Section B - Anxiety disorders
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Anxiety disorders are primarily characterized by overwhelming anxiety and fear, and are among the most prevalent mental health disorders. They are typically chronic, last at least six months, and are likely to get progressively worse without treatment. Impairments in social, occupational, and/or role functioning are most common. Antianxiety medication and psychotherapy can significantly improve symptoms.
This section describes the health states associated with the most common anxiety disorders. Panic disorder is an anxiety disorder characterized by unexpected and recurrent panic attacks. Agoraphobia is a disorder in which there is intense fear of public places. In the DSM-IV, individuals with panic disorder may also have agoraphobia; this section describes panic disorder in the absence of agoraphobia, while agoraphobia is described as a separate health state.
Social phobia is an anxiety disorder in which the individual fears situations in which they can be judged by others. An individual with generalized anxiety disorder has persistent unprovoked anxiety. Obsessive-compulsive disorder is a disorder in which the individual has persistent thoughts that produce anxiety, and need to fulfill a compulsion in order to relieve the anxiety. Posttraumatic stress disorder is caused by life-threatening or comparable emotional experiences; flashbacks and recurrent re-living of a traumatic event are the most specific symptoms.27
Part 1 - Panic disorder
Panic disorder is an anxiety disorder that is characterized by unexpected and recurrent panic attacks. A panic attack is a sudden episode of intense fear, accompanied by at least four physical symptoms that include heart palpitations, chest pains, nausea, trouble breathing/shortness of breath, flushing or chills, terror, fear of losing control or dying, sensory distortions, and others, which peak within 10 minutes of onset. The individual typically thinks they are having a heart attack or stroke and go to the emergency department thinking they are dying. Panic attacks often occur for no apparent reason, sometimes even during sleep.28 They can occur more than once a day and typically last only a few minutes. However, between attacks, the individual may experience considerable anxiety and fear in anticipation of having further attacks, particularly about where and when the next attack will take place. This anxiety is likely more disabling than the panic itself, and may be intense enough to trigger another attack.7,29
Occasional panic attacks are fairly common; many adults, however, do not develop the anxiety about having further attacks. Panic disorder is diagnosed if the individual has recurrent panic attacks (minimum four in a four-week period), and at least one of the attacks is accompanied by one or more physical symptoms, including persistent concern about having another attack, worry about the implication or consequences of the attack (i.e., having a heart attack), and/or a significant change in behaviour due to the attacks, such as quitting a job.7 In addition, the panic attacks cannot be due to the physiological effects of a substance or another general medical condition.
Panic disorder typically begins in late adolescence or young adulthood, but children and older adults can also be affected. Lifetime prevalence rates are approximately 1-2%.7 A study in the U.S. found a 12-month prevalence of 2.7%12 and a lifetime prevalence of almost 5%.14 In Canada, 12-month and lifetime prevalence rates are 1.6% and 3.7%, respectively.1 Women are twice as likely to develop the disorder than men.7,28,30 Although the disorder is chronic, the symptoms tend to wax and wane over time: some individuals have frequent attacks regularly for months at a time; others have less frequent attacks separated by weeks or months (even years) of remission. Individuals who experience terror in anticipation of the next attack will likely avoid places where panic attacks have occurred, or where they cannot escape easily, where help is not readily available, or where they will face embarrassment if an attack strikes. The avoidance may grow over time and lead to agoraphobia (see the next section), the inability to go anywhere beyond a surrounding that is known and safe due to intense fear. Agoraphobia can develop at any point in the course of panic disorder, but it usually develops within the first year of occurrence.7 About 1/3rd of individuals with panic disorder develop agoraphobia.28
The exact cause of panic disorder is unknown, but there appears to be a genetic component; an individual with a close relative with panic disorder has a 10-20% increase in risk.28 Stressful life events or periods (e.g., heavy workload), excess caffeine, and/or stimulating drugs may trigger an attack. Separation anxiety and psychological traumas during childhood have also been associated with onset of the disorder.30 Because there is no laboratory test to diagnose Panic Disorder, and because the symptoms tend to mimic other disorders (e.g., heart attack), diagnosis is frequently not made for years, often after repeated visits to the emergency room and to various doctors.
