Anxiety Disorders

Acute stress disorder (ASD) is the development of severe anxiety that occurs shortly after an extremely traumatic event such as death, threat to another person, or serious injury to one's personal integrity, such as rape or physical assault, or an event such as a natural disaster or robbery.

Acute stress disorder occurs within four weeks of the traumatic event and lasts from two days to 30 days. Anyone can develop ASD, but cannot be caused by drug use or any other condition. People with ASD can no longer function or socially interact as well at work or school as they did before the event. ASD can also lead to a trauma survivor not seeking help.

ASD versus PTSD

People with acute stress disorder are more likely to develop post-traumatic stress disorder (PTSD), which occurs when symptoms of ASD persist for more than a month. Studies have shown that more than 80% of people with ASD develop PTSD six months later, and even those who do not develop ASD may develop PTSD later. 

Studies show that a small number (4% to 13%) of survivors who do not develop ASD in the first month after trauma develop PTSD in later months or years. 

The symptoms of ASD and PTSD are similar.

Symptoms of Acute Stress Disorder

Dissociative Symptoms

While experiencing or after experiencing the distressing event, people with ASD have at least three of the following symptoms:

• Feeling emotionally numb or detached
  
• Feelings of unreality in one's sense of self (depersonalization)
  
• Feeling disconnected from reality (derealization)
  
• Dissociative amnesia (inability to remember details of the trauma)
  

Re-experiencing symptoms

The traumatic event is persistently re-experienced in at least one of the following ways:

• Flashbacks - recurrent images, thoughts, dreams, illusions, including physical symptoms like a racing heart or sweating
  
• Bad dreams
  
• Frightening thoughts
  

Avoidance Symptoms

Avoidance of anything that could cause recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).

• Staying away from places, events, or objects that are reminders of the experience
  
• Feeling emotionally numb
  
• Feeling strong guilt, depression, or worry
  
• Losing interest in activities that were enjoyable in the past
  
• Having trouble remembering the dangerous event
  

Hyperarousal symptoms

Hyperarousal symptoms are usually constant, rather than triggered by things that remind one of the traumatic event. They can make the person feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating. It's natural to have some of these symptoms after a dangerous event.

• Being easily startled
  
• Feeling tense or "on edge"
  
• Having difficulty sleeping and/or having angry outbursts
  

Diagnosis

There are no single laboratory tests or series of tests to detect an acute stress disorder. Your doctor can refer you to a mental health provider who will diagnose you based on your medical history, current signs and symptoms.

Treatment

An acute stress disorder can become a long-term PTSD if not treated.

Cognitive-behavioral therapy (CBT)

Cognitive-behavioral therapy (CBT) has been shown to have positive results in ASD patients. Research shows that those who suffer from acute stress disorder who receive CBT shortly after trauma are less likely to develop PTSD symptoms later on. A mental health care provider trained in treatment for trauma can determine the best treatment plan.

Medication

Antidepressant anti-anxiety drugs have been effective in reducing the symptoms of ASD. Be aware that each person suffering from ASD may have different symptoms that would determine the appropriate medication.

How to Help

A trauma survivor may have difficulty talking about his or her experience because it is too painful. Therefore, be patient and understanding if he or she does not want to talk about this topic. Educate yourself about ASD or PTSD to gain an understanding of the behavior of your family member or friend. Observe what triggers flashbacks and frightened reactions and try to minimize the triggers within your control.

CHI Health has well-trained mental health providers who can address the needs of those suffering from acute stress disorder. If you think you or someone close is suffering from acute stress disorder.

The main symptom of general anxiety disorder is frequent or excessive worry about multiple issues, with little or no clear cause, that lasts for at least six months. An individual's worries shift from one problem to another and may include family or other relationships, work, school, money and health. 

People with GAD cannot seem to get rid of their concerns, which may interfere with their school or work performance. Their worries persist even though they usually realize that their anxiety is more intense than the situation warrants.

GAD affects almost 7 million Americans, although it occurs twice as often in women. Although they don't avoid certain situations as a result of their disorder, people with GAD can have difficulty carrying out the simplest daily activities if their anxiety is severe.

