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Personality disorders & Psychopathy

Posted on March 8, 2014 by JmaC

Introduction

A personality disorder is defined, in the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition (DSM-IV), as an enduring pattern of inner experience and behaviour that differs markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment. Personality disorders are a long-standing and maladaptive pattern of perceiving and responding to other people and to stressful circumstances.

The International Classification of Mental and Behavioural Disorders (ICD-10) (World Health Organization 1992), defines a personality disorder as: a severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality and nearly always associated with considerable personal and social disruption.

The aetiology of personality disorders remains obscure. Traditional belief is that these behaviours result from a dysfunctional early environment that prevents the evolution of adaptive patterns of perception, response and defence.

Factors in childhood which are postulated to be linked to personality disorder include:[1]
•Sexual abuse
•Physical abuse
•Emotional abuse
•Neglect
•Being bullied

Emotional or behavioural factors that might play a part include:
•Truanting
•Bullying others
•Being expelled/suspended
•Running away from home
•Deliberate self-harm
•Prolonged periods of misery

The evidence base supporting a link between personality disorder and genetic factors is growing.[2]

People with personality disorders are at increased risk for many psychiatric disorders. Mood disorders are a particular risk across all personality diagnoses. Patients with depression and personality disorder have a more persistent condition than those who have depression alone.[3] Some types of mental illnesses are more specific to particular personality disorders.

It is unsurprising from the above that many people with personality disorders offend against the law.[1]

Classification[4]

The ICD-10 gives nine categories of personality disorder. In DSM-IV there are ten personality disorders that are divided into three clusters, designated A, B, C. They will be used here.

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Cluster A

Paranoid personality disorder may present as a prodrome to delusional disorder or frank schizophrenia. There is risk of agoraphobia, major depression, obsessive-compulsive personality disorder and substance abuse. Schizoid personality disorder may precede major depression. Patients with schizotypal personality disorder may develop a brief psychotic disorder, schizophreniform disorder, or delusional disorder. When diagnosed, between 30 and 50% already have major depression and most have a history of at least one major depressive episode.

Schizoid personality disorder has a slight male preponderance.

Cluster B

Antisocial personality disorder increases the risk for anxiety disorders, substance abuse, somatisation disorder and pathological gambling. Borderline personality disorder is associated with substance abuse, eating disorders (particularly bulimia) and post-traumatic stress disorder (PTSD). Suicide is a high risk in borderline patients. Histrionic personality disorder is often associated with somatoform disorders. Narcissistic personality disorder increases risk for anorexia nervosa and substance abuse as well as depression.

Antisocial personality disorder is three times more frequent in men than in women. Borderline personality disorder is three times as common in women as in men. Men account for 50% to 75% of people with narcissistic personality disorder.

Cluster C

Avoidant personality disorder is associated with anxiety disorders, especially social phobia. Dependent personality disorder increases risk for anxiety disorders and adjustment disorder. People with obsessive-compulsive personality disorder may be more liable to myocardial infarction because of their type A lifestyles. They may also be at risk for anxiety disorders. Obsessive-compulsive personality disorder occurs twice as often in men as in women.

The DSM-IV classification has been criticised for having too many personality disorders and there being a considerable overlap between them. DSM-V, due for publication before the end of 2013, is likely to reduce the number from ten to five.[1]

Epidemiology[4]

Studies estimate that personality disorder affects 4-11% of the UK population and between 60-70% of the prison population. This is so common as to be almost a variation of normal rather than pathological. Many of the features we can possibly recognise in ourselves or others but, often, several features are required to make a diagnosis. In the prison population there are probably comparatively few who do not have at least one of personality disorder, mental illness, learning difficulties and substance abuse. International figures must be viewed with caution as the diagnosis is highly dependent upon culture. Figures for prevalence in American society are as follows:[4]
•Paranoid personality disorder – 0.5%-2.5%.
•Schizotypal personality disorder – 3%.
•Antisocial personality disorder – 3% of men, 1% of women.
•Borderline personality disorder – 2%.
•Histrionic personality disorder – 2%-3%.
•Narcissistic personality disorder – less than 1%.
•Avoidant personality disorder – 0.5%-1%.
•Obsessive-compulsive personality disorder – 1%.

There is no genetic difference in incidence.[2]

Personality disorders should not normally be diagnosed in children and adolescents because the development of personality is incomplete and symptomatic traits may not persist into adulthood. The general guideline is that the diagnosis is unsafe until the person is at least 18 years old. The criteria for diagnosis under DSM-IV are closely related to behaviours of young and middle adulthood. Hence, they are unreliable in the elderly.[4]

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Borderline Personality Disorder
Antisocial Personality Disorder
Medically Unexplained Symptoms (Assessment and Management)
Somatic Symptom Disorder

Presentation[4]

Personality disorders present with a wide range of problems in social relationships and regulation of mood. Such individuals have usually been like it throughout their adult lives. The patterns of perception, thought and response are fixed and inflexible, although their behaviour is often unpredictable. These patterns do not adhere to their own culture’s expectations. To meet the DSM-IV criteria for clinical diagnosis, the pattern must produce clinically significant distress or impairment in social, occupational or other important areas of functioning. The disorder occurs in all settings, social as well as work, and it is not limited to one sphere of activity.

Cluster A

They tend to be odd or eccentric:
Paranoid personality disorder They display pervasive distrust and suspicion. Common beliefs include:
•Others are exploiting or deceiving them.
•Friends and associates are untrustworthy.
•Information confided to others will be used maliciously.
•There is hidden meaning in remarks or events others perceive as benign.
•The spouse or partner is unfaithful. Pathological jealousy is sometimes called the Othello syndrome.

Schizoid personality disorder This type of personality disorder is less common in clinical settings:
•They are detached from others and have little desire for close relationships.
•There is little pleasure in activities.
•They appear indifferent to praise or criticism and often seem cold or aloof.

Schizotypal personality disorder They show marked eccentricities of thought, perception and behaviour. Typical examples include:
•Ideas of reference (believing that public messages are directed personally at them).
•Odd beliefs or magical thinking.
•Vague, circumstantial, or stereotyped speech.
•Excessive social anxiety that does not diminish with familiarity.
•Idiosyncratic perceptual experiences or bodily illusions.

Cluster B

They tend to be dramatic and emotional:

Antisocial personality disorder See separate article Antisocial Personality Disorder and National Institute for Health and Clinical Excellence (NICE) guidance.[5] People with antisocial personality disorder have a pervasive pattern of disregard for and violation of the rights of others and the rules of society. Onset must occur by age 15 years.

Borderline personality disorder See separate article Borderline Personality Disorder and NICE guidance.[6] The important feature of borderline personality disorder is a pervasive pattern of unstable and intense interpersonal relationships, self-perception and moods. Impulses are poorly controlled. At times they may appear psychotic because of the intensity of their distortions. It is a commonly overused diagnosis in DSM-IV.

Histrionic personality disorder
•They also display excessive emotion and attention-seeking behaviour.
•They are quite dramatic and often sexually provocative or seductive.
•Their emotions are labile.
•In clinical settings, their tendency to vague and impressionistic speech is often apparent.

Narcissistic personality disorder Narcissistic patients are grandiose and require admiration from others.[7] Features include:
•Exaggeration of their own abilities or achievements.
•Sense of entitlement.
•Exploitation of others.
•Lack of empathy.
•Envy of others.
•An arrogant, haughty attitude.

Cluster C

They tend to be anxious and fearful:

Avoidant personality disorder
•They are generally very shy.
•There is a pattern of social inhibition, feelings of inadequacy and hypersensitivity to rejection.
•Unlike patients with schizoid personality disorder, they do desire relationships but are paralysed, by their fear and sensitivity, into social isolation.

Dependent personality disorder Many people exhibit dependent behaviours and traits but people with dependent personality disorder have an excessive need to be cared for and that results in submissive and clinging behaviour, regardless of consequences. Diagnosis requires at least five of the following features:
•Difficulty making decisions without guidance and reassurance.
•Need for others to assume responsibility for most major areas of the person’s life.
•Difficulty expressing disagreement with others.
•Difficulty initiating activities because of lack of confidence.
•Excessive measures to obtain nurture and support.
•Discomfort or helplessness when alone.
•Urgent seeking for another relationship when one has ended.
•Unrealistic preoccupation with fears of being left to self-fend.

Obsessive-compulsive personality disorder
•People with obsessive-compulsive personality disorder are markedly preoccupied with orderliness, perfectionism and control.
•They lack flexibility or openness.
•Their preoccupations interfere with efficient function despite their focus on tasks.
•They are often scrupulous and inflexible about matters of morality, ethics and values, to a point beyond cultural norms.
•They are often ‘stingy’ as well as stubborn.

Somatic Symptom Disorder

Posted on March 8, 2014 by JmaC

Definition[1]

This is a chronic condition in which there are numerous physical complaints. These complaints can last for years and result in substantial impairment. In the DSM-5 the condition has been renamed somatic symptom disorder (SSD). There are significant departures from the DSM-IV categorisation which identified somatisation disorder, hypochondriasis, pain disorder,and undifferentiated somatoform disorder . All these are now included under the heading of SSD. Another innovation is that the symptoms need no longer to be medically unexplained but may or may not be associated with another medical condition. Thus, patients who had organic comorbidities such as heart disease, osteoarthritis or cancer – who were previously excluded under DSM-IV – can now be included in the diagnosis of SSD and be considered for appropriate treatment.

In the ICD-10, somatisation is defined as multiple, recurrent and frequently changing physical symptoms usually present for several years, (at least two years) before the patient is referred to a psychiatrist. More latterly, the term ‘unexplained somatic complaints’ was introduced ito describe patients presenting with any physical symptom and frequent medical visits in spite of negative investigations. This term is thought to be more acceptable to patients and has fewer aetiological implications.

