3 (see Box 9.9). Risk factors for depression following a bereavement Previous history of depression, intense grief or depressive symptoms early in the grief reaction, few social supports, little expe rience of death, \200\230trau- matic \200\231 or unexpected death. Management Generally \200\230normal \200\231 grief does not require speci \201 c treatmen t, although BDZs may be used to reduce severe autonomic arousal or treat prob- lematic slee p disturbance in the short-term. Where there are features of \200\230abnormal \200\231 gri ef, or where there are clinical symptoms of depression/anxi- ety, treatment with antidepres sants ought to be considered, along with culturally appropriate supportive counseling1 (e.g . through organizations such as CRUSE). 09_Semple_Chap09.indd 388 12/7/2012 3:34:10 PM NORMAL AND ABNORMAL GRIEF REACTIONS 389 Box 9.9 Prolonged Grief Disorder (PGD) (aka Complicated Grief Disorder, Traumatic Grief) Prigerson et al.1, a group of international researchers, have attempted to re \201 ne this syndrome for inclusion in DSM-V and ICD-11 with criteria to identify bereaved persons at h eightened risk for enduring distress and dysfunction. Criteria require reactions to a signi \201 cant loss that involve the experience of yearning (e.g., physical or emotional suffe ring as a result of the desired, but unful \201 lled, reunion with the deceased) and at le ast 5 of the following 9 symptoms experienced at least daily or to a disabling degree: \200 \200 \200 \200 \200 \200 \200 feeling emotionally numb, stunned, or that life is meaningless; experiencing mistrust; bitt erness over the loss; dif \201 culty accepting the loss; identity confusion; avoidance of the reality of the loss; dif \201 culty moving on with life. Symptoms must be present at suf \201 ciently high levels at least 6mths from the death and be associated with functional impairment. 1 Prigerson HG, Horowitz MJ, Jacobs SC, et al. (2009) Prolonged grief disorder: Psychometri c validation of criteria proposed for DSM-V and ICD-11. PLoS Med 6:e1000121. Epub. Near the end of his life Sigmund Freud was consulted by a woman who had become depressed fo llowing the death of her husband. After listen- ing to her, Freud quietly stated, \200\230 Madam, you do not have a neurosis, you have a misfortune \200\231. Wahl CW (1970) Arch Found Thanatol 1: 137. \200\230I know of only one functional psychiatr ic disorder, whose cause is known, whose features are distinctive, and whose course is usua lly pre- dictable, and this is grief, the reaction to loss. Yet this condition has been so neglected by psychiatrists that until recently it was not even mentioned in the indexes of most of the best-known general textbooks of psychiatry. \200\231 Parkes CM (1986) Bereavement studies of grief in adult life. 2nd edn. Tavistock Publication s, London and New York. 1 Stroebe MS, Hanson RO, Stroebe W, et al. (eds) (2007) Handbook of bereavement research an d practice: 21st century perspectives. Washington, DC: American Psychological Association P ress. 2 Results vary, e.g. in one study 16% of late-life widows had depression 13mths after bereavement. Zisook S, Paulus M, Shuchter SR, and Judd LL (1997) The many faces of depress ion following spousal bereavement. J Affect Disord 45: 85 \200\22395. 3 Parkes CM (1986) Be reavement: studies of grief in adult life, 2nd edn. International Universities Press. 09_Semple_Chap09.indd 389 12/7/2012 3:34:10 PM CHAPTER 9 Anxiety and stress-related disorders 390 Post-traumatic stress disorder 1: diagnosis Essence Severe psychological disturbance following a traumatic event (see b p. 380) charact erized by involuntary re-experiencing of elements of the event, with symptoms of hyperarous al, avoidance, emotional numbing. Symptoms/signs Symptoms arise within 6mths (ICD-10) of the traumatic event (delayed onset i n 710% of cases) or are present for at least 1mth, with clinically sig- ni \201 cant distr ess or impairment in social, occupational, or other important areas of functioning (DSM-IV) . Both ICD-10 and DSM-IV include: \200 2 or more \200\230persistent symptoms of increased psychological sensitivity and arousal \200\231 (not present before