Symptoms of GAD

Generalized anxiety disorder can cause many symptoms, such as:

• Difficulty concentrating
  
• Irritability
• Easily startled
• Easily fatigued
• Restlessness
• Sleep problems (falling asleep or staying asleep)
• Headaches
• Lightheadedness
• Muscle tension
• Having to use the bathroom frequently
• Excessive sweating or hot flashes
• Upset stomach
• Breathlessness
• Trembling or twitching

Diagnosis

A physician or mental health professional will diagnose generalized anxiety disorder if the individual has:

• Six months of excessive anxiety and worry
  
• Three or of the above symptoms for most days for six or more months
  
• Difficulty controlling his or her anxiety or worry
  
• Symptoms are not due to another psychiatric disorder
  

Treatment

GAD rarely occurs alone. A treatment plan may include Cognitive-behavioral therapy, medication or both and will take into account whether the individual is suffering from other anxiety disorders, depression, or substance abuse.

Cognitive-behavioral Therapy

In cognitive-behavioral therapy, the client and therapist examine negative responses to everyday situations. The client learns about how distorted thoughts can cause physical and behavioral responses that amplify anxiety. Individuals also learn the difference between helpful and unhelpful worry, what triggers their worries; and the physical, cognitive and behaviors strategies to control anxiety.

Medications

Anti-Depressants

Serotonin-norepinephrine re-uptake inhibitors (SNRIs) - These medications influence the activity of the brain chemicals serotonin and norepinephrine which are neurotransmitters thought to play a role in anxiety disorders. A neurotransmitter is a chemical substance that carries messages between nerve cells. 

• SNRIs correct serotonin and norepinephrine imbalances by reducing the re-uptake (re-absorption) of them into the brain and enabling it to build up. This increases brain activity, which in turn, boosts mood.
  
• Examples of antidepressants used to treat generalized anxiety disorder include:
  
  • Desvenlafaxine: Similar to Venlafaxine
    
  • Duloxetine 
  • Venlafaxine: Also used to treat generalized anxiety disorder, panic disorder and social anxiety disorder.

Anti-Anxiety

Buspirone 

• This anti-anxiety medication may be used on an ongoing basis. As with most antidepressants, it typically takes up to several weeks to become fully effective. It may cause lightheadedness shortly after taking it. Less common side effects include headaches, nausea, nervousness and insomnia.

Benzodiazepines

• Examples include lorazepam (Ativan), diazepam (Valium), chlordiazepoxide (Librium) and alprazolam (Xanax). This class of drugs is frequently used for short-term management of anxiety. Benzodiazepines are effective in promoting relaxation and reducing muscular tension and other physical symptoms of anxiety. 
• Long-term use may require increased doses to achieve the same effect, which may lead to problems related to tolerance and dependence. They can be habit forming and can cause a number of side effects, including drowsiness, reduced muscle coordination, and problems with balance and memory.

Everyone has a routine they follow before leaving their homes, such as checking to see if appliances and lights are turned off. But some people with obsessive compulsive disorder (OCD) go back and perform these checks many times.

Obsessive compulsive disorder (OCD) is an anxiety disorder which causes a person to have frequent unwanted and repeated impulses, feelings, thoughts and sensations (obsessions) that make them feel driven to do something (compulsions), to the degree that the compulsions become unwanted rituals.

People with obsessive compulsive disorder may recognize their compulsive rituals are senseless, and unwanted, and performing them is not comforting. But the compulsive behavior produces temporary relief from the anxiety created by their obsessive thoughts. Then, the ritual itself is recognized as a rut, which causes anxiety and the cycle starts again.