The DSM-IV diagnosis of somatisation disorder requiring a specific number of complaints from four symptom groups is no longer a requirement in the DSM-5 diagnosis of SSD. Recent literature has used the terms somatisation disorder, somatic symptom disorder, functional somatic syndromes and somatisation syndromes more or less interchangeably. Much of the evidence base relating to somatisation disorder is, however, also relevant to SSD and has been quoted where appropriate.[2]

SSD.can be associated with a great deal of stigma; there is a risk that patients may be dismissed by their physicians as having problems that are ‘all in their head’.

However, as researchers study the connections between the brain, the digestive system and the immune system, SSD is becoming better understood. It should not be seen as a ‘malingering’ condition that the patient can control.

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Aetiology
•Recent research has shown higher percentages of this disorder in people with irritable bowel syndrome and in chronic pain patients.[3][4]
•A high proportion of patients with post-traumatic stress disorder also suffer from somatisation.[5]
•Antisocial personality disorder is associated with a risk for SSD.[6]
•The somatising patient seems to seek the sick role, which affords relief from stressful or impossible interpersonal expectations (‘primary gain’):[7] •In most societies this provides attention, caring and sometimes even monetary reward (‘secondary gain’).
•This is not malingering, because the patient is not aware of the process through which the symptoms arise, cannot will them away and genuinely suffers from the symptoms.

•Several studies have suggested an association between somatisation and a history of sexual or physical abuse in a significant proportion of patients.[8]
•One study reported that patients with somatisation syndromes were often associated with the interpersonal representation of the unmet need for closeness with others.[9]
•Another study suggested that neuroendocrine genes may be implicated.[10] .

Epidemiology
•Information concerning the epidemiology of SSD as strictly defined by DSM-5 is hard to come by, as the umbrella term encompasses several different disorders. Such information as does exist in the literature chiefly relates to the individual disorders identified in DSM-IV.
•Epidemiological studies generally quote a prevalence of 0.1-0.2% for the general population and a figure of 5% has been quoted for general practice.[11] One general practice study reported a prevalence rate of somatoform disorders of 16.1% increasing to 21.9% when disorders with mild impairment were included.[12]
•The disorder usually begins before the age of 30 and occurs more often in women than in men.[13][14]

Presenting features

DSM-5 has reformulated the criteria to rely less on strict patterns of somatic symptoms and more on the degree to which a patient’s thoughts, feelings and behaviours about their symptoms are disproportionate or excessive.[1] The symptoms are generally severe enough to affect work and relationships and lead the person to consult a doctor and take medication. A lifelong history of ‘sickliness’ is often present:
•DSM-5 acknowledges that patients may have a combination of symptoms for which an organic cause can be found and symptoms for which there is no underlying physical explanation.
•Stress often worsens the symptoms.

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Symptoms

Some of the numerous symptoms that can occur with somatisation disorder include:
•Cardiac: •Shortness of breath
•Palpitations
•Chest pain

•Gastrointestinal: •Vomiting
•Abdominal pain
•Difficulty swallowing
•Nausea
•Bloating
•Diarrhoea

•Musculoskeletal: •Pain in the legs or arms
•Back pain
•Joint pain

•Neurological: •Headaches
•Dizziness
•Amnesia
•Vision changes
•Paralysis or muscle weakness

•Urogenital: •Pain during urination
•Low libido
•Dyspareunia
•Impotence
•Dysmenorrhoea, irregular menstruation and menorrhagia

Making a diagnosis
•A thorough physical examination and diagnostic tests are performed to rule out physical causes – which tests are done are determined by the symptoms present.
•A psychological evaluation should also be performed to rule out related disorders: •However, finding evidence of a psychiatric condition does not rule somatisation in or out.
•It can be a clue to the diagnosis.
•There is considerable evidence that patients with common psychiatric conditions such as depression and anxiety disorders may present to primary care physicians with nonspecific somatic symptoms, including fatigue, aches and pains, palpitations, dizziness and nausea.

Somatisation is often a diagnosis of exclusion; however, it is much more effective to pursue a positive diagnosis of somatisation when the patient presents with typical features:
•There may be multiple symptoms, often occurring in different organ systems.
•Symptoms that are vague or that exceed objective findings.
•Chronic course.
•Presence of a psychiatric disorder.
•History of extensive diagnostic testing.
•Rejection of previous physicians.

The general practitioner’s emotional response to a patient can serve as an early cue to pursue a somatisation diagnosis:
•A feeling of frustration or anger at the number and complexity of symptoms and the time required to evaluate them in an apparently well person.
•A sense of being overwhelmed by a patient who has had numerous evaluations by other physicians.

These can be a signal to the clinician to consider somatisation in the differential diagnosis early in the patient’s evaluation.

Management

Doctors’ explanations of their symptoms are often at odds with these patients’ own thinking and clinicians should take time to ensure their explanations are ‘tangible, exculpating and involving’. Empowering explanations have been shown to improve these patients’ well-being.[13]

The first occasion that the diagnosis is discussed (after the initial investigations have failed to show any organic pathology) is a key moment in the physician-patient relationship. The challenge is to describe the condition to the patient in a manner that avoids any implication of a psychosomatic illness. One journal suggests the following:

‘The results of my examination and of the tests we conducted show that you do not have a life-threatening illness. However, you do have a serious and impairing medical condition, which I see often but which is not completely understood. Although no treatment is available that can cure it completely, there are a number of interventions that can help you deal with the symptoms better than you have so far.'[15]

Once other causes have been ruled out and a diagnosis of somatisation disorder secured, the goal of treatment is to help the person learn to control the symptoms:
•There is often an underlying mood disorder which can respond to antidepressants.
•Unfortunately, those with this disorder rarely admit that it can be caused, at least in part, by mental health problems and may refuse psychiatric treatment.

It is important to ask open-ended questions. The BATHE technique provides a framework for exploration of psychosocial stressors in less than five minutes:[16]

•Background: ‘What is going on in your life?’
•Affect: ‘How do you feel about it?’
•Trouble: ‘What troubles you the most about that situation?’
•Handle: ‘What helps you handle that?’
•Empathy: ‘This is a tough situation to be in. Your reaction makes sense to me.’

It is sensible to avoid setting unrealistic goals:
•In severe cases of somatoform disorder, symptoms are unlikely to resolve completely. Therefore, avoid making the goal of the treatment plan to relieve the patient’s illness. The physician and patient will soon become frustrated and tempted to engage in a new flurry of diagnostic tests and invasive procedures.
•Attempts to ‘take away the symptom’ may cause the patient to substitute another symptom as a result of the need-to-be-sick phenomenon.

A better goal is to help the patient succeed in coping with the symptoms. Treatment is successful if it keeps the patient out of the hospital.

General advice
•The whole primary care health team should be aware of the diagnosis and management plan. This will make the approach to management consistent across the practice.
•Interventions directed at reducing specific sources of stress are most helpful; these may include advice about dealing with marital conflict.
•Some physical exercise is important, as it prevents loss of fitness, enhances self-esteem and provides an opportunity for patients to take a break from oppressive duties or unpleasant situations. One study reported a reduction in symptoms with low-grade short bouts of exercise.[16]
•The importance of pleasurable private time should be emphasised. This may include yoga classes or meditation, bowling or nature walks, which, under the general title of ‘stress management’, can be presented as necessary medical treatments.[17]

Some patients may request tests repeatedly but they should be reminded that they will be followed with frequent and regular visits so that any problems will be identified early. Sometimes requesting investigations becomes a ‘negotiating’ process designed to give the patient some control over what test is performed and to enhance the trust level between the physician and patient.

NB: somatising patients also develop organic diseases, especially common disorders such as osteoarthritis, coronary artery disease and cancer. Thus, preventative health measures and regular screenings must be integrated into the overall treatment plan.

Psychotherapy

Approaches derived from cognitive behavioural therapy have been shown to reduce the intensity and frequency of somatic complaints and to improve functioning in many somatising patients:[18]
•This type of treatment starts with the mutual agreement that whatever the patient has been thinking and doing about the condition has not been successful.
•It then begins to challenge the patient’s beliefs and maladaptive behaviours in a caring manner.
•Short course intervention therapy (eight to 16 sessions) specifically for treatment of somatising patients has been shown to be remarkably effective in improving function and reducing distress.[19]
•The sessions combine general advice such as stress management, problem solving and training in social skills, with specific interventions targeted at the amplification and need-to-be-sick features of somatisation.

Mindfulness therapy is a feasible and acceptable treatment.[20]

Pharmacological

There are psychiatric disorders associated with somatisation, specifically anxiety and depression. These respond well to treatment but, especially with antidepressants,[21] it is important to start with low doses and to increase them progressively to avoid side-effects that may be present at the beginning of treatment and which might discourage the patient from continuing. One study reported the successful use of duloxetine.[22]

A supportive relationship with a sympathetic healthcare provider is the most important aspect of treatment. Regular appointments should be maintained to review symptoms and the person’s coping mechanisms.

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Complications
•Complications may result from invasive testing and from multiple evaluations that are performed while looking for the cause of the symptoms.
•A dependency on pain relievers or sedatives may develop.
•A poor relationship with the healthcare provider seems to worsen the condition, as does evaluation by many providers.

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Anti-social personality disorder

Posted on March 8, 2014 by JmaC

Antisocial personality disorder is one of nine personality disorders defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition (DSM-IV). For more information, see separate article Personality Disorders and Psychopathy.