exposure to the stressor): dif \201 culty falling or staying asleep; irritability or outbursts of anger; dif \201 culty in concentrating; hypervigilanc e; exaggerated startle response. Other ICD-10 criteria \200 Persistent remembering or \200\230reliving \200\231 of the stressor in intrusive \202 as hbacks, vivid memories, or recurring dreams; and in experiencing distress when exposed to c ircumstances resembling or associated with the stressor. Actual or preferred avoidance of c ircumstances resembling or associated with the stressor which was not present before exposu re to the stressor. Inability to recall, either partially or completely, some important asp ects or the period of exposure to the stressor. Other DSM-IV criteria (see Box 9.10) Epidemiology Risk of developing PTSD after a traumatic event 8 \200\22313% for men, 20 \200 \22330% for women. Lifetime prevalence estimated as 7.8% (4:5 = 1:2).1 Cultural differences exist. Some types of stressor are associated with higher rates of PTSD (e.g. rape, torture , being a prisoner of war). Etiology \200 \200 see b p. 384. Psychological/biological: Neuroimaging: reduced hippocampal volume (may relate to appreciat ion of safe contexts and explicit memory de \201 cits). Dysfunction of the amygdala, hippo campus, septum, and prefrontal cortex may lead to enhanced fear response. High arousal appe ars to be mediated by anterior cingulate, medial prefrontal cortex, and thalamus; dissociat ion by parietal, occipital, and temporal cortex. Genetic: higher concordance rates seen in MZ than DZ twins. Risk factors \200 Vulnerability factors: low education, lower social class, Afro-Carribbean/ Hispanic, female gender, low self-esteem/neurotic traits, previous (or 09_Semple_Chap09.indd 390 12/7/2012 3:34:10 PM PTSD 1: DIAGNOSIS 391 family) history of psychiatric problems (esp. mood/anxiety disorders), previous traumatic e vents (including adverse childhood experiences and abuse). Peri-traumatic factors: traumati c emotions, peri-traumatic dissociation. Protective factors: psychopathic traits, chance to view body of dead person. trauma severity, perceived life threat, peri- high IQ, higher social class, Caucasian, male gender, Comorbidity (may be primary or secondary) Depressive/mood disorders, other anxiety disorder s, alcohol and drug misuse disorders, somatization disorders. Differential diagnosis Acute stress reaction/disorder, enduring personality change after a cata- strophic event (duration at least 2yrs, see b p. 380), adjustment disorder (less seve re stressor/different symptom pattern), other anxiety disorder, depressive/mood disorder, O CD, schizophrenia (or associated psychosis), substance-induced disorders. Box 9.10 Other DSM-IV criteria Traumatic event is persistently re-experienced in 1 (or more) of the following ways: \200 Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions (or repetitive play in which themes or aspects of the trauma are expressed in children). Recurrent distressing dreams of the event (or frightening dreams without reco gnizable content in children). Acting or feeling as if the traumatic event were recurring ( or trauma- speci \201 c re-enactment in children). Intense psychological distress at expos ure to internal or external cues that symbolize or resemble an aspect of the traumatic even t. Physiological reactivity at exposure to internal or external cues that symbolize or rese mble an aspect of the traumatic event. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiv eness (not present before the trauma), as indicated by 3 (or more) of: \200 Efforts to avoid thoughts, feelings, or conversations associated with the trauma. Efforts t o avoid activities, places, or people that arouse recollections of the trauma. Inability to recall an important aspect of the trauma. Markedly diminished interest or participation in signi \201 cant activities. Feeling of detachment or estrangement from others. Restricted range of affect. Sense of foreshortened future. \200 \200 \200 \200 1 Kessler RC, Sonnega A, Bromet E, et al. (1995) Posttraumatic stress disorder in the Natio nal Comorbidity Survey. Archives of General Psychiatry 52: 1048 \200\22360. 