Wide-Ranging PTSD Intervention Not Beneficial

By Rick Nauert PhD Senior News Editor
Reviewed by John M. Grohol, Psy.D. on July 22, 2009

Imagine a deadly campus shooting occurs. It might seem sensible to offer everyone on campus psychological support to prevent psychological repercussions, including post-traumatic stress disorder (PTSD).

However, a new review from Wales and Australia suggests the opposite: Researchers found no evidence to support offering interventions to everyone involved in a traumatic event. In fact, they found that some forms of blanket intervention might foster worse outcomes than no intervention whatsoever.

“Some experts argue everyone should be offered help. Others argue that only those considered at particular risk of developing a psychological disorder should be treated. This study attempted to examine whether any psychological intervention offered over more than one session was effective in preventing PTSD,” said lead author Dr. Neil Roberts, a psychologist with the University Hospital of Wales in Cardiff.

“The results found no evidence to support the use of an intervention offered to everyone,” he said.

“There was some evidence that multiple session interventions may result in worse outcomes than no intervention for some individuals, although I don’t want to overplay the risk of harm. The effects for most interventions we studied were neutral; that is, treatment and control participants did equally well.”

The stakes are high. In some people, severe PTSD precipitates family breakdown, job loss and substance abuse.

Roberts’ team evaluated findings from 11 studies that tested diverse psychological interventions aimed at preventing PTSD after one-time traumatic events. Together the studies comprised 941 adult participants.

Participants included mothers who had experienced traumatic births, people in serious traffic accidents, persons involved in armed robberies involving violence and parents of children newly diagnosed with cancer.

Interventions fell into six categories including cognitive behavioral therapy (CBT), individual counseling, group therapy and adapted debriefing. The authors noted that counseling was the most often used intervention and that the evidence provided no support for its use to prevent PTSD. They said that no individual study showed a significant difference in favor of any treatment intervention in comparison to the control.

The new review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews like this one draw evidence based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

Only one study reported adverse effects due to treatment. In that case, researchers found that individuals with a psychiatric history did worse at six-month follow up if they had received a counseling intervention than similar individuals who received none.

“Our study builds on the findings of previous research showing that a popular intervention –psychological debriefing — delivered in the first few days after trauma was not effective in preventing PTSD. Although many mental health professionals have stopped using debriefing as a result of this research, uncertainty has remained about best practices,” Roberts said.

His team found no evidence to support offering any type of intervention to everybody present at a traumatic incident. However, the review did show that interventions aimed at people showing early signs of PTSD was effective at preventing chronic PTSD. Roger Pitman, M.D., a professor of psychiatry at Harvard Medical School, considered the findings noteworthy.

“The results of this Cochrane review appear to establish limits for outreach efforts to trauma victims,” Pitman said.

“Whereas it makes sense to inform them of the availability of therapy should they desire it, encouraging them to make use of it may be imprudent, unless there’s clear evidence of psychiatric symptoms.”

Meaghan O’Donnell, Ph.D., a clinical psychologist and senior research fellow with the Australian Centre for Posttraumatic Mental Health at the University of Melbourne, also deemed the review’s findings important.

“After a traumatic event, most people will experience high levels of distress. This review shows us that despite this distress, most people will not need intervention from a mental health professional,” O’Donnell said.

“It also tells us that by identifying those people facing high risk for developing later PTSD, early cognitive behavioral therapy is very useful in preventing chronic PTSD.”

The review called for further research to evaluate the best ways to provide psychological help soon after a traumatic event. Both O’Donnell and Pitman concur: “Early intervention is dependent on effective screening instruments to help target treatments, and we need more research to establish screening instruments that will identify high-risk trauma survivors,” O’Donnell said.

“Furthermore, we need to find out whether other psychiatric or psychological interventions are as useful as cognitive behavioral therapy in preventing chronic PTSD.”

These findings might reassure trauma survivors. This research clearly showed mental health professionals what not to do — offer counseling to everyone, and provides guidelines about best practices to prevent chronic PTSD — provide CBT for those with serious early PTSD symptoms. This information could help trauma survivors on their road to recovery.

Source: Health Behavior News Service

Iraq vets' caregivers seek training, compensation

Play Video ABC News – PTSD Diagnosis on the Rise

• Play Video Iraq Video:First Person: Caring for injured vets AP
• Play Video Iraq Video:Wounded troops' families ask Congress for help AP
• Play Video Iraq Video:Sandstorms strafe Iraq AFP

AP – Bob Briggs works on his computer as he gets help from his wife Michelle in their home, Wednesday, July …

By KIMBERLY HEFLING, Associated Press Writer Kimberly Hefling, Associated Press Writer –

WASHINGTON – On good days, Michelle Briggs has to remind her 40-year-old husband to shower and eat. On bad days, she lifts him out of bed and picks him up when he falls.