People with antisocial personality disorder exhibit traits of impulsivity, high negative emotionality, low conscientiousness and associated behaviours including irresponsible and exploitative behaviour, recklessness and deceitfulness.[1][2]

People with antisocial personality disorder have often grown up with parental conflict and harsh inconsistent parenting. Their childhoods have typically featured parental inadequacies and often transfer of care to outside agencies. Associated with this is a high incidence of truancy, delinquency and substance misuse.[3] This in turn results in increased rates of unemployment, problems with housing and difficulties with relationships. Many people with antisocial personality disorder have a criminal conviction and are imprisoned or die prematurely as a result of reckless behaviour.[1][2]

Criminal behaviour is central to the definition of antisocial personality disorder but there is much more to the disorder than just criminal behaviour. It is often preceded by other long-standing difficulties (socio-economic, educational, family, relationship). Psychopathy is considered to be a considerably severe form of antisocial personality disorder.[2]

The National Institute for Health and Clinical Excellence (NICE) guidance[1] exemplifies a progression from recognition and definition towards more effective management. The challenge posed by this guidance to the mental health services, substance misuse services, social care and criminal justice system is considerable.

Epidemiology[4]
•The prevalence of antisocial personality disorder in the general population is 3% in men and 1% in women.
•The prevalence of antisocial personality disorder among prisoners is less than 50%.
•However, only 47% of people with antisocial personality disorder have significant arrest records.

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Presentation[4]

Features include:
•Unstable interpersonal relationships.
•Disregard for the consequences of their behaviour.
•A failure to learn from experience.
•Egocentricity.
•A disregard for the feelings of others.
•A wide range of interpersonal and social disturbance.
•Comorbid depression and anxiety.
•Comorbid alcohol and drug misuse.

It is important to note that antisocial personality disorder is not formally diagnosed before the age of 18 but there may be a history of conduct disorders before this age.

Conduct disorders may be manifested as antisocial, aggressive or defiant behaviour, which is persistent and repetitive. This includes aggressive behaviour (to people or animals), destruction of property, deceitfulness, theft and serious rule-breaking.

Diagnostic criteria[4][5]

People with antisocial personality disorder have a pervasive pattern of disregard for and violation of the rights of others and the rules of society. A history of conduct disorder before the age of 15 is a requirement for a diagnosis of antisocial personality disorder (in the DSM-IV criteria) and includes the following features:
•Repeated breaches of the law. They may well have recurrent criminal convictions.
•Frequent lying and deception, even when there is no obvious gain.
•Physical aggression.
•Reckless disregard for safety of self or others.
•Utter irresponsibility in work and family environments.
•Lack of remorse.

The impending DSM-V classification may well see a re-assessment of the diagnostic criteria in due course.[6]

Differential diagnosis[4]

Diagnosis can be very difficult because of overlapping features and the high frequency of comorbid conditions and problems. Premorbid and developmental history from third parties can be helpful when making a diagnosis:
•Alcoholism.
•Mental disorders secondary to medical conditions (head injuries, seizure disorders).
•Anxiety disorders.
•Other personality disorders.
•Mental retardation.
•Brief psychotic disorder.
•Post-traumatic stress disorder.
•Depression.
•Schizoaffective disorder.
•Schizophrenia.
•Ganser’s syndrome.

Investigations[4]
•Toxicology screen because substance abuse is common (as with many personality disorders). Intoxication can lead patients to present with some features of personality disorders.
•Screening for HIV and other sexually transmitted diseases may be appropriate because of the poor impulse control and disregard of risk associated with antisocial personality disorder.
•Psychological testing may support or direct the clinical diagnosis. For example: •The Minnesota Multiphasic Personality Inventory (MMPI)[7]
•The Eysenck Personality Inventory (EPI)[8]
•The Personality Diagnostic Questionnaire (PDQ)[9]
These have not been reliably validated against DSM-IV Text Revision (DSM-IV-TR) diagnoses.

The Structured Clinical Interview for DSM-IV-TR for Axis II Disorders (SCID-II) can also be used to aid in diagnosis.[2]

Associated diseases[2][4]
•Anxiety.
•Alcohol misuse.
•Drug misuse.
•Depression.
•Attention deficit hyperactivity disorder (ADHD) in childhood.

Management[4][10]

Antisocial personality disorder poses a big challenge to the different agencies which frequently and almost inevitably, have to manage individuals with this disorder. Management by any single agency is not usually possible or recommended. Management in general practice alone is not recommended and referral to psychiatric services is essential.

Practice tips
•Such patients can create very difficult and frightening problems for staff in primary healthcare.
•It is important to identify patients who have antisocial personality disorders and enlist help with appropriate referral.
•It is also important to identify patients at risk of violent behaviour. Assessing risk of violence is not routine in primary care but, if such assessment is required, consider:[1] •Current or previous violence, including severity, circumstances, precipitants and victims.
•The presence of comorbid mental disorders and/or substance misuse.
•Current life stressors, relationships and life events.
•Additional information from written records or families and carers (subject to the person’s consent and right to confidentiality), because the person with antisocial personality disorder might not always be reliable.

•Once identified, a tailored management plan can be used to avoid crises and violent episodes. This will involve staff training and collaboration with other agencies. Use of ‘panic buttons’, chaperones and other measures should be considered.

The treatment of people with antisocial personality disorder must involve a wide range of services including particularly:
•Mental health services.
•Substance misuse services.
•Social care.
•The criminal justice system and associated forensic mental health services.[2]

Drug treatment

No drug has UK marketing authorisation specifically for the treatment of antisocial personality disorder. However, antidepressants and antipsychotics are often used to treat some of the associated problems and symptoms.

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Borderline Personality Disorder
Personality Disorders and Psychopathy

Psychological treatments

Psychotherapy is at the core of care for personality disorders generally. In theory, psychotherapy aims to help patients cope with the disorder by, for example:
•Improving perceptions of social and environmental stressors.
•Improving responses to social and environmental stressors.

Different types of psychotherapy have been used to try to achieve such aims. Cognitive behavioural therapy and group therapy are perhaps the most widely used and available forms of psychotherapy. These should target reduction in offending and antisocial behaviour.[1]

Other considerations
•Good communication is essential between all concerned but especially between healthcare professionals and people with antisocial personality disorder.
•NICE recommends that services should consider establishing antisocial personality disorder networks, where possible linked to other personality disorder networks. They may be organised at the level of primary care trusts, local authorities, strategic health authorities or government offices.[1] These networks should be multi-agency.
•Treatment and care should take into account people’s needs and preferences. People with antisocial personality disorder should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.[1] If the person is under 16, healthcare professionals should follow the guidelines in ‘Seeking consent: working with children’.[11]
•If the person agrees, carers (who may include family and friends) should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need.[1]

Complications[4]
•Suicide
•Substance abuse
•Accidental injury
•Depression
•Homicide

Prognosis[2]

The disorder used to be thought of as lifelong. However, a growing body of research suggests that positive changes can be seen over time. Many patients no longer meet the diagnostic criteria for the condition after a decade. It is acknowledged that the condition is difficult to diagnose and that misdiagnosis may be partly to blame for this ‘improvement’ but it is also considered that many patients do respond to therapeutic interventions. Core characteristics such as lack of empathy do not lessen but evidence suggests that patients develop more control over their impulsivity and cultivate a sense of responsibility.[2]

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Prevention[4]

The incidence of antisocial personality disorder is reduced during times of war and in many Asian cultures. This suggests that social cohesion and an emphasis on communities rather than individuals are significant preventative factors.[2] Families or carers are thus important in prevention and treatment of antisocial personality disorder.[1] NICE suggests that services should establish robust methods to identify children at risk of developing conduct problems and that vulnerable parents could be identified antenatally. For example, identifying:
•Parents with other mental health problems, or with significant drug or alcohol problems.
•Mothers aged younger than 18 years, particularly those with a history of maltreatment in childhood.
•Parents with a history of residential care.
•Parents with significant previous or current contact with the criminal justice system.

The interventions employed after identification of at-risk parents are many and varied according to the problems identified and the age. Examples include:
•Parenting courses
•Anger management
•Cognitive problem solving
•Family therapy
•Multi-systemic therapy
•Multidimensional treatment
•Foster care

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Anxiety Disorder

Posted on March 8, 2014 by JmaC

Most people feel anxious from time to time. However, anxiety can become abnormal if it interferes with your day-to-day activities. Anxiety is a symptom of various anxiety disorders which are discussed below. They can often be treated. Treatments include various talking treatments, and medication.

This leaflet is part of our series on anxiety and phobias

Agoraphobia
Generalised Anxiety Disorder
Obsessive-compulsive Disorder
Panic Disorder
Social Anxiety Disorder

What is anxiety?

When you are anxious you feel fearful and tense. In addition you may also have one or more unpleasant physical symptoms. For example, you might have a fast heart rate, a thumping heart (palpitations), feeling sick, shaking (tremor), sweating, dry mouth, chest pain, headaches, fast breathing.

The physical symptoms are partly caused by the brain which sends lots of messages down nerves to various parts of the body when you are anxious. The nerve messages tend to make the heart, lungs, and other parts of the body work faster. In addition, you release stress hormones (such as adrenaline) into the bloodstream when you are anxious. These can also act on the heart, muscles and other parts of the body to cause symptoms.

Anxiety is normal in stressful situations, and can even be helpful. For example, most people will be anxious when threatened by an aggressive person, or before an important race. The burst of adrenaline and nerve impulses which we have in response to stressful situations can encourage a ‘fight or flight’ response.

Anxiety is abnormal if it:
•Is out of proportion to the stressful situation; or
•Persists when a stressful situation has gone, or the stress is minor; or
•Appears for no apparent reason when there is no stressful situation.

Related articles q

Phobias
Social Anxiety Disorder
Panic Attack and Panic Disorder

What are anxiety disorders?

There are various conditions (disorders) where anxiety is a main symptom. You may have an anxiety disorder if anxiety symptoms interfere with your normal day-to-day activities, or if worry about developing anxiety symptoms affects your life. About 1 in 20 people have an anxiety disorder at any one time. The following is a brief overview of the main anxiety disorders. Some people have features of more than one type of disorder.

