Bipolar4LifeSupport

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

Save time & improve your PDP on Patient.co.uk

• Notes Add notes to any clinical page and create a reflective diary
• Track Automatically track and log every page you have viewed
• Print Print and export a summary to use in your appraisal

Click to find out more »

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]

PatientPlus o

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.

http://www.bipolar4lifesupport.co

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

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.

Related articles q

Anxiety – Self Help Guides
Relaxation Exercises
Controlled Breathing (Pursed Lips Breathing)

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.

Related blogs Q

Panic attacks – nothing to panic about

Why being stress aware matters

Anxious all the time? You’re not alone

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.

p

6
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.

Articles you may like _

Beverlea’s story – I’ve learnt to live with the noises in my head
Managing stress with exercise
Giving and caring may improve your health
Clinical anxiety is becoming a worry
More Wellbeing articles ▶
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.

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.

Save time & improve your PDP on Patient.co.uk

• Notes Add notes to any clinical page and create a reflective diary
• Track Automatically track and log every page you have viewed
• Print Print and export a summary to use in your appraisal

Click to find out more »

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.

PatientPlus o

Nutritional Support in Primary Care
Seasonal Affective Disorder
Premenstrual Syndrome
Post-traumatic Stress Disorder

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]

Related blog posts Q

Panic attacks – nothing to panic about

Obsessive Compulsive Disorder

Bottoms up! Knowing your safe alcohol limits

Avoiding the winter blues

Economic crisis hits youth health – my reaction

More from the blogs ▶

Important interactions
•With monoamine oxidase inhibitors (MAOIs)/moclobemide: serious toxicity risk. If changing from an SSRI, an MAOI or moclobemide should not be started until: 5 weeks after stopping fluoxetine; 2 weeks after stopping sertraline; 1 week after other SSRIs. Also, more than 5 weeks should elapse if on high doses or chronic use of fluoxetine. If changing from an MAOI, do not start SSRIs until 2 weeks after stopping an MAOI (but after stopping moclobemide, SSRIs can be started the following day, as moclobemide has a short duration of action).
•There is a range of interactions with a number of drugs, particularly with psychiatric medications, including other antidepressants (including St. John's wort (SJW)).
•The risk of serotonin syndrome is increased by interactions with other drugs and care should be taken to monitor for its symptoms when starting new therapies in those on SSRIs. It is worth checking for known interactions of the individual SSRI with other drugs when starting new treatments.
•SSRIs inhibit platelet function and thus interact with other antiplatelet agents, eg aspirin, clopidogrel, glycoprotein IIb/IIIa inhibitors. This interaction appears to be beneficial in acute coronary syndromes but the risk of bleeding is increased.[30]

Problems
•Minor sedation and antimuscarinic side-effects may occur but are usually less frequent and troublesome than with TCAs.
•GI side-effects such as nausea, vomiting, dyspepsia and constipation are quite common. Anorexia or increased appetite with weight gain may occur.
•Hypersensitivity reactions with rash may be encountered and discontinuation should be considered as it may herald a vasculitis.
•Urticaria, angioedema, anaphylaxis, arthralgia, myalgia and photosensitivity may occur as idiosyncratic reactions. A range of minor CNS symptoms such as headache, insomnia, tremor and dizziness may occur.
•Hallucinations, drowsiness and convulsions have been reported (see the note on epilepsy under 'Cautions' above). Sexual dysfunction, including ejaculatory delay and anorgasmia may occur.[31]
•Hyponatraemia may occur in the elderly with SSRIs and less commonly with other antidepressants. It is thought to be due to the syndrome of inappropriate antidiuretic hormone (ADH) secretion. CSM advises to consider the diagnosis in all elderly patients on antidepressants who develop drowsiness, confusion or convulsions.[20]
•Other side-effects include sweating, galactorrhoea, urinary retention, movement disorders and dyskinesias and cutaneous bleeding (purpura and ecchymoses).
•Increased risk of suicidal ideation is postulated but as yet unproven.[29][32]
•Serotonin syndrome – this can occur with overdose or concurrent MAOI use. It includes altered mental state, autonomic dysfunction, and neuromuscular abnormalities.[33]
•There may also be an increased tendency of apathy in elderly individuals treated with SSRIs, despite improvement of depression.[34] Similarly, some data suggest an increase in fracture risk in patients over the age of fifty on SSRIs.[35]

Support groups e

Anxiety Alliance
No Panic

Find support near you ▶

Initiation and discontinuation
•Before starting SSRIs ensure that patients are aware that they may take a few weeks to work, that they must stop if they develop a rash and that they must get help if agitation/suicidal feelings occur.
•Patients should be reviewed 1-2 weeks after starting treatment.
•A trial of at least 4-8 weeks (6 weeks in older patients) should be given before deciding to discontinue/change an agent.
•If there is partial response, allow another two weeks to decide if effective or not.
•There is little evidence to support the use of dose escalation in patients who do not respond to standard doses.[36]
•After remission of symptoms, continue for at least 4-6 months (12 months in the older patient).
•Maintenance treatment may be needed in those with recurrent depression.

'Withdrawal' symptoms

These may occur after stopping SSRIs. GI symptoms, 'chills', insomnia, hypomania, anxiety and restlessness may occur. Aim to reduce the dose gradually over about 4 weeks or so to try to avoid/ameliorate this. In patients who have taken the drug long-term, they may need 6 months or so to withdraw gradually.

Monitoring

As there is a potential risk of increased suicidal ideation in those taking SSRIs, it is a good idea to ask explicitly about these symptoms and to document them before initiating these agents, and when reviewing a patient on SSRIs.

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.

Related articles q

Prisoner Anxiety – A Self Help Guide
Relaxation Exercises
Controlled Breathing (Pursed Lips Breathing)

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.

Related blogs Q

Why being stress aware matters

Panic attacks – nothing to panic about

Obsessive Compulsive Disorder

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:

p

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.

Articles you may like _

Managing stress with exercise
Deputy Prime Minister sets out mental health action plan
Beverlea’s story – I’ve learnt to live with the noises in my head
Giving and caring may improve your health
More Wellbeing articles ▶
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.

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.

Related articles q

Prisoner Post Traumatic Stress – A Self Help Guide
Post Traumatic Stress – Self Help Guides
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.

Decision Aids Decision Aids icon

Doctors and patients can use Decision Aids together to help choose the best course of action to take.

Compare the options for Post-traumatic Stress Disorder.See treatment options

Support groups e

No Panic
Traumatic Stress Clinic

Find support near you ▶

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.