Robert W. Briggs, a former Army sergeant, was severely injured in Iraq and needs constant monitoring because of traumatic brain injury, blindness in one eye and paralysis on one side. He walks with the help of a service dog. Briggs gave up her job as a veterinarian technician to care for him and their two kids.

With tissue in hand, Michelle Briggs huddled Monday in a hotel conference room with 15 other caregivers who shared hugs and exchanged stories. They will go to Capitol Hill this week with a message to Congress: We need help.

"Mentally, it takes a very big toll on you," said Briggs, 34, of Hillsboro, Iowa, whose husband was injured in a rocket grenade attack in 2005 while serving with the Iowa National Guard. "You have to be a very strong person to get through a lot of it. It's a choice whether you stay or not. It's very much a choice."

Briggs said she's met other spouses of injured veterans who sought a divorce.

"It doesn't make them a bad person at all, but they just couldn't handle the situation because it's very, very stressful and you have to fight for the things that you're entitled to," Briggs said.

The caregivers say parents, spouses and siblings of the disabled have given up jobs, health insurance and college to care for a loved one. Yet they get no compensation to ease the burden.

"We're providing them with such a better quality of life and we need support in order to provide that," said Tracy Keil, 31, of Parker, Colo., whose husband, Matthew Keil, was paralyzed from the chest down from a sniper's bullet in 2007 and now needs around-the-clock care.

The two married six weeks before he was injured. She said she gave up the job she had as an accountant for 11 years and makes $60,000 less working from home part-time for a nonprofit organization.

The caregivers seek passage of legislation that would require the Veterans Affairs Department to offer more training to primary caregivers of severely injured veterans from the recent wars. Those certified would be eligible for benefits such as health care and a stipend of a few hundred dollars a week.

The alternative, they say, would be life in an institution for some veterans now mostly in their 20s or 30s.

Sen. Daniel Akaka, chairman of the Senate Veterans' Affairs Committee, who authored legislation in the Senate to address the issue with Sen. Richard Burr, R-N.C., said there are more than just an isolated few families asking for help.

"This has been growing, growing to the point now where we can not ignore it," Akaka said.

Akaka, D-Hawaii, said he's waiting for a final analysis about how much the legislation would cost, although he's confident keeping a veteran in the home is cheaper than a nursing home.

The VA has expressed concerns about the cost of the legislation. It has also said it would divert from the agency's mission of providing care to veterans and training clinicians, and said some of the same services are provided in other programs.

Phil Budahn, a VA spokesman, said in a statement the agency would continue to look for ways to "appropriately support these compassionate providers."

Steven Nardizzi, executive director of the Jacksonville, Fla.-based Wounded Warrior Project, which organized the caregivers' effort this week, said what the VA provides simply isn't adequate. He said the VA needs to adapt its primary mission to include helping families of the wounded, and providing health benefits and a stipend would go a long way.

"If the VA thinks they're already providing or the administration thinks they're already providing support, it's because they're simply not paying attention and not listening to the families right now," Nardizzi said.

His group estimates that under legislation it's seeking, about 750 caregivers would be eligible long-term, whereas several thousand would participate for about one to three years.

Briggs said she's thrown out her back at different times lifting her husband. She said she went through a period of depression as she adjusted to their new life but has learned to find comfort talking to other caregivers. She said she's dedicated to making their arrangement work but could use more resources.

"I love him and we've been married — it will be 15 years in November. It's like your marriage vows for better or worse," Briggs said. "This wasn't his fault, and there would be no one else to take care of him properly. He would be in a nursing home."

___

On the Net:

Wounded Warrior Project: http://www.woundedwarriorproject.org/

Senate Veterans' Affairs Committee: http://veterans.senate.gov/

Veterans Affairs Department: http://www.va.gov/

Anger Management Techniques?

What are some Anger Management Techniques?

Image by ☆Mi☺Λmor☆ via Flickr

Having trouble controlling anger is a major issue in many individuals lives. Addressing this issue can be difficult if the person is unwilling to admit to their problem and seek help. It is imperative that people be supportive and encouraging to those with anger issues. At times it may seem impossible since these people can be hurtful and even violent. Helping them to realize they need help would be the initial step to controlling their anger.

Once an individual is willing to work on their anger problem and turn to anger management, there are anger management techniques which will be taught to help them. There are many techniques which are beneficial regarding anger management. It might be necessary for the individual to try them all in order to find anger management techniques that work best for them.

One technique recommended for anger management is relaxation. Angry feelings and emotions can be calmed by relaxing exercises such as deep breathing, relaxing imagery and slow non strenuous exercise similar to yoga. When a person becomes irritated and headed for a fit of anger, it is suggested they breathe deeply. This technique recommends that the person breathe from their diaphragm in order to relax. Using relaxing imagery may work for some people. Allowing their mind and thoughts to go to a happy place, a relaxing experience may help to calm them down. This imagery may be of a past experience or the individual could use their imagination. The yoga-like exercises used as an anger management technique are meant to relax the muscles which in turn will help the individual feel much calmer.