Reactions to stress

Anxiety can be one of a number of symptoms as a reaction to stressful situations. There are three common types of reaction disorders:

Acute reaction to stress (sometimes called acute stress reaction)

Acute means the symptoms develop quickly, over minutes or hours, reacting to the stressful event. Acute reactions to stress typically occur after an unexpected life crisis such as an accident, bereavement, family problem, bad news, etc. Sometimes symptoms occur before a known situation which is difficult. This is called situational anxiety. This may occur, for example, before an examination, an important race, a concert performance, etc.

Symptoms usually settle fairly quickly, but can sometimes last for several days or weeks. Apart from anxiety, other symptoms include low mood, irritability, emotional ups and downs, poor sleep, poor concentration, wanting to be alone.

See separate leaflet called Acute Stress Disorder for more details.

Adjustment reaction

This is similar to the above, but symptoms develop days or weeks after a stressful situation, as a reaction or adjustment to the problem. For example, as a reaction to a divorce or house move. Symptoms are similar to acute reaction to stress but may include depression. The symptoms tend to improve over a few weeks or so.

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) may follow a severe trauma such as a serious assault or life-threatening accident. Symptoms last at least one month, often much longer. Anxiety is only one symptom which may come and go. The main symptoms of PTSD are:
•Recurring thoughts, memories, images, dreams, or flashbacks of the trauma, which are distressing.
•You try to avoid thoughts, feelings, conversations, places, people, activities or anything else which may trigger memories or thoughts of the trauma.
•Feeling emotionally numb and detached from others. You may find it difficult to have loving feelings.
•Your outlook for the future is often pessimistic. You may lose interest in activities which you used to enjoy.
•Increased arousal which you did not have before the trauma. This may include difficulty sleeping, being irritable, difficulty concentrating, and increased vigilance.

See separate leaflet called Post-traumatic Stress Disorder for more details.

Phobic anxiety disorders

A phobia is strong fear or dread of a thing or event. The fear is out of proportion to the reality of the situation. Coming near or into contact with the feared situation causes anxiety. Sometimes even thinking of the feared situation causes anxiety. Therefore, you end up avoiding the feared situation, which can restrict your life and may cause suffering.

Social anxiety disorder

Social anxiety disorder (also known as social phobia) is possibly the most common phobia. With social anxiety disorder you become very anxious about what other people may think of you, or how they may judge you. Therefore, you fear meeting people, or ‘performing’ in front of other people, especially strangers. You fear that you will act in an embarrassing way, and that other people will think that you are stupid, inadequate, weak, foolish, crazy, etc. You avoid such situations as much as possible. If you go to the feared situation you become very anxious and distressed.

See separate leaflet called Social Anxiety Disorder for more details.

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Agoraphobia

This too is common. Many people think that agoraphobia means a fear of public places and open spaces. But this is just part of it. If you have agoraphobia you tend to have a number of fears of various places and situations. So, for example, you may have a fear of:
•Entering shops, crowds, and public places.
•Travelling in trains, buses, or planes.
•Being on a bridge or in a lift.
•Being in a cinema, restaurant, etc where there is no easy exit.

But they all stem from one underlying fear. That is, a fear of being in a place where help will not be available, or where you feel it may be difficult to escape to a safe place (usually to your home). When you are in a feared place you become very anxious and distressed, and have an intense desire to get out. To avoid this anxiety many people with agoraphobia stay inside their home for most or all of the time.

See separate leaflet called Agoraphobia for more details.

Other specific phobias

There are many other phobias of a specific thing or situation. For example:
•Fear of confined spaces or of being trapped (claustrophobia).
•Fear of certain animals.
•Fear of injections.
•Fear of vomiting.
•Fear of being alone.
•Fear of choking.

But there are many more.

Other anxiety disorders

Panic disorder

Panic disorder means that you get recurring panic attacks. A panic attack is a severe attack of anxiety and fear which occurs suddenly, often without warning, and for no apparent reason. The physical symptoms of anxiety during a panic attack can be severe and include a thumping heart (palpitations), trembling, feeling short of breath, chest pains, feeling faint, numbness, or pins and needles. Each panic attack usually lasts 5-10 minutes, but sometimes they come in waves for up to two hours.

See separate leaflet called Panic Disorder for more details.

Generalised anxiety disorder

If you have generalised anxiety disorder (GAD) you have a lot of anxiety (feeling fearful, worried and tense) on most days. The condition persists long-term. Some of the physical symptoms of anxiety (detailed above) may come and go. Your anxiety tends to be about various stresses at home or work, often about quite minor things. Sometimes you do not know why you are anxious. In addition, you will usually have three or more of the following symptoms:
•Feeling restless, on edge, or ‘keyed up’ a lot of the time.
•Tiring easily.
•Difficulty concentrating and your mind going blank quite often.
•Being irritable a lot of the time.
•Muscle tension.
•Poor sleep (insomnia). Usually it is difficulty in getting off to sleep, or difficulty in staying asleep.

See separate leaflet called Generalised Anxiety Disorder for more details.

Mixed anxiety and depressive disorder

In some people, anxiety can be a symptom when you have depression. Other symptoms of depression include low mood, feelings of sadness, sleep problems, poor appetite, irritability, poor concentration, decreased sex drive, loss of energy, guilt feelings, headaches, aches, pains, and palpitations. Treatment tends to be aimed mainly at easing depression, and the anxiety symptoms often then ease too.

See separate leaflet called Depression for more details about depression.

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) consists of recurring obsessions, compulsions, or both.
•Obsessions are recurring thoughts, images, or urges that cause you anxiety or disgust. Common obsessions are fears about dirt, contamination, germs, disasters, violence, etc.
•Compulsions are thoughts or actions that you feel you must do or repeat. Usually a compulsion is a response to ease the anxiety caused by an obsession. A common example is repeated hand washing in response to the obsessional fear about dirt or germs. Other examples of compulsions include repeated cleaning, checking, counting, touching, and hoarding of objects.

See separate leaflet called Obsessive-compulsive Disorder for more details.

What is the treatment for anxiety disorders and phobias?

The main aim of treatment is to help you to reduce symptoms so that anxiety no longer affects your day-to-day life.

The treatment options depend on what condition you have, and how severely you are affected. They may include one or more of the following:

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NON-MEDICATION TREATMENTS

Understanding

Understanding the cause of symptoms, and talking things over with a friend, family member or health professional may help. In particular, some people worry that the physical symptoms of anxiety, such as a thumping heart (palpitations), are due to a physical illness. This can make anxiety worse. Understanding that you have an anxiety disorder is unlikely to cure it, but it often helps.

Counselling

This may help some people with certain conditions. For example, counselling which focuses on problem-solving skills may help if you have GAD.

Anxiety management courses

These may be an option for some conditions, if courses are available in your area. The courses may include: learning how to relax, problem-solving skills, coping strategies, and group support.

Cognitive and behavioural therapy

These therapies, if available in your area, can work well for persisting anxiety disorders and phobias:
•Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as anxiety and depression. The therapist helps you to understand your current thought patterns – in particular, to identify any harmful, unhelpful, and false ideas or thoughts which you have that can make you anxious (or depressed). The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part, and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious or develop physical symptoms of anxiety.
•Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your behaviour or response to the feared object is harmful, and the therapist aims to help you to change this. Various techniques are used, depending on the condition and circumstances. As with cognitive therapy, several sessions are needed for a course of therapy.
•Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours. (Note: cognitive and behavioural therapies do not look into the events of the past. They deal with, and aim to change, your current thought processes and/or behaviours.) See separate leaflet called Cognitive Behavioural Therapy (CBT) for more details.

Self-help

There are various national groups which can help by giving information, advice and support (see below). They, or your doctor or practice nurse, may also be able to put you in touch with a local group for face-to-face support.

You can also get leaflets, books, tapes, videos, etc, on relaxation and combating stress. They teach simple deep-breathing techniques and other measures to relieve stress, help you to relax, and possibly ease anxiety symptoms. See separate leaflet in this series, called Stress and Tips on How to Avoid It.

MEDICATION

Antidepressant medicines

These are commonly used to treat depression, but also help to reduce the symptoms of anxiety even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing anxiety symptoms.
•Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up and the anxiety symptoms are helped. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good. This is often too soon to know if the medication will work.
•Antidepressants are not tranquillisers, and are not usually addictive.
•There are several types of antidepressants, each with various pros and cons. They may differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used for anxiety disorders. Two examples of SSRIs are escitalopram and sertraline.
•Note: after first starting an antidepressant, in some people the anxiety symptoms become worse for a few days before they start to improve. Your doctor or practice nurse will want to keep a check on you in the first few weeks of treatment to see if you have any problems.

Benzodiazepines

Benzodiazepines such as diazepam used to be the most commonly prescribed medicines for anxiety. They were known as the minor tranquilisers but they do have some serious known side-effects. They often work well to ease symptoms. The problem is they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Now they are not used much for persistent anxiety conditions. A short course of up to two weeks may be an option for anxiety which is very severe and short-term, or now and then to help you over a bad spell if you have persistent anxiety symptoms.

Buspirone

Buspirone is sometimes prescribed to treat GAD. It is an anti-anxiety medicine, but different to the benzodiazepines and is not thought to be addictive. It is not clear how it works. It is thought to affect serotonin, a brain chemical which may be involved in causing anxiety symptoms.

Beta-blocker medicines

A beta-blocker, for example propranolol, can ease some of the physical symptoms such as trembling and a thumping heart (palpitations). They do not directly affect the mental symptoms such as worry. However, some people relax more easily if their physical symptoms are eased. These tend to work best in short-lived (acute) anxiety. For example, if you become more anxious before performing in a concert then a beta-blocker may help to ease ‘the shakes’.