Early diagnosis and treatment are key components to improved prognosis. However, many people do not seek psychiatric treatment until they develop unbearable anticipatory anxiety or agoraphobia.28 Benzodiazepines (antianxiety medication) and antidepressants, including serotonin reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors, are the most effective medications to reduce or eliminate panic attacks. The most effective treatment (with lower relapse rates) is a combination of medication and psychotherapy. Cognitive-behavioural therapy teaches the patient to examine and analyze their thoughts associated with the situations they fear, and to reassure themselves when they are frightened. Between 70% and 90% of treated patients have significant improvement with their symptoms.31 Relapse may occur, but recurrent attacks can be effectively treated just like the initial episode.
ICD-9: 300.01 ICD-10 Panic disorder F41.0
Panic disorder is characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms. While the panic attack is the hallmark of panic disorder, many people develop intense anxiety between episodes (the chronic phase, which this health state describes), in anticipation of future attacks. Over time, the individual may avoid more and more places; their life may become so restricted that they cannot do everyday activities such as grocery shopping. They may become housebound, unless accompanied by someone they trust. Thus, the individual will likely lose or quit their job: only about 25% of patients with panic disorder are employed.32 Restrictions in mental functioning, predominantly intense anxiety and depression are also common,7,29 as are disturbances in concentration. Exacerbation might be accompanied with such somatic symptoms as chest pain and palpitations.
The panic attack is the core feature of panic disorder and is described in this health state as acute. Panic attacks often occur suddenly and without warning, although they may be a result of classical conditioning. They are defined by a sudden surge of overwhelming fear and have a strong physical component to them, including lightheadedness, a rapid heartbeat, chills or hot flashes, flushing, trouble swallowing, terror, dizziness, and chest pains. Typically the individual experiencing a panic attack feels 'crazy' or 'out of control', and has a feeling of imminent danger. Symptoms of a panic attack peak within 10 minutes, but the frequency and severity of them varies from individual to individual.7,29
Part 2 - Agoraphobia
Agoraphobia is a disorder characterized by an intense fear of public places, particularly places where help or immediate escape might be difficult (e.g., a bus or train), or places where the individual has previously had a panic attack. The most commonly feared places are elevators, bridges, public transportation, airplanes, and shopping malls; standing in a line or in a crowd of people may also be feared. Often the fear is so extreme that the individual avoids such places; in severe cases, the individual is housebound. Agoraphobia often accompanies another anxiety disorder, especially Panic Disorder (there may be the presence of panic attacks). Alternatively, many individuals with agoraphobia have no history of panic attacks.33 The health states described in this section refer to a typical case of agoraphobia in the absence of panic attacks.
Agoraphobia can develop at anytime, but onset is typically in late adolescence or early adulthood.34 It affects between 0.5% and 1% of the population;12,34,35 the annual incidence rate is about 2 per 1000 people.36 In Canada, 12-month and lifetime prevalence rates are 0.7% and 1.5%, respectively.1 Women are more likely to have the disorder than men.34,35,36 The course is usually chronic.
Agoraphobia is diagnosed by the DSM-IV if the individual has anxiety about being in places where it may be difficult or embarrassing to escape or places where they could not get help in the case of a panic attack. These situations are either avoided or endured with extreme anxiety and distress, or the individual insists that someone accompanies them. Finally, the anxiety and/or avoidance must not be better accounted for by another mental health disorder; this may be the case if the individual avoids only one or two situations and therefore is considered to have social or other phobia(s).7
Causes of agoraphobia are unknown but several risk factors have been identified, including having panic disorder or an alcohol or substance use disorder, experiencing a stressful life event, being female, or having a tendency to be nervous or anxious.37 A study of the incidence of agoraphobia identified previous panic disorder as the strongest predictor; having other additional phobias was also a predictor.36 Another study found individuals with subsequent chronic health conditions and individuals who were widowed or divorced/separated (as opposed to those who were married) at increased risk for agoraphobia.35