Problem solving is used as an anger management technique. It is important for an individual to discover the reason for their anger. Anger is a natural response to certain situations and at times it is an acceptable reaction but there are other incidents when the anger is not appropriate. There is a reason for the anger and to every problem there is said to be a solution. When a situation arises, the individual is taught not to focus on the solution but rather the problem. Finding ways to handle the problem and confront it is the main objective in this anger management technique. It may take awhile to conform to this plan. It is important to stick to it, eventually the answers will come.

People with anger issues are taught through anger management techniques to practice better communication skills. Often a fit of anger arises because an individual misunderstood a conversation. Before giving it any thought, they become enraged and filled with anger. Anger management teaches the individual to slow down their thinking, think before they speak or react. The easily angered person needs to listen to the underlying message and try not to jump to conclusions. When feeling on the defensive side, the individual should learn not to fight back. Listening rationally to what the other person has to say might make a huge difference in a reaction.

These are just a few anger management techniques. There are many others which may be helpful to an individual requiring help. There are many books, movies and website on the Internet which can provide information regarding anger management techniques.
Here are just a few:
Anger Management For The Twenty First Century Ebook

Anger Management - Regaining Control Of

Stop The Insanity - Control Your Anger Today

Psychological Self-improvement: Ways to Overcome Fear

Image by Will Lion via Flickr

People are usually afraid of negative things. They are afraid of self-improvement because of this fear. Psychological self-improvement may help you in this situation.

In psychological self-improvement, The best way to remove this fear is to understand that life is always in the cycle of ups and downs. No one is permanently up or permanently down. Remember that no one can avoid these ups and downs even the most envied Hollywood stars.

What we should do about these downs is to learn from it and not to avoid it. We should learn how to handle our problems for our psychological self-improvement.

Problems affect us every day. These problems bring us misery due to the fact that we have feelings. We should never loose hope in figuring out solutions to these problems. All we need is to learn how to overcome it and not to be overcome.

Problems can never be overcome but we can learn from them. This is where Psychology plays an important role.

Psychologists say that we should always be careful in our decisions concerning our problems. We should handle our problems properly and learn how to deal with it. Learning from mistakes helps us in preparing ourselves for psychological self-improvement

There are a lot of myths about every event in our lives. Another belief says that what we encounter in our lives today is our preparation for other things that may come in our lives. To understand what may happen to us in the future, we must learn from the present.

With all that, it is also true that the unexpected can happen anytime. However, you should keep in mind that a psychological self-improvement is not always for the worse and consequently, you must never let go of a chance, because you are afraid to take the risk.

Remember that, from time to time, something has to happen in order to free you from monotony, so you shouldn't be surprised if, at a certain moment in time, instead of being afraid of change, you desire it with all your heart.

If there are some things that hinder you from going on, here are some tips to help you move forward:
Just think of the positive impacts results from the psychological self-improvement. Know important they are and reflect on how to increase them, by adding some other good aspects, which need certain assistance.

Try to picture somebody else in your situation, as picturing ourselves in a less desirable position, always looks more dramatic than it really is. If you realize that the other person can handle the change, you can be sure you’ll be able to handle it as well. This is a good psychological self-improvement.

Think of the worst situation that can result after the self-improvement. Try to find various solutions to it. Reflect on how much you can loose, if the worst happened, and how important those things are to you. If you find more than one reasonable solution, you are safe and the self-improvement can’t be stronger than you are!

Self-improvement is not bad at all. All we need is to learn how to handle some negative changes. We should also reflect from it to learn and use it in the future events that we may encounter. This could be your ultimate psychological self-improvement.

More Resources:

Belief Busters get the free course

Wide Asleep My newest release

Panic Away Excellent Solutions

Living with an Anxiety Disorder By Margarita Tartakovsky, M.S.

Learning that you have an anxiety disorder may bring relief (finally having a name for your struggles), more questions (why me?) and more worry (not knowing what to do next). The good news is that anxiety disorders are among the most treatable.

According to Peter J. Norton, Ph.D, Director of the Anxiety Disorder Clinic at the University of Houston and co-author of The Anti-Anxiety Workbook, anxiety disorders have success rates that make other researchers jealous. The key is to get the right treatment and stick with it.

Here’s a look at what effective treatment entails, including the ins and outs of psychotherapy and medication, plus tips for finding a qualified therapist, managing panic attacks and more.