In some cases a combination of treatments such as cognitive therapy and an antidepressant may work better than either treatment alone.

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Alcohol and anxiety

Although alcohol may ease symptoms in the short term, don’t be fooled that drinking helps to cure anxiety. In the long run, it does not. Drinking alcohol to ‘calm nerves’ can lead to problem drinking and may make problems with anxiety and depression worse in the long term. See a doctor if you are drinking alcohol (or taking street drugs) to ease anxiety.

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Panic Disorder

Posted on March 8, 2014 by JmaC

Panic disorder can be a severe and disabling illness and is common in primary care. It can be difficult to assess when it presents acutely, as many symptoms may also be experienced with physical illness. Sufferers often present repeatedly to their GP or local emergency department with worrying episodes of multiple symptoms that the patient may ascribe to life-threatening illness.

This condition often co-exists with agoraphobia – the avoidance of exposed situations for fear of panic or inability to escape. Agoraphobia is not a stand-alone diagnosis and occurs very rarely without panic disorder. Panic disorder is often classified into panic disorder with, or without, agoraphobia. Social anxiety disorder can often co-exist and is diagnosed where the situations avoided are predominantly social and interactive in nature.

The first panic attack may be associated with a stressful episode but gradually the attacks become dissociated and occur ‘out of the blue’. It is a chronic condition with relapses and leads to much distress and social dysfunction.[1] Gamma-aminobutyric acid (GABA) receptor dysfunction is thought to play an important role in panic disorder pathophysiology.

Definition
Panic attacks must be associated with >1 month’s duration of subsequent, persisting anxiety about recurrence of the attacks, the consequences of the attacks, or significant behavioural changes associated with them.

A panic attack is defined as a discrete episode of intense subjective fear, where at least four of the characteristic symptoms, listed below, arise rapidly and peak within 10 minutes of the onset of the attack: •Attacks usually last at least 10 minutes but their duration is variable.
•The symptoms must not arise as a result of alcohol or substance misuse, medical conditions or other psychiatric disorders, in order to satisfy the diagnostic criteria.

Characteristic symptoms experienced during panic attacks
Panic disorder manifests as the sudden, spontaneous and unanticipated occurrence of panic attacks, with variable frequency, from several in a day to just a few per year: •Palpitations, pounding heart or accelerated heart rate.
•Sweating.
•Trembling or shaking.
•Dry mouth.
•Feeling short of breath, or a sensation of smothering.
•Feeling of choking.
•Chest pain or discomfort.
•Nausea or abdominal distress.
•Feeling dizzy, unsteady, light-headed or faint.
•Derealisation or depersonalisation (feeling detached from oneself).
•Fear of losing control or ‘going crazy’.
•Fear of dying.
•Numbness or tingling sensations.
•Chills or hot flushes.

Epidemiology and aetiology

Panic disorder is a common problem. The prevalence of panic disorder with or without agoraphobia in one UK study was 1.70%.[2] In the USA, lifetime prevalence is estimated at 3-5.6% for panic attacks and 1.5-5% for panic disorder. Psychiatric case-finding studies of patients presenting with chest pain to emergency departments found that up to 25% satisfied criteria for panic disorder.[3]

There are many aetiological theories, none of which are proven in isolation. Several aetiological factors may contribute to its occurrence in a given individual. The postsynaptic serotonergic/adrenergic hypersensitivity hypotheses are probably the most biologically plausible and relevant to treatment response but there are also important genetic and environmental factors involved.

Panic disorder can also be associated with the use of certain medications: selective serotonin reuptake inhibitors (SSRIs), benzodiazepine withdrawal and withdrawal from zopiclone. These should be considered in assessing any patient who presents with panic disorder.

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Presentation

Symptoms

The condition is commonly unrecognised and untreated. Most patients are seen in general practice, although patients may present to A&E with somatic symptoms such as chest pain. As attention is given to the physical symptoms, the diagnosis of panic attacks may not be made. Therefore, a high index of suspicion is needed. Screening tools are available.[4][5]

As detailed above the patient will describe a history of sudden onset of episodes of panic featuring four or more of the characteristic symptoms. These will usually peak within 10 minutes and can last for 20-30 minutes but they will rarely persist beyond one hour. There is marked individual variation in the length of attacks. It is worth asking about any triggering caused by alcohol or drugs (including legal drugs such as caffeine, nicotine, complementary remedies or over-the-counter (OTC) preparations). Enquiry about other triggers for the attacks helps in constructing the differential diagnosis:
•Those that arise unexpectedly and without any obvious triggering situation or event are characteristic of panic disorder without agoraphobia.
•Those that arise in a predictable way as a follow-on to a given anxiety-provoking situation or event usually reflect a specific phobia-type diagnosis, or panic disorder with social phobia if the precipitant is a social phenomenon.
•Those that arise in an inconsistent or unpredictable way following exposure to a given anxiety-provoking situation or event suggest panic disorder with agoraphobia.

One cross-sectional study of older patients with persistent dizziness found that anxiety and/or a depressive disorder were present in 22% and this could be a presentation for conditions such as panic disorder.[6]

Signs

There are no specific physical signs associated with the condition, unless the patient is seen during a panic attack, when increased sympathetic outflow may manifest as tachycardia, hypertension, tremors, sweating, etc.

During the panic attack the patient may be extremely preoccupied about suffering death or a severe, life-threatening physical illness. Examination of the mental status reveals no specific findings other than a reflection of anxiety and/or urgency in their appearance, speech or mood (this is not necessary to make the diagnosis). The patient’s affect should be congruent with their mental state. Thought processes should be normal and thought content should be essentially normal but may be preoccupied with death or illness. Thought content should be assessed for suicidal or homicidal ideation, or thoughts of self-harm. Judgement and insight are normally preserved. Abnormalities in thought processes or content (other than impulsive thoughts of suicide or self-harm) suggest alternative psychiatric diagnoses. The presence of incongruent affect should raise concerns that panic disorder is the wrong diagnosis.

Associated diseases

Psychiatric disorders

Panic disorder is frequently associated with agoraphobia (affecting about 26% of sufferers) and/or social phobia (affecting about 33% of sufferers). There is a significant association with mood disorders, particularly depression, with lifetime prevalence rates as high as 50-60%. There appears to be a higher risk of suicide attempts than in the general population. One study found that 98% of panic disorder patients had at least one comorbid disorder.[7] Major depressive disorder and other anxiety disorders were the most common. The other anxiety disorders tended to be persistent, although other depressive disorders and alcohol use disorders had high remission rates.[7] Alcohol and substance misuse can complicate the picture and these can be used in some cases to self-medicate.

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Psychotherapy and its Uses
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Medical conditions

These may co-exist but one would not generally use the term panic disorder if the symptoms arise directly from the physical illness. Cardiovascular disease such as mitral valve prolapse, cardiomyopathy and hypertension are associated. Chronic obstructive airways disease and migraine headaches are also present in a larger proportion of sufferers than chance would suggest, as are functional disorders such as irritable bowel syndrome and tension-type headache. A recent link with joint hypermobility disorder has been elucidated, further suggesting a genetic basis for panic disorder.[8]

Differential diagnosis

Although a good description of the episode may suggest a panic attack, it is important to exclude other organic conditions. For example, there is a rare case report of a cingulate ganglioma presenting as panic attacks in a teenager.[9] More typical alternatives include:

Psychiatric conditions
•Agoraphobia (often co-exists).
•Social anxiety disorder (often co-exists).
•Anxiety disorders, including generalised anxiety disorder (may co-exist).
•Adjustment disorders.
•Bipolar disorder.
•Depression.
•Dissociative disorders.
•Factitious illness.
•Somatisation disorder.
•Mental symptoms arising as a result of physical illness.
•Obsessive-compulsive disorder.
•Specific phobic disorders.
•Post-traumatic stress disorder.
•Stimulant-drug misuse (including caffeine-related illness).

Physical conditions
•Hyperthyroidism.
•Phaeochromocytoma.
•Carcinoid syndrome.
•Hypoglycaemic episodes (possibly due to insulinoma in those not using insulin/oral hypoglycaemic agents).
•Paroxysmal cardiac dysrhythmia.
•Mitral valve prolapse.
•Myocardial infarction.
•Recurrent small pulmonary emboli.
•Epileptiform disorders, particularly temporal lobe epilepsy.
•Withdrawal from alcohol/sedatives/opiates.
•Paroxysmal vestibular disorders – eg, Ménière’s disease.

Nightmare disorder

Posted on March 8, 2014 by JmaC

Nightmares can be defined as vivid and terrifying dreams which awaken the dreamer from sleep. Typically, the dreamer wakes from the rapid eye movement (REM) stage of sleep and can remember a detailed, perhaps bizarre dream plot.[1][2]

Although such dreams are part of normal human experience, for some they can be a recurrent and extremely troubling problem. This is particularly so for young children but they can be disruptive to the whole family. Explanation and reassurance are often helpful particularly for parents who can then in turn be more reassuring to the affected child.

It is important to distinguish nightmare disorder from night terrors (which are episodes of panic and confusion, with difficulty waking or bringing to awareness, and of which the sufferer has no recollection). The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnostic criteria for nightmare disorder are listed below:

DSM-IV criteria for nightmare disorder[3]
•Repeated awakening from sleep or naps with detailed recall of extended and extremely frightening dreams. The nightmare usually involves a significant threat to survival, security or self-esteem.
•Awakening from sleep generally occurs during the second half of the sleep period.
•On awakening, the sufferer is usually rapidly orientated and alert.
•The dream experience, or the sleep disturbance caused by it, leads to clinically significant distress or impairment of social, occupational or other important areas of functioning.
•The nightmares are not exclusively associated with another mental disorder (eg delirium, post-traumatic stress disorder (PTSD)) and are not due to the effects of a substance on the body (eg medication, drugs of abuse, drug or alcohol withdrawal) or a medical condition.