Treatment for agoraphobia is important for better prognosis,38 but often individuals are too fearful or embarrassed to seek treatment. It is particularly challenging because the individual is generally made to confront his/her fears and subsequently learn to function effectively. Treatment is often successful and begins with a combination of medication and psychotherapy. Antianxiety and antidepressant medications are commonly prescribed. Cognitive-behavioural therapy helps the individual learn about the disorder, how to cope with it and how to control it (i.e., what makes it worse). Desensitization therapy is a form of exposure therapy in which the individual imagines (or confronts) the situations that cause fear, in order from the least fearful to the most fearful, in order to change their unwanted behaviour.37 In general, the success of treatment depends on the severity of the disorder.33
ICD-9: 300.2 ICD-10 – Agoraphobia F40.0
Agoraphobia in its moderate form is quite a disabling phobia that causes a high level of anxiety. Individuals are limited to the places and situations that they consider to be safe, or require the accompaniment of a trusted friend or family member. Consequently, they feel helpless and dependent on others. In addition, their social and occupational opportunities are limited or avoided.7,33
ICD-9: 300.2 ICD-10 – Agoraphobia F40.0
Individuals with severe agoraphobia suffer an extreme level of anxiety and avoid the places and situations in which they are most fearful. In fact, often the individual with severe agoraphobia is housebound. They are unable to leave trusted, safe places and people. As a result, they are unable to work or socialize outside the home, and feel detached and estranged from others. If forced to undergo the feared situation, individuals experience intense anxiety and considerable dread, "break out in a" sweat, or have a rapid heart rate or high blood pressure. As well, nausea, abdominal pain, diarrhea, and headaches are common. Symptoms of a panic attack may also be experienced: lightheadedness, dizziness, flushing, chest pain, trouble swallowing, and a feeling of a loss of control.7,33
Part 3 - Social phobia
Social phobia, also known as social anxiety disorder, is a disorder characterized by a fear of situations in which there is potential for embarrassment or humiliation in front of others. There are generally two subtypes of social phobia: one involves a fear of speaking in front of people, whether it be public speaking or simply talking with a person of authority; the other subtype involves more generalized anxiety and complex fears, such as eating in public or using public washrooms, and in these cases individuals may experience anxiety around anyone other than family.39 The anxiety becomes worse when the individual anticipates/fears that they will do something embarrassing and thus be singled out or ridiculed. Although the individual is aware that this anxiety is excessive and unreasonable, they cannot overcome it. Consequently, the individual desperately tries to avoid these situations, causing interference in work, school, or other daily activities. In extreme cases, the individual eventually avoids, or endures with intense distress, all social interaction, resulting in withdrawal even from friends and family.
Social phobia is one of the most common anxiety disorders,40 and is among the most common psychiatric illnesses.41 The lifetime prevalence rate of social phobia ranges from 3-13%;1,7,14,42 Canadian rates are between 8% and 13%.1,43 The one-year prevalence rate in Canada is 6.7%;43 in the U.S., it is about 7%.12 About half of all cases have the speaking fear subtype, and half the complex fears subtype.43 Women are more likely than men to have the disorder.40,42,43,44 Onset is typically in childhood or early adolescence,7,44 a critical time period for developing social skills; rarely does social phobia develop in later adulthood.44 The usual course is chronic and lifelong; some estimate an average duration of about 20 years.38 Symptoms may fluctuate with stress and demands, and may enter remission for an unspecified period of time.
The DSM-IV diagnoses social phobia if there is striking and persistent fear towards a situation in which the individual is exposed to potential scrutiny by others, and exposure to the situation provokes anxiety. The individual realizes that this fear is excessive and unreasonable but still either avoids the situation or undergoes it despite intense anxiety or distress. For a diagnosis to be made, the avoidance or distress must cause significant impairments in the individual's daily routine, or in their occupational and social functioning. In addition, the fear is not due to the physiological effects of a substance or a medical condition.7 Finally, if the individual is under 18 years of age, these symptoms must have occurred for at least six months.
Although the exact cause of social phobia is unknown, it appears that individuals with relatives that have the disorder are at greater risk of developing it, suggesting a genetic predisposition.7,38,40,41 Familial and environmental factors, particularly in early childhood, also likely play a role: child-rearing style— overprotective parents may restrict the child from exposure to challenging or stressful situations, in which case the child does not develop effective coping skills, causing anxiety and avoidance; parental/peer (social) modeling— a child may observe the reactions and behaviours of his/her parents or friends and develop the same fears; behavioural inhibition—most individuals with social phobia were shy as children and were always uncomfortable in front of others.41 It is possible that an embarrassing, humiliating, or traumatic event can precede the disorder, at which time the individual develops fear for that particular situation.