Common Misconceptions

1. Anxiety disorders aren’t that serious. This myth persists because “anxiety is a universal and normative emotion,” said Risa Weisberg, Ph.D, Assistant Professor (research) and Co-Director of the Brown University Program for Anxiety Research at Alpert Medical School. However, anxiety “can be a hugely distressing and impairing symptom.”
2. “I can overcome this on my own.” In her research on anxiety disorders in primary care, Weisberg found that nearly half of primary care patients with anxiety disorders weren’t taking medication or attending therapy. When asked about their reasons for not engaging in treatment, one of the most common answers was that they didn’t believe in receiving these treatments for emotional problems. Anxiety disorders have a chronic course and “the bottom line is that good treatments exist, so there is no reason to suffer on your own,” Weisberg said.
3. Anxiety disorders are a character defect. “Anxiety has a genetic and neurological basis,” said Tom Corboy, MFT, Director of the OCD Center of Los Angeles.
4. “I need medication in order to improve.” Though medication can be effective in treating anxiety disorders, “research suggests that in many cases, cognitive-behavioral therapy (CBT) is better or just as good as CBT plus medication,” said Jon Abramowitz, Ph.D, Associate Professor at the University of North Carolina at Chapel Hill and Director of the UNC Anxiety and Stress Disorders Clinic. CBT teaches patients the skills for lasting benefits.

Disclosing Your Diagnosis

You may be unsure about sharing your diagnosis with others. Corboy suggested discussing your anxiety with individuals you trust, who have your best interests in mind. If you’re considering telling a significant other, wait “until that person has earned your trust,” he said.

Treatment

A great deal of research over the past 10 to 15 years has shown that CBT is the most effective treatment for most anxiety disorders, Corboy said, making it the first line of treatment. Research also has shown that selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants and benzodiazepines are effective in treating anxiety.

Doctors usually prescribe SSRIs and SNRIs first because they’re effective, can treat depression — which often co-occurs — and tend to be better tolerated. According to the scientific literature, there’s a higher rate of relapse with medication, Norton said. The key is to supplement medication with CBT, said Peter Roy-Byrne, M.D., Professor and Chief of Psychiatry at the University of Washington at Harborview Medical Center. In fact, medication is sometimes used to facilitate psychotherapy.

Psychotherapy

The first step in CBT is to understand your anxiety, Abramowitz said. You and the therapist will work together to gain insight into how your thoughts and behaviors fuel your anxiety. “People with anxiety tend to jump to conclusions and overestimate,” he said. Behavior such as regularly rehearsing what you’re about to say actually feeds your anxiety, nourishing the belief that you can’t think on your feet and you’re a poor public speaker.

Cognitive restructuring helps patients identify their thoughts and expectations and modify problematic patterns, Abramowitz said. He pointed out that cognitive restructuring “is not the power of positive thinking; it’s the power of logical thinking.”

In exposure therapy, another CBT technique, therapists help patients face their fears in various contexts in a systematic and safe way. Together, you and your therapist create a hierarchy, listing the least anxiety-provoking situation to the greatest, and work your way up, confronting each situation.

Most CBT programs consist of 8 to 15 weekly sessions, Norton said. When individuals start to experience gains varies. At his clinic, Norton typically sees patients improve the most from the 5th to 7th session of their 12-week program. However, there’s no universal standard for staying in therapy. Weisberg recommended that patients continue with CBT until they fully understand and have mastered the above skills to manage their anxiety.

Preventing and Overcoming a Lapse

It’s not uncommon to experience a resurgence of symptoms—a lapse—after treatment, especially during stressful times, Abramowitz said. “We want people to recognize that this is entirely normal.” CBT helps clients recognize signs of an impending episode so that they can take action to prevent it, Norton said. Usually, this involves creating a plan with a series of signs — like not leaving the house for two days — and actionable steps — like reviewing your anxiety workbook or calling your old therapist.

“This helps prevent a lapse from turning into a relapse,” Norton said. Whereas a lapse is a hiccup — like having a double cheeseburger when trying to eat healthy — a full relapse involves reverting to old patterns, where anxiety and avoidance dominate your life, he said. If you do experience a relapse, you may need several booster sessions.

So the work doesn’t just stop at the end of therapy. Norton likened this to reaching a healthy weight: You don’t stop exercising and eating well after getting to your goal weight. Norton helps his patients develop long-term plans for managing and challenging their anxiety. For a socially anxious person, part of the plan may include signing up for Toastmasters, an organization that helps members develop their public speaking and leadership skills in a nonthreatening environment.