Epidemiology

Nightmares are common, particularly in children.
•Children: •10-50% of those aged 3-6 years are estimated to suffer from nightmares that disturb their sleep, or that of their parents.
•This is the normal age for the experience of nightmares to begin.
•The peak incidence of nightmare disorder occurs in this age group. Some studies found that up to 80% of young children experience ‘scary dreams’.[4]

•Adults: •Estimates of adult prevalence of nightmares and troubling dreams are difficult to come by due to variable definitions and recall bias.
•It is thought that the adult incidence of this disorder is low.

Aetiology[1]
•Usually there is no underlying pathology.
•It is thought that recent traumatic events and psychological stress may contribute.
•Many medications are reported to increase nightmares:

Drugs linked to nightmares[1]
•Antihypertensives: •Betablockers (the water-soluble betablockers such as atenolol are less likely to cause nightmares as they are less likely to cross the blood-brain barrier).[5]
•Centrally-acting antihypertensives.

•Antidepressants: selective serotonin reuptake inhibitors (SSRIS), tricyclic antidepressants and monoamine oxidase inhibitors( MAOIs).
•Antiparkinsonian agents: levodopa, selegiline
•Sedatives: •Ketamine
•Short-acting barbiturates

•Miscellaneous: •Rauwolfia alkaloids
•Alpha-agonists
•Flutamide
•Procarbazine

•Medication withdrawal: benzodiazepine or alcohol withdrawal leads to a rebound of REM sleep which may increase nightmares

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Presentation[1][2]
•Nightmares tend to start in the latter half of the sleep cycle, during REM sleep.
•The nightmare usually involves a threat of danger. This may be a physical threat such as being pursued, or a psychological one such as being teased. Frequent threatening characters for children are monsters, ferocious animals, ghosts. bullies or ‘bad’ people.
•It is unusual for the person to shout out, move or have autonomic disturbance during the experience, although these things may occur to a minor degree.
•When awoken it is usual for the person to be orientated, alert and responsive and to be receptive to calming by their parents/others. The details of the dream are usually remembered. This contrasts with night terrors where the person may be difficult to rouse and may not recall what has been troubling them.
•There may be a family history of similar problems.

Assessment
•Take a careful history, preferably also from parents, carers or relatives who have witnessed the event.
•Assess whether mental impairment, mental illness, depression, other central nervous system (CNS) disease or a febrile illness could be contributing.
•Consider medication history and alcohol/benzodiazepine withdrawal.
•Ask if there has been any recent traumatic event or conflict/stress.

Differential diagnosis[1][6]

See related separate article Night Terrors and Parasomnias.
•Night terrors – the difference from nightmares is that: they tend to occur earlier rather than later during the night; the person may initially be unresponsive or disorientated; unlike nightmares, they usually cannot recall the event; signs of autonomic arousal such as dilated pupils, tachypnoea and tachycardia are more likely.
•Underlying organic brain disorder, eg delirium or mental impairment.
•Post-traumatic stress disorder (PTSD): nightmares are a feature of PTSD. However, in PTSD the dream content often involves reliving the trauma, and there are other symptoms such as poor sleep and daytime anxiety.
•Medication or withdrawal from medication.
•Recurrent febrile illness causing delirium or predisposing to nightmares (this may also cause night terrors).
•Seizures.
•Depressive illness with melancholic features may be associated in adults.[7]
•REM sleep behaviour disorder (a problem affecting particularly older adults).[8]

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Night Terrors and Parasomnias

Investigations

Investigations are not usually necessary if the diagnosis is clear from the history. However, bear in mind that:
•Night terrors (sleep terrors) and sleepwalking (which differ from nightmares, as explained above) have been linked to physical sleep disorders such as obstructive sleep apnoea and other types of sleep disordered breathing.[9] If these problems are suspected, or the diagnosis is unclear, assessment at a sleep clinic may help.[10]
•If there is reason to suspect an underlying cause then EEG, blood tests and CNS imaging may be considered.

Management[1][2]
•Reassurance of the patient or child and parents is all that is usually required.
•Helpful tips for children: •It may help to develop a relaxing bedtime routine that does not vary. Attention to causes of stress and upheaval within the home may help reduce the propensity to nightmares.
•Use of night lights and other strategies that may reduce a child’s anxiety levels at night can help.
•If the nightmare is recurrent then it may help for the parents to talk through the nightmare and imagine a less scary ending.

•If the problem is occurring, say, on a more than twice-weekly basis persistently, then it may be worth referring for psychological or child-psychiatric input. There is evidence that psychological techniques such as imagery rehearsal treatment may help.[11]
•Drug treatment is not usually helpful and is more likely to cause nightmares. (This contrasts with some other types of sleep disorder, where medication may help.)

Prognosis[2]

The prognosis is very good. The symptoms should resolve as time passes and after reassurance of the child and parents that this is a relatively normal experience for some young children.

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GAD (Generalized Anxiety Disorder)

Posted on March 8, 2014 by JmaC

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Generalised anxiety disorder (GAD) is a condition where you have excessive anxiety on most days. You are most likely to be offered ideas about how to help yourself (self-help) and/or psychological treatment in the first instance. Other treatment options include antidepressant medicines and sometimes other types of medicines.

This leaflet is part of our series on anxiety and phobias

Agoraphobia
Generalised Anxiety Disorder
Obsessive-compulsive Disorder
Panic Disorder
Social Anxiety Disorder

What is anxiety?

When you are anxious you feel fearful and tense. In addition you may also have one or more unpleasant physical symptoms. These may be: a fast heart rate, palpitations, feeling sick, shaking (tremor), sweating, dry mouth, chest pain, headaches, fast breathing. The physical symptoms are partly caused by the brain which sends lots of messages down nerves to various parts of the body when we are anxious. The nerve messages tend to make the heart, lungs and other parts of the body work faster. In addition, you release stress hormones (such as adrenaline) into the bloodstream when you are anxious. These can also act on the heart, muscles and other parts of the body to cause symptoms.

Anxiety is normal in stressful situations and can even be helpful. For example, most people will be anxious when threatened by an aggressive person. The burst of adrenaline and nerve impulses which we have in response to stressful situations can encourage a ‘fight or flight’ response. Some people are more prone to normal anxieties. For example, some people are more anxious than others before examinations. Anxiety is abnormal if it:
•Is out of proportion to the stressful situation; or
•Persists when a stressful situation has gone; or the stress is minor; or
•Appears for no apparent reason when there is no stressful situation.

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What are anxiety disorders?

There are various conditions (disorders) where anxiety is a main symptom. This leaflet is about generalised anxiety disorder (GAD). There are other separate leaflets for other types of anxiety disorders (such as panic disorder, phobias, acute reaction to stress, post-traumatic stress disorder, etc).

What is generalised anxiety disorder?

If you have GAD you have a lot of anxiety (feeling fearful, worried and tense) on most days. The condition persists long-term. Some of the physical symptoms of anxiety (detailed above) may come and go. Your anxiety tends to be about various stresses at home or work, often about quite minor things. Sometimes you do not know why you are anxious.

It can be difficult to tell the difference between normal mild anxiety in someone with an anxious personality and someone with GAD. As a rule, symptoms of GAD cause you distress and affect your day-to-day activities. In addition, you will usually have some of the following symptoms:
•Feeling restless, on edge, irritable, muscle tension, or keyed up a lot of the time.
•Tiring easily.
•Difficulty concentrating and your mind going blank quite often.
•Poor sleep (insomnia). Usually it is difficulty in getting off to sleep.

You do not have GAD if your anxiety is about one specific thing. For example, if your anxiety is usually caused by fear of one thing then you are more likely to have a phobia.

Who gets generalised anxiety disorder?

GAD develops in about 1 in 50 people at some stage in life. Twice as many women as men are affected. It usually first develops in your 20s but is frequently being recognised in older people.

What causes generalised anxiety disorder?

The cause is not clear. The condition often develops for no apparent reason. Various factors may play a part. For example:
•Your genetic ‘makeup’ may be important (the material inherited from your parents which controls various aspects of your body). Some people have a tendency to have an anxious personality, which can run in families.
•Childhood traumas such as abuse or death of a parent, may make you more prone to anxiety when you become older.
•A major stress in life may trigger the condition. For example, a family crisis or a major civilian trauma such as a toxic chemical spill. But the symptoms then persist when any trigger has gone. Common minor stresses in life, which you may otherwise have easily coped with, may then keep the symptoms going once the condition has been triggered.

Some people who have other mental health problems such as depression or schizophrenia may also develop GAD.

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How is generalised anxiety disorder diagnosed?

If the typical symptoms develop and persist then a doctor can usually be confident that you have GAD. At the moment, guidelines suggest the diagnosis should be made if you have had your symptoms for six months but new guidelines are about to be published (DSM-5) which suggest that the diagnosis should be made if you have had your symptoms for a month. It is sometimes difficult to tell if you have GAD, panic disorder, depression, or a mixture of these conditions.

Some of the physical symptoms of anxiety can be caused by physical problems which can be confused with anxiety. So, sometimes other conditions may need to be ruled out. For example:
•Drinking a lot of caffeine (in tea, coffee and cola).
•The side-effect of some prescribed medicines. For example, selective serotonin reuptake inhibitor (SSRI) antidepressants.
•An overactive thyroid gland.
•Taking some street drugs.
•Certain heart conditions which cause palpitations (uncommon).
•Low blood sugar level (rare).
•Tumours which make too much adrenaline and other similar hormones (very rare).

What is the outlook (prognosis)?