Early diagnosis and treatment of social phobia are essential in improving prognosis of the disorder and preventing comorbidity with other disorders. However, many individuals with social phobia do not seek treatment for their disorder,42 likely because they are either embarrassed to see a professional or because they feel their shyness is part of their personality or simply a social problem rather than a mental health problem.38,42 To escape the constant anxiety, often individuals use alcohol as self-medication because they are aware that alcohol consumption can reduce their performance anxiety;41,42 rates of social phobia are nine times higher among individuals who abuse alcohol.41 Medication and psychotherapy are effective treatments. Cognitive-behavioural therapy, specifically exposure therapy, gradually teaches the individual to become more comfortable in the situations that create fear. Techniques for controlling the anxiety, such as relaxation/breathing exercises, are also taught. Group and family support therapy are effective in educating others about the disorder.
ICD-9: 300.23 ICD-10 – Social phobia F40.1
Individuals with social phobia experience intense anxiety and worry about any situation in which others could judge them. Physical symptoms, including a rapid heart rate, blushing, or trembling, often accompany the anxiety, which may be a source of further humiliation. Individuals with social phobia are constantly worried about looking foolish in front of others; for example, during public speaking, the individual has a fear of being embarrassed that others see their hands or voice tremble. Furthermore, the anxiety experienced may develop days or weeks before the social situation, and continue for days or weeks after the situation (individuals constantly experience guilt and worry over what others thought of them and their performance/how they were judged). This has tremendous implications for health. Social and occupational functioning are the areas most affected by this disorder; the individual likely has a hard time making friends or dating due to fear of the situation; opportunities at work may be limited and the individual may turn down promotions to avoid more social situations. Severe anxiety may cause the individual to avoid all social situations, such as drop out of school or quit their job, out of desperation to avoid public scrutiny. Low self-esteem and loneliness often result. Individuals with social phobia are at increased risk for depression and suicide.
Part 4 - Generalized anxiety disorder
Generalized anxiety disorder (GAD) is a disorder characterized by generalized and persistent excessive anxiety and worry that is accompanied by somatic symptoms such as muscle tension. Individuals with GAD are always thinking about the "what ifs", and fear the worst in every situation. This worry is exaggerated and unrealistic, with nothing specific to provoke it. Everyday concerns such as work, health or finances can cause marked discomfort and distress.7,45
GAD is the broadest anxiety disorder in its class, and one of the most common. It affects about 3% of the general population in a given year;7,12 lifetime prevalence is about 5%.7,14 Women are more likely to have the disorder than men.7,46,47GAD most often begins in childhood or adolescence, but onset in adulthood is not uncommon. Onset is typically gradual, with symptoms likely developing more slowly than other anxiety disorders.46,48 A stressful life event may cause the onset of symptoms.49 The usual course of symptoms is chronic, with periods of exacerbation, particularly during times of stress, and remission. Although individuals with GAD report having feelings of anxiety their whole life, the focus of their worry may shift from one concern to the next over the course of the disorder.
The DSM-IV diagnoses GAD if the individual experiences excessive anxiety and worry about life circumstances (events or activities, such as work or school), which occurs more often than not for at least six months. In addition, the individual has a hard time controlling the worry. At least three of the following symptoms accompany the worry: restlessness or feeling on edge; being easily fatigued; difficulty concentrating; irritability; muscle tension; or sleep disturbances. These symptoms cause clinically significant impairment in important areas of functioning, and are not the result of physiological effects of a substance or general medical condition.7 Symptoms typically vary in combination and severity.
The exact cause of GAD is unknown but there are likely a number of factors that contribute to the disorder. It has been suggested that GAD may have a genetic contribution.7,47,48 The brain's neurotransmitters (specifically serotonin and norepinephrine) may be disrupted. The buildup of stressful life situations or having a serious illness may trigger anxiety. Certain personality types that are prone to feelings of anxiety or worry or feelings of insecurity may also increase the risk of developing the disorder.
Individuals with GAD frequently seek treatment. The two most common treatments are medication and psychotherapy, which can be taken alone or in combination. Benzodiazepines (antianxiety medications) are effective for symptom reduction but are highly addictive and therefore can only be taken for short periods of time. Buspirone, another antianxiety medication, is also effective and can be used on an ongoing basis.46 Cognitive-behavioural therapy can help the individual to identify negative thoughts and behaviours and replace them with positive ones. During behavioural therapy, individuals with GAD learn techniques that they can use to cope with and reduce the anxiety, such as relaxation. Exposure therapy may be utilized to narrow down the anxiety-causing stimuli and help them to cope with their fears. Although no single treatment is best for everyone, GAD is treatable and remission can be successfully attained.