Common Challenges in Psychotherapy

• Lack of time and energy. Weisberg’s research found that a large proportion of patients believed that they were too busy for psychotherapy. Corboy sees many successful clients who work 60 to 70 hours a week while raising families. Yet, others might have so much on their plate — barely making ends meet, no babysitter — that they can’t attend therapy in the first place. Norton usually refers these patients to a psychiatrist for pharmacological treatment and asks them to stay in touch as things ease up. For patients who have milder symptoms, Norton recommends purchasing a self-help anxiety workbook—preferably one grounded in CBT—and creating their own hierarchy. Some workbooks still rely heavily on relaxation techniques, which are a good way to reduce anxiety in the moment but not long-term, Norton said.
• Active participation. In the beginning, patients may not be used to actively learning and practicing new skills. CBT requires a strong commitment and lots of work outside of therapy, Abramowitz said.
• Tackling anxiety head-on. To effectively treat anxiety, you have to be willing to confront your fears, so you may feel worse before you feel better. This means challenging anxiety “on a regular basis, between sessions,” Corboy said. The one hour in therapy pales in comparison to the other 167 hours in a week.

  If you’re having an especially difficult time applying the skills you learn in therapy, discuss it with your therapist. It might be that the exposure task is too frightening at this time, and your therapist may need to adapt it. Also, “it may be empowering to realize that avoidance is actually a choice,” Weisberg said. “Although no one chooses to have an anxiety disorder, they do choose to avoid certain things.” Weisberg works with patients to help them decide if they’d rather experience anxiety for several weeks during exposure therapy or live without ever doing a particular task. Facing your fears in the present leads to a calmer future, Abramowitz said.

Finding a Therapist

Because CBT is the gold standard for treating anxiety disorders, it’s important to find a therapist who’s well-trained in the technique and has extensive experience working with patients with anxiety disorders. Here are several suggestions for finding a qualified therapist:

• Visit the therapist finders at the Association for Behavioral and Cognitive Therapy for CBT-trained therapists and the Anxiety Disorders Association of America. Therapists listed on ADAA don’t necessarily specialize in CBT. Also, check whether your local university offers special services, which tend to be inexpensive treatments that use cutting-edge techniques, Norton said.
• Familiarize yourself with CBT. Dr. Roy-Byrne suggested reading a CBT patient manual from the series Treatments that Work. This will give you a good idea about what to expect from treatment and the kinds of questions to ask therapists.
• When speaking with a therapist on the phone, ask how he or she will treat your anxiety disorder, Abramowitz said. Does it line up with what you’ve read? He suggested also asking: How many patients with anxiety disorders have you worked with? What kind of training have you had in treating anxiety disorders and CBT? Attending several workshops isn’t enough. “You don’t learn CBT in a day; it takes years,” Abramowitz said.

Medication

The type of anxiety disorder, its severity, the presence of co-occurring disorders and level of distress typically will guide the medication you’re prescribed, the starting dose and the length of treatment. For someone with panic disorder, physicians usually prescribe a low dose of a SSRI — lower than that for depression or social anxiety disorder — because these patients are particularly sensitive to the effects of medication, said Michael R. Liebowitz, M.D., Professor of Clinical Psychiatry at Columbia University and Managing Director of The Medical Research Network.

In principle, patients take medication for about a year, but in practice, this can be longer, Dr. Roy-Byrne said. If someone is experiencing stress and still has some co-occurring anxiety, phobic or depressive symptoms, it’s very likely he or she will relapse after stopping medication, he said. Some anxiety disorders, such as obsessive-compulsive disorder (OCD), generally take longer to treat, Dr. Liebowitz said.

For more information on medication, see here. If you can’t afford medication, consider participating in clinical trials. In Dr. Liebowitz’s studies, participants receive six months of free treatment after completing the clinical trials.

Concerns about Medication

Concerns about side effects and withdrawal are common. Patients often worry that taking medication is somehow artificial, and some turn to herbal supplements and drugs like marijuana, Dr. Liebowitz said. The truth is exactly opposite: Medication serves as a correction. It doesn’t introduce new chemicals into the brain, but instead alters the level of certain neurotransmitters, Dr. Liebowitz said.

SSRIs, the first line of treatment, can cause insomnia, sexual dysfunction and weight gain. If a medication is helpful, the prescribing physician can help you work around these side effects. One way is to adjust the time you take the medication: If you’re experiencing insomnia, you may take medication during the day or at night if you’re drowsy, Dr. Liebowitz said. If weight gain is an issue, you may need to watch your calories and exercise regularly.

“Because medication causes neurochemical changes in the brain, you may experience some withdrawal symptoms after discontinuing use, as the brain re-adjusts itself to the lack of medication,” Dr. Roy-Byrne said. This is true of all medication, he said, not just that for psychiatric disorders.

Abruptly discontinuing medication can have fairly potent effects, even with SSRIs, according to Dr. Liebowitz. Slowly tapering off the dose under a physician’s guidance reduces these problems.

Dr. Liebowitz recalled helping a patient taper off 40 mg of Paxil. The patient gradually went from 40 mg to 10 mg without trouble; however, going from 10 to 0 caused the patient dizziness and discomfort. After informing Dr. Liebowitz, he and the patient agreed to adjust the dose to 10 mg every second day for several weeks. Communicating with your doctor about your progress and any problems is vital to your treatment.