09_Semple_Chap09.indd 391 12/7/2012 3:34:10 PM CHAPTER 9 Anxiety and stress-related disorders 392 Post-traumatic stress disorder 2: management1 Psychological Meta-analyzes support the super ior ef \201 cacy of trauma-focused treatments,2 speci \201 cally trauma-focused CBT and E MDR. These are recommended as \201 rst-line treatments in all recent guidelines. \200 CBT: includes elements of: education about the nature of PTSD, self- monitoring of symptoms , anxiety management, breathing techniques, imaginal reliving, exposure to anxiety-producin g stimuli in a supportive environment, cognitive restructuring (esp. for complicated trauma ), anger management. Eye movement desensitization and reprocessing (EMDR): treatment using voluntary multi-saccadic eye movements to reduce anxiety associated with disturbing thought s and help process the emotions associated with traumatic experiences (see Box 9.11). Other psychological treatments: Psychodynamic therapy \200\224 \200 provoked by the stressful events, the goal being to understand the meaning of the event in the context of the individ ual. Stress management (stress inoculation) cope with stress, such as relaxation, breathing , thought stopping, assertiveness, positive thinking. Hypnotherapy hyperarousal and distres s, enabling recollection of traumatic event. Concern over possible induction of dissociativ e states. Supportive therapy exploring thoughts, feelings, and behaviors to reach clearer s elf- understanding. 3 novel focus on resolving unconscious con \202 icts \200\224teaching skills to help \200\224use of focused attention to enhance control over \200\224non-directive, non-advisory method of Pharmacological Medication may be considered when there is severe ongoing threat, if the pa tient is too distressed or unstable to engage in psychological therapy, or fails to respond to an initial psychological approach. \200 (e.g. paroxetine 20 \200\22340mg/day; sertraline 50 \200\223200mg/day) are SSRIs licensed f or PTSD, and their use supported by systematic review.4 Other unlicensed possibilities incl ude: \202 uoxetine, citalopram, escitalopram, and \202 uvoxamine. Other antidepressants : TCAs (e.g. amitriptyline, imipramine); MAOIs (e.g. phenelzine) may also reduce anxiety (o ver-arousal), intrusiveness, and improve sleep; venlafaxine; mirtazapine. although unlicensed there is some evidence for It may be helpful to target speci \201 c symptoms: \200 Sleep disturbance mirtazapine (45mg/day), levomepromazine, prazosin (mean dose 9.5mg/day), or speci \201 c hypnotics (e.g. zopiclone, zolpidem). Anxiety symptoms/hyperarousal: 4 \200\2235mg/day), buspirone, antidepressants, propranolol. (including nightmares): may be improved by consider use of BDZs (e.g. clonazepam 09_Semple_Chap09.indd 392 12/7/2012 3:34:10 PM PTSD 2: MANAGEMENT 393 Intrusive thoughts/hostility/impulsiveness: carbamazepine, valproate, topiramate, or lithiu m. Psychotic symptoms/severe aggression or agitation: antipsychotic (some evidence for olan zapine, risperidone, quetiapine, clozapine, aripiprazole). some evidence for use of may warrant use of an Outcome 7 \200 50% will recover within 1st year, 730% will run a chronic course. \200 \200 Outcome depends on initial symptom severity. Recovery will be helped by: good social suppor t; lack of \200\223ve responses from others; absence of \200\230maladaptive \200\231 copi ng mechanisms (e.g. avoidance, denial, \200\230safety behaviors \200\231, not talking abou t the experience, thought suppression, rumination); no further traumatic life events (s pro blems such as physical health, acquired disability, dis \201 gurement, disrupted relations hips, \201 nancial worries, litigation). XBox 9.11 EMDR controversy In 1987 Francine Shapiro, a California psychologist in private p ractice, whilst walking in the woods, preoccupied with disturbing thoughts, dis- covered he r anxiety improved during the walk. She realized that she had been moving her eyes back and forth, from one side of the path to the other, while walking. Shapiro tried out variants o f this procedure with her clients and found that they felt better, too. Her \201 ndings w ere published in 1989 and EMDR was born.