Generalized anxiety disorder (moderate)
ICD-9: 300.02 ICD-10 - Generalized anxiety disorder F41.1
Individuals with generalized anxiety disorder (GAD) have chronic, exaggerated worry and tension even when nothing seems to be provoking it. The persistent anxiety that they feel is much more severe than the normal anxiety experienced by the average individual. In general, individuals with GAD always anticipate disaster, and excessively worry about health, family, or work. Even though individuals with GAD may have stretches of time when they are not consumed by their worries, they are anxious all of the time. Individuals with a moderate case of GAD will typically not avoid the situations that cause them to suffer anxiety; on the contrary, many can be relatively productive socially and uphold employment.45
Generalized anxiety disorder (severe)
ICD-9: 300.02 ICD-10 - Generalized anxiety disorder F41.1
Individuals with severe GAD experience intense anxiety over things both large and small, such as work, finances, or even car repairs. Their constant worry and anticipation for disaster may cause them to be restricted in their daily lives, avoiding situations that make them anxious. Even the simplest daily tasks can be difficult to overcome. A relatively high percentage of individuals with severe GAD are likely to be unemployed.50 Depression often results because the individual is frustrated that they cannot control the anxiety. Lack of concentration and fatigue are common because the individual cannot relax and has trouble falling or staying asleep. The individual may experience a feeling of dread or a general loss of interest in life.45
Part 5 - Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD), as its name implies, is a disorder that is characterized by obsessions, compulsions, or, most commonly, both. The obsessions are persistent, unwanted thoughts that produce intense anxiety, and the individual typically has compelling urges to perform repetitive, ritual-like behaviour(s) (i.e., compulsions) to ease and control this anxiety. However, the compulsions only relieve the anxiety temporarily, and may in fact contribute to worse functioning because they start controlling the individual. Consequently, the individual often experiences significant personal distress and/or social and occupational limitations.7,51
Symptoms of OCD usually first appear in childhood, adolescence or young adulthood, with onset earlier in males. Onset is typically gradual. In childhood, the disorder is more common in boys than girls;7,52 however, among adults, men and women are equally affected. The lifetime prevalence rate of the disorder is about 2%;7,12,53,54,55 one-year prevalence rates are slightly lower. The usual course of the disorder is chronic and relapsing, with symptoms waxing and waning over time. Predominant symptoms are variable and may differ over the course of the disorder.56 If the individual does not seek treatment, the disorder tends to get worse over time and with age. Diagnosis of OCD, therefore, is of crucial importance so that the individual can get appropriate treatment. However, OCD is a very secretive disorder: individuals with OCD are often embarrassed of their obsessions and compulsions and may attempt to avoid or resist the symptoms. Often they feel humiliated and therefore do not seek professional help. Unfortunately, there is approximately a 10-year gap between the onset of symptoms and seeking help, with the receipt of a correct diagnosis and/or treatment potentially taking another 7 years.57
Obsessive-compulsive disorder is diagnosed if the individual experiences either obsessions or compulsions in a manner that well exceeds normal. By definition, obsessions are recurrent and persistent thoughts that are intrusive and inappropriate and cause striking anxiety or distress.7 (These thoughts cannot simply be excessive worries about real-life problems as these would likely be deemed appropriate.) The individual tries to ignore or neutralize these thoughts by thinking or acting something else. Finally, the individual is aware that these obsessional thoughts are a product of their own mind. Compulsions are defined as repetitive behaviours or mental acts that are performed rigidly in response to an obsession.7 These behaviours are intended to prevent or reduce distress or to prevent a feared situation from occurring, but are disconnected from reality and extremely excessive. In addition to the criterion for obsessions or compulsions, the individual must recognize that these behaviours are excessive and unreasonable for a diagnosis to be made, and they must be time consuming (at least one hour per day), cause marked distress, and interfere with normal, occupational, or social functioning. Finally, these symptoms must not be due to the direct physiological effects of a substance or a general medical condition.7 It is important to note that the DSM-IV requires the presence of either obsessions or compulsions only (as opposed to both). However, most people with compulsions have associated obsessions, despite the fact that those with obsessive disorders may not have compulsive behaviours. It is rare, however, that a diagnosis is made without the presence of compulsion rituals.54