Some Common Obsessions in OCD

• Worrying about dirt or bacteria that to the point that it causes stress or repeated hand-washing, showering or cleaning.
• Repeatedly checking things such as the stove or oven, door and window locks, or flipping light switches
• Excessive worrying about losing something important
• Needing to have things arranged in a particular order and if they are not, feeling agitated until they are made right
• Pulling out hairs
• Inability to throw anything away
• Touching things or eating foods in a certain order
• Combing one’s hair in a mirror and staring at the mirror
• Impulsively doing tasks over and over until they are done perfectly; or doing tasks a certain number of times or in a certain order
• Excessive fear of accidentally hurting someone
• Counting things mentally or aloud, such as tiles on a wall or floor, steps taken between places
• Having repeated intrusive disturbing thoughts about doing things that are upsetting or embarrassing

Causes

It is believed that obsessive compulsive disorder can result from a combination of biological and environmental factors. Research links low levels of a neurotransmitter, serotonin, as a factor in the development of OCD. It can start at an early age. Some researchers believe it can result from a strep or other type of infection. Environmental factors that can contribute to OCD include life changes, such as the death of a loved one or relationship change, abuse, an illness, or problems at work or school. Without treatment, OCD can become a debilitating condition.

Treatment

Cognitive-behavioral therapy

Cognitive-behavioral therapy for obsessive compulsive disorder includes ritual prevention and exposure therapies. Exposure therapy is a form of behavior modification that helps OCD sufferers recognize situations that cause compulsions, and at increasing intervals, help them resist the urge to engage in ritual behaviors. After the exposure therapy exercise has been repeated a number of times, the anxiety diminishes. Since the response is usually far less harsh than the person fears, these anxieties are lessened with practice.

Medication

Selective serotonin re-uptake inhibitors (SSRIs) are the most commonly prescribed medications used for anxiety disorders, such as obsessive compulsive disorder.

How SSRIs Work:

Serotonin is a neurotransmitter, which is a chemical substance that carries messages between nerve cells. Serotonin affects mood, sleep, temperature, learning, memory, social behavior and several other functions. When used for treating obsessive compulsive disorder, SSRIs correct serotonin imbalances by reducing the re-uptake (re-absorption) of serotonin into the brain and enabling it to build up. Increasing the level of serotonin in the brain increases brain activity, which in turn boosts mood in people with OCD, depression, and some types of anxiety disorders.

Selective serotonin reuptake inhibitors are available only with a doctor's prescription and are sold in tablet, capsule, and liquid forms. Commonly used selective serotonin reuptake inhibitors are fluoxetine, paroxetine, sertraline, and fluvoxamine.

Panic Attack

A panic attack is a sudden wave of overwhelming fear and anxiety that can happen to anyone at any time during normal activity. Panic attacks can even occur when a person is asleep.

Most panic attacks peak after 10 to 20 minutes, but they can last for over an hour. At least 20% of Americans will suffer a panic attack at some point in their lives, and it can be a one-time event. Women are twice as likely as men to experience panic attacks.

A panic attack can result from the stress of a life-changing event, such as the loss of a loved one, a job or relationship change, having a baby, etc.

Symptoms

Someone who suffers a panic attack may think they are having a heart attack and seek medical treatment because the symptoms of both are similar. They may have chest pain, shortness of breath and a throbbing or racing heart.

This is because in stressful situations, the body releases adrenaline to encourage the impulse "fight or flight." This causes several changes in the body. It speeds up breathing and heart rate to absorb more oxygen so that the body can convert more sugar into energy to face or escape the danger. Additionally, the senses sharpen, muscles become tense and stiff, digestion slows, and perspiration increases.

Other symptoms of a panic attack include:

• Dizziness or lightheadedness
  
• Feeling out of control
• Nausea
• Shaking
• Feeling disconnected from reality
• Tingling sensations
• Fear of impending doom or dying
• Feeling of choking
• Excessive sweating, hot flashes or chills

Panic disorder

A panic disorder can arise when a person experiences multiple panic attacks or begins to fear another attack (anticipatory attack). These attacks can have lasting effects that can affect work, family commitments and social situations. For example, people with panic attacks can associate their panic attacks with situations, objects or places where their previous attacks have occurred - this can cause fear of normal activities such as shopping at the grocery store or driving a car.

Panic disorder with agoraphobia

Some people with panic disorder may develop agoraphobia (an intense fear of situations and places that they think could lead to another panic attack). For such individuals, home becomes a safe haven from the embarrassment of having a panic attack in a public place or being in a place where help is unavailable.