In addition to tapering off the medication, your physician may prescribe another medication to ease discontinuation syndrome. For patients taking Paxil, Dr. Roy-Byrne adds Prozac. They stop taking Paxil but continue taking Prozac for about six weeks before quickly tapering off this over a few days. (Prozac has a very short half-life, or the time it takes for a drug to lose half its activity in the bloodstream, thus making it ideal in such situations.) Using this technique can eliminate withdrawal symptoms, Dr. Roy-Byrne said.

And it may not be withdrawal after all. Patients can mistake the original anxiety for withdrawal symptoms. “If you stop an anxiety drug, the anxiety may come back, and with the passage of time, it could be worse than before,” Dr. Roy-Byrne said.

Tips for Taking Medication

1. Before. Weisberg has seen many patients accept a prescription without asking many questions or without knowing what symptoms or disorder the medication is supposed to be treating. Remember that you and your prescribing physician are a “health care team,” she said. Before taking medication, Dr. Roy-Byrne and Dr. Liebowitz suggested asking the following:
   • What is my diagnosis?
   • What are my treatment options, including medication and psychotherapy?
   • How will I know if this medication is working?
   • What are the side effects, and what do I do if I experience them?
   • When will the medication start to work?
   • How long will I have to take it?
   • If I take it for X amount of time, what’s the likelihood of reducing symptoms?
   • What are the dose requirements?
   • Will you be monitoring me throughout the course of this medication?
   • When will you talk to me next?
2. During. Dr. Roy-Byrne has patients keep track of symptoms and side effects using a rating scale. Recording your reactions to medication lets you and your doctor know if you’re getting better, whether your health problem is anxiety or high blood pressure. “I want to know if you’re 20, 40, 60 percent better, so I can know what to do next,” Dr. Roy-Byrne said. He also has his patients monitor their symptoms before they start medication, so they don’t attribute natural changes in their anxiety to the medication. “This is consistent with ‘measurement-based care,’ which is becoming the state-of-the-art approach to monitoring treatments and their outcomes,” he said.
3. Other tips. Avoid skipping your medication and make sure you don’t run out, Dr. Liebowitz said. If you go away for the weekend and leave your pills at home, call your physician for an emergency prescription. For additional advice, see here.

Managing Panic Attacks

Patients can suffer panic attacks with any anxiety disorder. Corboy suggested four steps in managing them:

1. Accept the anxiety. Individuals with an anxiety disorder become exceedingly sensitive to anxiety. “At the first hint of anxiety, they often become terrified that a panic attack is imminent,” Corboy said. Accepting that anxiety exists doesn’t mean liking it or resigning yourself to being anxious forever; “it just means accepting reality as it is.”
2. Challenge distorted thoughts. People often interpret a panic attack as a significant threat, but it’s important to realize that “nothing catastrophic is going to occur as a result of being anxious or even panicking.”
3. Breathe. Instead of hyperventilating, which energizes anxiety, “make a point of consciously breathing.”
4. Resist the urge to flee. Running away from anxiety only reinforces the idea that you’re unable to handle it and that escaping the situation is your best solution. Instead, a long-term solution is to “learn that we can tolerate the discomfort, that it won’t hurt us and that it will naturally dissipate over time if we sit with it.”

Pitfalls and Pointers

You may hit some snags as you work toward managing your anxiety. Here’s a list of common ones and practical solutions for them:

• Keeping symptoms to yourself. A primary care physician can’t make a proper diagnosis or treatment recommendation without having all the information.

  “If you have been feeling uncontrollably worried, anxious, fearful, have been having panic attacks, or have found that you are avoiding things that are important to you or to those around you because of fear – tell your doctor,” Weisberg said.

• Fighting anxiety as if it were your adversary. It’s important to understand that anxiety is a helpful response and a normal part of life, Abramowitz said.
• Masking it. Whether it’s alcohol, illicit drugs or benzodiazepines (such as Xanax or Ativan), these substances offer short-term relief and are akin to running away from anxiety, Abramowitz said. Because benzodiazepines quell anxiety quickly and strongly, they can increase avoidance and impair your ability to overcome anxiety-provoking situations, Dr. Roy-Byrne said.

  Instead of pursuing what maintains your anxiety — avoidance — face your fears directly with the help of a therapist.

• Giving up too quickly. Whether it’s medication or CBT, these interventions “can take a while to work,” Weisberg said. “Keep your long-term goals clearly in mind, giving each treatment enough time and effort.”
• Being too motivated. Jumping in head-first isn’t recommended either, Norton said. Instead of sprinting through treatment, give it time to sink in and strike a balance.