Although GAD gets better in some people, in others it tends to come and go. Some people need to take medicines for a long time but are otherwise able to lead perfectly normal lives.

Symptoms may flare up and become worse for a while during periods of major life stresses. For example, if you lose your job or split up with your partner.

People with GAD are more likely than average to smoke heavily, drink too much alcohol, and take street drugs. Each of these things may ease anxiety symptoms in the short term. However, addiction to nicotine, alcohol or drugs makes things worse in the long term,and can greatly affect your general health and well-being.

What are the treatment options?

TALKING TREATMENTS AND OTHER NONDRUG TREATMENTS

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is probably the most effective treatment. It probably works for over half of people with GAD to reduce symptoms and improve quality of life.
•Cognitive therapy is based on the idea that certain ways of thinking can trigger or fuel certain mental health problems such as anxiety. The therapist helps you to understand your current thought patterns – in particular, to identify any harmful, unhelpful and false ideas or thoughts which you have that can make you anxious. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious or develop physical symptoms of anxiety.
•Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your behaviour or response to the feared object is harmful and the therapist aims to help you to change this. Various techniques are used, depending on the condition and circumstances. As with cognitive therapy, several sessions are needed for a course of therapy.
•CBT is a mixture of the two where you may benefit from changing both thoughts and behaviours. (Note: cognitive and behavioural therapies do not look into the events of the past. They deal with and aim to change, your current thought processes and/or behaviours.)

Counselling

In particular, counselling that focuses on problem-solving skills may help some people.

Anxiety management courses

These may be an option if they are available in your area. Some people prefer to be in a group course rather than have individual therapy or counselling. The courses may include learning how to relax, problem-solving skills, coping strategies and group support.

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Spotting stress
Self-help

You can get leaflets, books, tapes, videos, etc on relaxation and combating stress. They teach simple deep-breathing techniques and other measures to relieve stress and help you to relax. They may ease anxiety symptoms. There are also websites offering self-help advice, treatment and support on the internet. – eg Fearfighter© (see Further Reading, below). See separate leaflet called Stress and Tips on How to Avoid it.

MEDICATION

Antidepressant medicines

These are commonly used to treat depression but also help reduce the symptoms of anxiety even if you are not depressed. Research trials suggest that antidepressants can ease symptoms in over half of people with GAD. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing anxiety symptoms.
•Antidepressants do not work straight away. It takes 2-4 weeks before their effect builds up. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good. You need to give them time to work.
•Antidepressants are not tranquillisers and are not usually addictive. There are several types of antidepressants, each with various pros and cons. For example, they differ in their possible side-effects. However, SSRI antidepressants are the ones most commonly used for anxiety disorders. The two SSRIs licensed to treat GAD are escitalopram and paroxetine. Other antidepressants that have been found to help include venlafaxine and duloxetine.
•Note: after first starting an antidepressant, in some people the anxiety symptoms become worse for a few days before they start to improve.

Tranquillisers

Benzodiazepines, such as diazepam, used to be the most commonly prescribed medicines for anxiety. They usually work well to ease symptoms. The problem is, they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Therefore, they are not used much now for persistent anxiety conditions such as GAD. A short course of up to 2-4 weeks may be an option now and then to help you over a particularly bad spell.

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Buspirone

Buspirone is another option to treat GAD. It is an anti-anxiety medicine but different to the benzodiazepines. It is not clear how it works but it is known to affect serotonin, a brain chemical which may be involved in causing anxiety symptoms. It causes less drowsiness than benzodiazepines but is also addictive and it should only be used for a short time.

Hydroxyzine

Hydroxyzine is an antihistamine which is sometimes used to ease anxiety symptoms. A common side-effect though is drowsiness.

Pregabalin

Pregabalin is a medicine used for several conditions (principally epilepsy). It has been found useful in GAD. It tends to be considered for GAD if the other treatments mentioned above have been unhelpful.

Beta-blocker medicines

Beta-blockers, such as propranolol, tend to work better in acute (short-lived) anxiety rather than in GAD. They may ease some of the physical symptoms such as trembling but do not affect the mental symptoms such as worry.

A combination of treatments

CBT plus an antidepressant medicine may work better in some cases than either treatment alone.

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Selective Serotonin Reuptake inhibitors

Posted on March 8, 2014 by JmaC

http://www.bipolar4lifesupport.co on line support group

Selective serotonin reuptake inhibitors (SSRIs) selectively inhibit the reuptake of serotonin (5-hydroxytryptamine, 5-HT) in central nervous system (CNS) synapses, thus increasing the intra-synaptic concentration of serotonin.

Depression and serotonin

It has long been postulated that a deficiency in CNS serotonergic activity is the cause of, or a predisposing factor for, depression.[1] However, the evidence for this association is largely circumstantial and it certainly does not represent an adequate and full model for depression, probably due to there being multiple aetiological factors.[2] Some pharmacological trial data also cast doubt on the efficacy of SSRIs compared with placebo.[3][4][5] Despite this, manipulation of the serotonin axis by SSRIs seems to be beneficial in treating patients with moderate-to-severe depression.

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Selective serotonin reuptake inhibitors versus other antidepressants

SSRIs appear to be similar in efficacy to the older tricyclic antidepressants (TCAs) but have fewer antimuscarinic side-effects and are less cardiotoxic in overdosage. Although SSRIs are, on the whole, better tolerated than older antidepressants, the difference is not significant enough to justify always choosing SSRIs as first-line agents to treat depression.

A meta-analysis of primary care trials of SSRIs and TCAs demonstrates similar efficacy and tolerability for both, which is superior to placebo.[6] A Cochrane review has similar findings and concludes that there are no clinically significant differences in effectiveness between SSRIs and TCAs and that treatment decisions should be based on considerations of relative patient acceptability, toxicity and cost.[7] An analysis of antidepressant drug adherence shows that any differences in tolerability between SSRIs and TCAs are relatively subtle and difficult to extrapolate into improved acceptance of SSRIs by real patients in the real world.[8] Where there is a significant risk of overdose, medical comorbidity which precludes antimuscarinic activity, or diabetes, SSRIs are usually preferred as first-line agents over TCAs.

St John’s wort (SJW) has also been compared to SSRIs. Szegedi and colleagues reported that SJW use was associated with greater depressive symptom reduction and fewer adverse effects compared with SSRIs (paroxetine).[9] However a meta-analysis of SJW failed to find a substantial benefit over other forms of therapies.[10] However, it may be that SJW is safe and effective in the short-term relief of depression. SJW may be more useful in milder depression.[10] Further randomised controlled trials, of longer duration, are necessary for SJW in depression.

Currently available Selective serotonin reuptake inhibitors
•Citalopram[11]
•Fluoxetine (long half-life)[12]
•Fluvoxamine[13]
•Paroxetine[14]
•Sertraline[15]

Refer to each individual drug’s Specific Product Characteristics (SPC) for details.

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Seasonal Affective Disorder
Premenstrual Syndrome
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Indications
•Depression – all SSRIs are licensed for this indication; paroxetine is licensed only for the treatment of major depression.
•Panic disorder – citalopram, escitalopram, paroxetine.
•Social anxiety disorder/social phobia – escitalopram, paroxetine.
•Bulimia nervosa – fluoxetine.
•Obsessive-compulsive disorder – fluoxetine, fluvoxamine, paroxetine, sertraline (the latter under specialist supervision in children).[16]
•Post-traumatic stress disorder – paroxetine, sertraline (latter in females only).
•Generalised anxiety disorder – paroxetine.
•Premenstrual disorder (unlicensed).[17][18]

There have been a number of trials assessing the role of SSRIs as add-on therapy to improve the negative symptoms of schizophrenia. Unfortunately, a recent meta-analysis failed to find any difference with SSRIs.[19]

Contra-indications

Use in children and adolescents

The Committee on Safety of Medicines (CSM) advises that balance of risks and benefits for the treatment of depressive illness in individuals <18 years is unfavourable for the SSRIs citalopram, escitalopram, paroxetine and sertraline.[20] They may be used by specialists with close supervision for suicidal behaviour, self-harm or hostility. Fluoxetine has shown some benefit but there may be increased risk of self-harm and suicidal thoughts in individuals. Careful observation and monitoring are advised.

A meta-analysis of a number of trials of SSRIs in children suggests that the benefits of SSRIs appear to outweigh any suicidal risks in a number of conditions including depression and anxiety disorders.[21] Furthermore, the use of SSRIs in children is associated with a number of problems of which increased activity is prominent.[22]

Mania

SSRIs should be discontinued or avoided in patients displaying active manic symptoms.

Cautions
•History of mania.
•Epilepsy – there is the need to weigh up the risks and benefits; avoid if poorly controlled and discontinue if there is deterioration; seek specialist advice if necessary.
•Fluoxetine is reported to prolong seizure duration with concurrent electroconvulsive therapy (ECT).
•Cardiac disease – however, SSRIs (such as sertraline) are probably the safest antidepressants in cardiac disease.[23]
•Acute angle-closure glaucoma.
•Diabetes mellitus (monitor glycaemic control after initiation).
•Concomitant use with drugs that cause bleeding, gastrointestinal (GI) bleeding, or history of GI bleeding.[24][25]
•Hepatic/renal impairment.
•Pregnancy and breast-feeding – seek specialist advice, eg National Teratology Information Service[26] (neonatal withdrawal syndrome, particularly with paroxetine).[27][28]
•Young adults (possible increased suicide risk).[29]
•Suicidal ideation.[29]

Acute stress reaction

Posted on March 8, 2014 by JmaC

http://www.bipolar4lifesupport.co on line support group

An acute stress reaction occurs when symptoms, including anxiety, develop quickly as a reaction to exceptionally stressful events. Symptoms often go quickly, and you may not need any treatment. Sometimes other treatments, such as talking therapies, may be helpful.