Individuals with OCD are aware of the fact that their obsessions and compulsions do not make sense, and typically make some attempt to resist them. Nevertheless, the urge to perform the ritual is overwhelming and only leads to worse anxiety and distress if they do not perform them. The most common obsession is that concerned with contamination by dirt or germs (also known as misophobia). The individual consequently tries to avoid all sources of contamination, such as doorknobs. The associated compulsion (and the most common) is extensive washing, showering or cleaning, possibly up to hours per day. Mental distress about being contaminated may be alleviated once the skin is raw from washing too much. Another common obsession is that of repeated doubts; for example, the individual constantly wonders if they have left the door to their house unlocked or if they turned off the stove. The associated compulsion is checking. The individual is worried that if they do not check carefully enough, they may harm others. This checking often leads to greater doubt, and they check again. The individual may even recruit family or friends to also check to ensure it has been checked correctly. This doubt leads to difficulty in concentrating and endless uncertainty. Consequently, the individual may not even go to work because they are constantly checking. Other common obsessions include concerns about symmetry, requiring that objects or events be in a certain order or position, or a sense that something horrible or dangerous will happen if a particular ritual is not performed. Other common compulsions involve counting, ordering, hoarding, repeating actions, and requesting or demanding assurances. Washing, checking, and ordering compulsions are especially common in children.7
The exact cause of OCD is unknown. A genetic component is implied, since first-degree biological relatives of individuals with OCD have a higher risk of developing the disorder.7 Abnormal activity in the brain, including poor functioning of the chemical serotonin, may also be associated.52,53 Behavioural conditioning has also been suggested to play a role in the development (and maintenance) of the disorder: compulsions are the result of learned responses intended to reduce or avoid anxiety from the associated obsession; it is this compulsion that negatively reinforces the obsession-compulsion cycle.52 With treatment, however, most patients show a significant improvement in their symptoms and quality of life, particularly that the symptoms no longer interfere with functioning or cause severe distress. Serotonin reuptake inhibitors (antidepressants) are often prescribed and are effective in reducing the obsessive-compulsive symptoms.51 Behavioural therapy may also be prescribed so that individuals with OCD can face the situations that cause them anxiety and attempt to de-sensitize them. Repeated exposure to the anxiety-provoking stimulus may cause the individual to no longer fear it. This, in turn, may prevent future episodes of OCD. Behavioural therapy also teaches the individual techniques to avoid their compulsive ritual, and to deal with the anxiety. Education for patients and their families is crucial to the success of treatment.58
Obsessive-compulsive disorder (moderate)
ICD-9: 300.3 ICD-10 - Obsessive-Compulsive Disorder F42
Individuals with moderate obsessive-compulsive disorder (OCD) suffer intensely from recurrent, unwanted obsessions and compulsions which they feel they cannot control. Often the obsessions/compulsions require an excessive amount of time to complete; even getting dressed may take a few hours. Hence, these obsessions/compulsions interfere with an individual's daily functioning. Limitations in social and occupational functioning are the most common; individuals with OCD may not be able to carry out normal responsibilities because of the time required to complete a ritual. Psychological well-being is affected due to extreme anxiety and distress. Depression is often experienced. Relationships with parents, family and friends are affected, likely due to conflict from provoking other people to engage in their ritualistic behaviours. Concentration and other mental tasks are likely disrupted due to obsessional distractions.7,51
Obsessive-compulsive disorder (severe)
ICD-9: 300.3 ICD-10 - Obsessive-Compulsive Disorder F42
Individuals with severe obsessive-compulsive disorder (OCD) suffer from the same limitations as an individual with moderate OCD, but on a larger scale. Anxiety and distress are extremely intense. Their preoccupation with obsessions and/or compulsions interferes with almost all areas of general functioning. The impairments to social and occupational functioning may lead to low self-esteem, lower career aspirations, marital problems, guilt, depression, sleep disturbances, and even greater anxiety. Avoidance of objects or situations that provoke anxiety can cause the individual to become housebound.7,51
Part 6 - Post traumatic stress disorder (PTSD)