General Tips

• Have realistic expectations. It’s unrealistic to think that you’ll eliminate anxiety forever. Instead, realize that you’ll be able to manage symptoms and stop avoiding certain situations.
• See stress as normal. It’s normal to feel stressed. You can’t fight stress, but you can work through it, Abramowitz said.
• Adopt a balanced approach. Rather than overestimating the magnitude of a situation, “step back and look at things in a more objective light,” Abramowitz said. Instead of thinking that you’ll lose your savings in today’s shaky economy, consider that the market will return and focus on the steps you can control to manage your money.
• Adopt an anxiety-free lifestyle. In The Anti-Anxiety Workbook, Norton includes the ingredients for an anxiety-free life: adequate sleep; a balanced diet (think food pyramid, not diets that delete food groups); exercise and a solid support system, all of which are powerful in decreasing anxiety. Like a pricey car that needs high-grade gasoline to run optimally, our incredibly efficient body functions better with the right nutrients, Norton said.

  How we treat our bodies also directly affects anxiety sensations. Being out of shape can make your heart race even when you’re just walking. Caffeine and poor nutrition can amplify anxiety, producing jitteriness and trembling. Simply curtailing one’s caffeine intake can be helpful, Norton said.

  For more information on anxiety disorders, see Psych Central’s resources at http://psychcentral.com/disorders/anxiety/

Contrarian Approach for PTSD

By Rick Nauert PhD Senior News Editor
Reviewed by John M. Grohol, Psy.D. on June 17, 2009

A different approach to managing PTSD suggests that for some people repressing rather than exposing the traumatic memories may be better for an individual’s health.

Geisinger Health System senior investigator and U.S. Army veteran Joseph Boscarino, Ph.D., is proud of his military service, yet he doesn’t like to talk much about his combat experiences.

Before becoming a renowned researcher of psychological trauma, Dr. Boscarino served a tour of duty with an artillery unit in Vietnam from 1965-66, during which he witnessed heavy combat and its aftermath. To this day, he tries hard not to reflect on those battlefield memories.

The research by Dr. Boscarino and Tulane University investigator Charles Figley, Ph.D., shows that for some people exposed to traumatic events, repressing these memories may be less harmful in the long run.

“Going back to the days of Sigmund Freud, psychiatrists and mental health experts have suggested that repression of traumatic memories could lead to health problems,” Dr. Boscarino said. “Yet we have found little evidence that repression had an adverse health impact on combat veterans exposed to psychological trauma many years later.”

In a study that appears in the June issue of the research publication Journal of Nervous & Mental Diseases, Drs. Boscarino and Figley examined the long-term mortality rates of Vietnam veterans who were evaluated in 1985 with followup in 2000.

By studying the death certificates and records of a random sample of more than 4,000 veterans 30 years after military service, the researchers found that having PTSD along with a repressive personality trait does not necessarily lead to premature death.

The researchers say this is an important finding because exposure therapy is a prevailing practice in psychiatry, a technique that encourages patients to relive painful or traumatic events. Yet, for some patients, this therapy may inadvertently cause a resurfacing of PTSD symptoms and psychological distress, putting that patient at risk for health problems.

Previous research by Boscarino has shown that PTSD may cause premature death from heart disease, leads to elevated white blood cell counts and higher erythrocyte sedimentation rate levels (both of which indicates inflammation), and may cause other diseases such as rheumatoid arthritis.

“While the dominant therapy model for PTSD should not be abandoned at this point, emerging research suggests that it might need to be seriously re-evaluated, at least for some PTSD patients,” Dr. Boscarino said. “More research is clearly needed.”

Dr. Figley, another renowned trauma scholar who co-authored the 2007 book Combat Stress Injuries, said he was not surprised by the findings since they are consistent with a new theory of combat-related stress.

“Repression is a self-regulator and a method of memory management,” Dr. Figley said. “In other words, ‘keeping your stressful memories inside or it will kill you’ is a myth.”

Dr. Figley, who served in Vietnam as a Marine at the same time as Dr. Boscarino, believes this study is a wakeup call to all those who care about combat veterans.

“These men and women deserve our respect in recognizing that they often know better than we do in how to manage their stressful memories, in most cases,” Dr. Figley said.

Source: Geisinger Health System

Find out what your dreams mean

By TIFFANY SHARPLES Tiffany Sharples

Dreams may not be the secret window into the frustrated desires of the unconscious that Sigmund Freud first posited in 1899, but growing evidence suggests that dreams - and, more so, sleep - are powerfully connected to the processing of human emotions.

According to new research presented last week at the annual meeting of the Associated Professional Sleep Societies in Seattle, adequate sleep may underpin our ability to understand complex emotions properly in waking life. "Sleep essentially is resetting the magnetic north of your emotional compass," says Matthew Walker, director of the Sleep and Neuroimaging Lab at the University of California, Berkeley. (See the top 10 scientific discoveries of 2008.)