What is an acute stress reaction?

An acute stress reaction occurs when symptoms develop due to a particularly stressful event. The word acute means the symptoms develop quickly, but do not usually last long. The events are usually very severe and an acute stress reaction typically occurs after an unexpected life crisis. This might be, for example, a serious accident, sudden bereavement, or other traumatic events. Road traffic accidents cause many casualties each year and you may be directly or indirectly affected by this kind of exceptionally stressful event. Acute stress reactions may also occur as a consequence of sexual assaults or domestic violence.

Acute stress reactions have been seen in people who experience terrorist incidents or major disasters. They may also occur in people who experience war in their countries. Military personnel are at more risk as a result of extreme experiences during conflicts.

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What are the symptoms of an acute stress reaction?

Symptoms usually develop quickly over minutes or hours – reacting to the stressful event. They usually settle fairly quickly, but can sometimes last for several days or weeks. Symptoms of acute stress reactions may include the following:
•Psychological symptoms such as anxiety, low mood, irritability, emotional ups and downs, poor sleep, poor concentration, wanting to be alone.
•Recurrent dreams or flashbacks, which can be intrusive and unpleasant.
•Avoidance of anything that will trigger memories. This may mean avoiding people, conversations, or other situations, as they cause distress and anxiety.
•Reckless or aggressive behaviour that may be self-destructive.
•Feeling emotionally numb and detached from others.
•Physical symptoms such as: •A thumping heart (palpitations)
•Feeling sick (nausea)
•Chest pain
•Headaches
•Tummy (abdominal) pains
•Breathing difficulties

The physical symptoms are caused by stress hormones, such as adrenaline (epinephrine), which are released into the bloodstream, and by overactivity of nervous impulses to various parts of the body.

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What are the treatments for acute stress disorder?

No treatment may be needed, as symptoms usually go once the stressful event is over and you deal with it. Understanding the cause of symptoms, and talking things over with a friend or family member, may help. However, some people have more severe or prolonged symptoms. One or more of the following may then help:

6
Spotting stress
Cognitive behavioural therapy (CBT)

Cognitive Behavioural Therapy (CBT) is a talking therapy and is based on the idea that certain ways of thinking can trigger or fuel certain mental health problems. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful and false ideas or thoughts. The aim is then to change your ways of thinking in order to avoid these ideas and help your thought patterns to be more realistic and helpful. When it is used for acute stress reactions it is known as trauma-focused CBT.

Counselling

This may be an option if symptoms are persistent or severe. Counselling helps you to explore ways of dealing with stress and stress symptoms. This may be available locally but some charities also offer online resources and helplines that may be useful.

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Medications

Taking a medicine may be an option:
•A beta-blocker is one medicine that can help relieve some physical symptoms that are caused by the release of stress hormones. Beta-blockers are not addictive, are not tranquillisers, and do not cause drowsiness or affect performance. You can take them as required.
•Diazepam is a benzodiazepine tranquilliser. These are very rarely used and are reserved for exceptional cases for very short periods. It is addictive and will quickly lose its effect when taken for more than a few days.

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Post Tramatic Stress Disorder

Posted on March 8, 2014 by JmaC

http://www.bipolar4lifesupport.co on line support group

Post-traumatic stress disorder (PTSD) is a condition where you have recurring distressing memories, flashbacks and other symptoms after suffering or witnessing a traumatic event. Treatment options include antidepressant medication and non-medicinal treatments such as cognitive behavioural therapy (CBT).

What is post-traumatic stress disorder?

Post-traumatic stress disorder (PTSD) is a condition which develops after you have been involved in, or witnessed, a serious trauma such as a life-threatening assault. During the trauma you feel intense fear, helplessness or horror. In some people PTSD develops soon after the trauma. However, in some cases the symptoms first develop several months, or even years, after the trauma.

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Post-traumatic Stress Disorder (PTSD)

Who gets post-traumatic stress disorder?

The strict definition of PTSD is that the trauma you had or witnessed must be severe; for example: a severe accident, rape, a life-threatening assault, torture, seeing someone killed, etc. However, symptoms similar to PTSD develop in some people after less severe traumatic events.

It is estimated that up to 3 in a 100 people may develop PTSD at some stage in life. One large survey of the general population in England found that 3 in 100 adults screened positive for PTSD.

It is much more common in certain groups of people. For example, some studies have found that PTSD develops in about:
•1 in 5 firefighters.
•1 in 3 teenage survivors of car crashes.
•1 in 2 female rape victims.
•2 in 3 prisoners of war.

Some people have risk factors which make them more prone to develop PTSD when they are exposed to a traumatic event. These include:
•Previous mental health problems.
•Being female.
•Coming from a poor background.
•Lack of education.
•Coming from an ethnic minority.
•Being exposed to trauma in the past.
•A family history of mental illness.

What are the symptoms of post-traumatic stress disorder?
•Recurring thoughts, memories, images, dreams, or flashbacks of the trauma which are distressing.
•You try to avoid thoughts, conversations, places, people, activities or anything which may trigger memories of the trauma, as these make you distressed or anxious.
•Feeling emotionally numb and feeling detached from others. You may find it difficult to have loving feelings.
•Your outlook for the future is often pessimistic. You may lose interest in activities which you used to enjoy and find it difficult to plan for the future.
•Increased arousal which you did not have before the trauma. This may include: •Difficulty in getting off to sleep or staying asleep.
•Being irritable which may include outbursts of anger.
•Difficulty concentrating.
•Increased vigilance.
•Being more easily startled than you were before.

Note: it is normal to feel upset straight after a traumatic event. But for many people the distress gradually eases. If you have PTSD the distressing feelings and symptoms persist. In some cases the symptoms last just a few months and then ease or go. However, in some cases the symptoms persist long-term.

Up to 4 in 5 people with PTSD also have other mental health problems; for example, depression, persistent anxiety, panic attacks, phobias, drug or alcohol abuse.

Having a mental health disorder before the trauma seems to increase your chance of developing PTSD. But also, having PTSD seems to increase your risk of developing other mental health disorders.

What is the treatment for post-traumatic stress disorder?

You may need no treatment if your symptoms are mild, particularly if the trauma happened less than a month ago. However, if your symptoms are prolonged and moderate or severe, treatment can help you to adjust. If you have severe symptoms 2-4 weeks after the incident, you are likely to need treatment.

You should be aware that no treatment will ‘wipe the slate clean’ and erase all memories of the event.

Note: some non-medicinal treatments mentioned below may not be available on the NHS in every area.

Talking treatments and other non-medicinal treatments
•Cognitive behavioural therapy (CBT) may be advised. Briefly, CBT is based on the idea that certain ways of thinking can trigger or fuel certain mental health problems such as PTSD. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful and false ideas or thoughts. The aim is then to change your ways of thinking in order to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. It may help especially to counter recurring distressing thoughts and avoidance behaviour. Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part and are given homework for between sessions.
•Eye movement desensitisation and reprocessing (EMDR) is a treatment that seems to work quite well for PTSD. Briefly, during this treatment a therapist asks you to think of aspects of the traumatic event. Whilst you are thinking about this you follow the movement of the therapist’s moving fingers with your eyes. It is not clear how this works. It seems to desensitise your thought patterns about the traumatic event. After a few sessions of therapy, you may find that the memories of the event do not upset you as much as before.
•Other forms of talking treatments such as anxiety management, counselling, group therapy and learning to relax may be advised.
•Self-help. Joining a group where members have similar symptoms can be useful. This does not appeal to everyone but books and leaflets on understanding PTSD and how to combat it may help.

Medication

Antidepressant medicines are often prescribed. These are commonly used to treat depression but have been found to help reduce the main symptoms of PTSD even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing symptoms.

Antidepressants take 2-4 weeks before their effect builds up and can take up to three months. A common problem is that some people stop the medicine after a week or so as they feel that it is doing no good. You need to give an antidepressant time to work. If one does help, it is usual to stay on the medication for 6-12 months, sometimes longer.

There are several types of antidepressants. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used for PTSD. There are various types and brands of SSRI. Paroxetine has been found to be particularly useful for general use. Non-SSRI medicines sometimes used by specialists are mirtazapine and phenelzine.

Benzodiazepines such as diazepam are sometimes prescribed for a short time to ease symptoms of anxiety, poor sleep and irritability. The problem is, they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Therefore, they are not used long-term. A short course of up to 2-3 weeks may be prescribed now and then if you have a particularly bad spell of anxiety symptoms.

Other medicines such as beta-blockers, mood stabilisers and anticonvulsants are being studied. These are normally used to treat other conditions but there is some evidence that they may help some people with PTSD. Further research is needed to clarify their role.

A combination of treatments such as CBT and an SSRI antidepressant may work better in some cases than either treatment alone.

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How can family and friends help people with post-traumatic stress disorder?

Family and friends can:
•Keep a look out for behavioural changes, such as taking time off from work.
•Look out for mood changes such as anger and irritability.
•Provide a sympathetic ear and ask general questions.
•Give the person time to talk and not interrupt them.

Can post-traumatic stress disorder be prevented?

Debriefing used to be offered to people affected by natural disasters, etc. It is no longer considered effective for individuals but has been found useful for selected groups (eg, emergency workers before going back to work in stressful situations). No other treatment or medication is yet approved to prevent people from developing PTSD should they be exposed to a traumatic event; however, a medicine called clonidine is showing promising results in research studies.

Screening is appropriate for people who have been subjected to major disasters and for asylum seekers and refugees.

What is the outlook (prognosis) for post-traumatic stress disorder?

Statistics show that about 2 in 3 people with PTSD eventually get better without treatment, although the improvement may take several months. In about 1 in 3 people the symptoms last longer, sometimes for many years and can be quite severe in some people. The response to treatment can vary from person to person.

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