Causes

Panic disorder can occur as a result of another disorder, such as social phobia, schizophrenia, post-traumatic stress disorder (PTSD), or depression. Genetics have been shown to be a factor, as panic attacks can be passed on from a parent.

Certain medications can also cause panic attacks. Drug and alcohol abuse can contribute to a panic disorder. People with chronic pain tend to have panic attacks, although it is unclear whether those attacks are caused by pain or the medications used to treat chronic pain.

Diagnosis

Before a panic attack can be diagnosed, a doctor will order blood tests and x-rays to rule out other conditions that can cause symptoms of a panic attack (e.g., heart attack, mitral valve prolapse, hyperthyroidism, hypoglycemia, or stimulants).

Treatment options for panic disorder

Once a physical cause has been ruled out, the individual and the doctor can discuss the severity of the disease. In many cases, medication is used alongside cognitive behavioral therapy. Medicines can be prescribed to help with anxiety. Cognitive behavioral therapy helps sufferers of panic attacks to recognize and deal with irrational fears.

Cognitive behavioral therapy

Cognitive behavioral therapy is used to help clients learn how negative thoughts contribute to anxiety. Behavioral therapy helps clients learn how to respond to anxiety-inducing situations or physical sensations by replacing them with healthier behaviors. 

Exposure therapy helps clients cope with situations that cause panic attacks. For example, if someone has had a panic attack in an elevator, they can associate the attack with going into an elevator. Now, the panic attack has been mistakenly connected to the elevator, but it does not guarantee that a panic attack will not happen elsewhere. Thus, avoiding elevators does not rule out the possibility of another panic attack. Cognitive behavior therapy helps individuals separate an attack from a location and deal with intervals in which they find themselves in situations that gradually cause anxiety for longer periods of time.

Lifestyle Changes

Stress reduction through exercise and deep breathing, a healthy diet and sufficient sleep can help to reduce panic attacks.

Medications

Below are various types of medications that can be used in combination with psychotherapy to control symptoms.

Antidepressants

Selective Serotonin re-uptake inhibitors (SSRIs)

• These are the most commonly prescribed medications used for anxiety disorders. SSRIs work by regulating the activity of serotonin, a neurotransmitter which carries messages between nerve cells. Serotonin affects mood, sleep, temperature, learning, memory, social behavior and several other functions. 
• SSRIs correct serotonin imbalances by reducing the re-uptake (re-absorption) of serotonin into the brain and enabling it to build up. Increasing the level of serotonin in the brain increases brain activity, which in turn boosts mood in people with OCD, depression, and some types of anxiety disorders. 
  
• Examples of SSRI antidepressants include: 
  
  • Citalopram
    
  • Escitalopram
  • Paroxetine - Also used to treat panic disorder, OCD, social anxiety disorder, generalized anxiety disorder and PTSD;
  • Fluoxetine - Also used to treat OCD, bulimia, and panic disorder.
  • Fluvoxamine - Although primarily used in the treatment of OCD, a doctor may prescribe it for depression.
  • Sertraline - Also used to treat panic disorder, OCD, PTSD, social anxiety disorder, premenstrual dysphoric disorder.

Serotonin-norepinephrine re-uptake inhibitors (SNRIs) 

• These medications influence the activity of brain chemicals (neurotransmitters) thought to play a role in anxiety disorders. They work by increasing the levels of the neurotransmitters serotonin and norepinephrine by blocking their re-absorption into cells in the brain. 
• Examples of antidepressants include:
  
  • Desvenlafaxine: Similar to Venlafaxin
    
  • Duloxetine
  • Venlafaxine: Also used to treat generalized anxiety disorder, panic disorder and social anxiety disorder.

Anti-anxiety Drugs - Benzodiazepines

This class of drugs is frequently used for short-term management of anxiety. Benzodiazepines are effective in promoting relaxation and reducing muscular tension and other physical symptoms of anxiety. 

Long-term use may require increased doses to achieve the same effect, which may lead to problems related to tolerance and dependence. They can be habit forming and can cause a number of side effects, including drowsiness, reduced muscle coordination, and problems with balance and memory.