A recent study by Walker and his colleagues examined how rest - specifically, rapid eye movement (REM) sleep - influences our ability to read emotions in other people's faces. In the small analysis of 36 adults, volunteers were asked to interpret the facial expressions of people in photographs, following either a 60- or 90-minute nap during the day or with no nap. Participants who had reached REM sleep (when dreaming most frequently occurs) during their nap were better able to identify expressions of positive emotions like happiness in other people, compared with participants who did not achieve REM sleep or did not nap at all. Those volunteers were more sensitive to negative expressions, including anger and fear.

Past research by Walker and colleagues at Harvard Medical School, which was published in the journal Current Biology, found that in people who were sleep deprived, activity in the prefrontal lobe - a region of the brain involved in controlling emotion - was significantly diminished. He suggests that a similar response may be occurring in the nap-deprived volunteers, albeit to a lesser extent, and that it may have its roots in evolution. "If you're walking through the jungle and you're tired, it might benefit you more to be hypersensitive to negative things," he says. The idea is that with little mental energy to spare, you're emotionally more attuned to things that are likely to be the most threatening in the immediate moment. Inversely, when you're well rested, you may be more sensitive to positive emotions, which could benefit long-term survival, he suggests: "If it's getting food, if it's getting some kind of reward, finding a wife - those things are pretty good to pick up on."

Our daily existence is largely influenced by our ability "to understand our societal interactions, to understand someone else's emotional state of mind, to understand the expression on their face," says Ninad Gujar, a senior research scientist at Walker's lab and lead author of the study, which was recently submitted for publication. "These are the most fundamental processes guiding our personal and professional lives."

REM sleep appears to not only improve our ability to identify positive emotions in others; it may also round out the sharp angles of our own emotional experiences. Walker suggests that one function of REM sleep - dreaming, in particular - is to allow the brain to sift through that day's events, process any negative emotion attached to them, then strip it away from the memories. He likens the process to applying a "nocturnal soothing balm." REM sleep, he says, "tries to ameliorate the sharp emotional chips and dents that life gives you along the way." (See the top 10 medical breakthroughs of 2008.)

"It's not that you've forgotten. You haven't," he says. "It's a memory of an emotional episode, but it's no longer emotional itself."

That palliative safety-valve quality of sleep may be hampered when we fail to reach REM sleep or when REM sleep is disrupted, Walker says. "If you don't let go of the emotion, what results is a constant state of anxiety," he says.

The theory is consistent with new research conducted by Rebecca Bernert, a doctoral candidate in clinical psychology at Florida State University who specializes in the relationship between sleep and suicidal thoughts and behaviors, and who also presented her work at the sleep conference this week.

In her study of 82 men and women between the ages of 18 and 66 who were admitted into a mental-health hospital for emergency psychiatric evaluation, Bernert discovered that the presence of severe and frequent nightmares or insomnia was a strong predictor of suicidal thoughts and behaviors. More than half of the study participants had attempted suicide at least once in the past, and the 17% of the study group who had made an attempt within the previous month had dramatically higher scores in nightmare frequency and intensity than the rest. Bernert found that the relationship between nightmares or insomnia and suicide persisted, even when researchers controlled for other factors like depression.

Past studies have also established a link between chronic sleep disruption and suicide. Sleep complaints, which include nightmares, insomnia and other sleep disturbances, are listed in the current Substance Abuse and Mental Health Services Administration's inventory of suicide-prevention warning signs. Yet what distinguishes Bernert's research is that when nightmares and insomnia were evaluated separately, nightmares were independently predictive of suicidal behavior. "It may be that nightmares present a unique risk for suicidal symptoms, which may have to do with the way we process emotion within dreams," Bernert says.

If that's the case, it may help explain the recurring nightmares that characterize psychiatric conditions like posttraumatic stress disorder (PTSD), Walker says. "The brain has not stripped away the emotional rind from that experience memory," he says, so "the next night, the brain offers this up, and it fails again, and it starts to sound like a broken record ... What you hear [PTSD] patients describing is, 'I can't get over the event.' "

At the biological level, Walker explains, the "emotional rind" translates to sympathetic nervous-system activity during sleep: faster heart rate and the release of stress chemicals. Understanding why nightmares recur and how REM sleep facilitates emotional processing - or hinders it, when nightmares take place and perpetuate the physical stress symptoms - may eventually provide clues to effective treatments of painful mental disorders. Perhaps, even, by simply addressing sleeping habits, doctors could potentially interrupt the emotional cycle that can lead to suicide. "There is an opportunity for prevention," Bernert says.

The new findings highlight what researchers are increasingly recognizing as a two-way relationship between psychiatric disorders and disrupted sleep. "Modern medicine and psychiatry have consistently thought that psychological disorders seem to have co-occuring sleep problems and that it's the disorder perpetuating the sleep problems," says Walker. "Is it possible that, in fact, it's the sleep disruption contributing to the psychiatric disorder?"

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