Examples include: 

• Lorazepam
  
• Diazepam
• Chlordiazepoxide
• Alprazolam

Post-Traumatic Stress Disorder (PTSD) is a psychiatric disorder that can occur after experiencing a traumatic event, such as rape or physical violence, combat, disaster, threat to personal integrity, or witnessing an event in which another person has been killed or injured. Child neglect and physical / sexual abuse of children can cause PTSD. 

Most Americans will experience a traumatic event that triggers a stress response at least once in their lives. Up to 20% of these people will develop PTSD, with women twice as likely as men to develop PTSD. If the reactions do not subside over time or interfere with your life, you may develop PTSD.

Signs and symptoms of PTSD

These symptoms can be divided into three categories:

1. Re-experiencing symptoms

• Flashbacks--reliving the trauma over and over, including physical symptoms like a racing heart or sweating
• Bad dreams
  
• Frightening thoughts.
  

Re-experiencing symptoms can start with the person's own thoughts and feelings. Words, objects, or situations that are reminders of the event also can trigger re-experiencing and may cause problems in a person's everyday routine.

2. Avoidance symptoms

• Staying away from places, events, or objects that are reminders of the experience
• Feeling emotionally numb
  
• Feeling strong guilt, depression, or worry
  
• Losing interest in activities that were enjoyable in the past
  
• Having trouble remembering the dangerous event.
  

Anything that reminds a person of the traumatic event can trigger avoidance symptoms. Avoidance symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.

3. Hyperarousal symptoms

• Being easily startled
• Feeling tense or "on edge"
  
• Having difficulty sleeping, and/or having angry outbursts.
  

Hyperarousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic event. They can make the person feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating. It's natural to have some of these symptoms after a dangerous event. 

Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a few weeks and become an ongoing problem, they might be PTSD. Some people with PTSD don't show any symptoms for weeks or months.

Children and Adults

Children and adolescents may have extreme reactions to trauma, but their symptoms may not be the same as adults. In very young children, PTSD symptoms may include:

• Bedwetting when they'd learned how to use the toilet before
  
• Forgetting how or being unable to talk
  
• Acting out the scary event during playtime
  
• Being unusually clingy with a parent or other adult.
  

Older children and adolescents typically exhibit symptoms that are more similar to those of adults. They can also develop disruptive, irreverent, or destructive behaviors. Older children and adolescents may feel guilty for not being able to prevent injury or death. They may also have thoughts of revenge.

PTSD is associated with increased likelihood of co-occurring psychiatric disorders. Co-occurring disorder or dual diagnosis are terms used to describe a person who may have started using mood-altering substances to cope with their PTSD.

The following is a list of psychiatric disorders that is most prevalent for people who have PTSD:

• Alcohol/Drug Abuse and Dependency
  
• Major Depressive Disorder
  
• Conduct Disorder
  
• Generalized Anxiety Disorder
  
• Social Phobia
  
• Personality Disorders.
  

Treatment

There is no definitive treatment and no cure, but there are some treatments that are quite promising.

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) involves the reinterpretation of negative thoughts that evoke highly charged emotions. A form of cognitive-behavioural therapy is exposure therapy, which uses a careful, repeated, detailed presentation of trauma exposure in a safe, controlled context to help the survivor face fear and suffering and gain control of the trauma, which has been overwhelming through the use of relaxation techniques.

Eye movement desensitization and reprocessing (EMDR)

EMDR is a relatively new treatment that has seen success with PTSD patients. This treatment method comprises elements of exposure therapy and cognitive behavioral therapy, combined with eye movements, palpitations, or sounds that produce bilateral brain stimulation.

Medication

Antidepressant anti-anxiety medication has been effective in reducing the symptoms of PTSD. Be aware that each person suffering from PTSD may have different symptoms that would determine the appropriate medication.

If someone you know has symptoms of PTSD, talk to them and encourage them to get help by having a psychiatric evaluation conducted by a licensed psychiatrist or psychologist. The person may have difficulty talking about the tragedy because it is too painful, so you should be patient and understanding if they do not want to talk about this issue. 

Learn about PTSD to gain an understanding of your family member's behavior. Observe what triggers flashbacks and frightened reactions, and try to minimize the triggers in the house you control.