Post traumatic stress disorder (PTSD) is a disorder caused by a traumatic event that is outside the normal realm of human experience, such as rape, assault, torture, being kidnapped or held captive, military combat, severe car accidents, and natural or manmade disasters. In general, the traumatic event involves real or threatened physical harm to the self or to others, and causes intense fear, hopelessness, and/or horror. Emotional impairment results due to anxiety, depression, recurrent flashbacks, difficulty sleeping and concentrating, and feelings of guilt of having survived when others may not have.7,59,60
Lifetime prevalence of PTSD is approximately 8% in the population;7,14,61 12-month prevalence in the U.S. is 3.5%.12 Women are more likely to develop the disorder than men.39,61PTSD can occur at any age, and can be a chronic condition. Immediately following the traumatic event, the individual becomes estranged or oddly unaffected because they are generally in shock. Soon thereafter, the individual experiences recurrent images or thoughts of the traumatic event through nightmares or flashbacks. These may be triggered by a simple ordinary occurrence such as a car backfiring (resembling the sound of gunfire), and tend to be so realistic that the individual believes they are reliving in the situation. Symptoms typically begin within three months of the traumatic event, and last at least one month. Rarely, there is a delay of up to years before symptoms appear. About half of individuals with PTSD fully recover within three to six months of symptoms, but others can experience symptoms for years. Severity of the disorder is increased if the traumatic event was unanticipated. The disorder may also be more severe or longer lasting if the traumatic event was caused by another individual such as in rape or kidnapping.7 The most common traumatic events associated with PTSD in men are combat exposure and witnessing; in women, rape and sexual molestation are the most common.61
PTSD is diagnosed based on six criteria. First, the individual must have been exposed to a traumatic event that involved actual or threatened death or injury to themselves or to others, and responded with intense fear or horror. Second, the traumatic event is re-experienced persistently in the form of at least one of the following: recurrent and invasive recollections of the event, recurrent distressing dreams of the event, acting or feeling that the event is recurring (i.e., flashbacks), or intense distress at, or physically reacting to, exposure to cues that resemble an aspect of the event. Third, the individual persistently avoids stimuli that are associated with the trauma, as seen in the following: efforts to avoid thoughts, feelings or conversations of the trauma, including efforts to avoid activities, places, or people that may bring back thoughts or feelings of the trauma; inability to recall one or more important aspects of the trauma; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; restricted ability to feel emotions, particularly those of intimacy; and/or the sense of a foreshortened future (e.g., does not expect to have a career). Fourth, the individual experiences persistent symptoms of increased arousal that was not present before the trauma, as shown in the following: difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating; hypervigilance; and/or exaggerated startle response. Fifth, the symptoms experienced have been present for more than one month. And finally, the symptoms cause clinically significant impairment in social, occupational, or other area of functioning.7
The cause of PTSD is often obvious: it is the traumatic event that triggers feelings of terror and causes flashbacks. Factors that affect the likelihood of developing the disorder include the severity, duration, and proximity of the individual's exposure to that traumatic event.7,62 Risk is highest among individuals who thought they would be killed or seriously injured during the traumatic event.63 It has been suggested, however, that a susceptibility to the disorder may have a genetic contribution.7,39 In addition, pre-existing mental disorders, lack of social support, childhood experiences, depression, and personality factors (e.g., neuroticism) may increase the risk of developing PTSD.
Early diagnosis of PTSD is essential to improve prognosis; individuals who remain ill one year after the traumatic event rarely recover completely.60,61 Treatments for PTSD can improve symptoms, and patients should be treated with the long-term goal of achieving full remission. Effective medications include selective serotonin reuptake inhibitors (SSRIs) and/or tricyclic antidepressants; benzodiazepines are also effective. SSRIs appear to be the first-line treatment for long-term therapy of chronic PTSD.64 Psychotherapy, particularly cognitive-behavioural therapy, is also an effective treatment; individuals learn how to change their thought patterns to overcome anxiety. Support groups are also recommended to share thoughts and feelings of the traumatic event and gain confidence in coping. In some cases, continued treatment may be required for many years to prevent relapse.
Post traumatic stress disorder
ICD-9: 309.81 ICD-10 - Post traumatic stress disorder F43.1
This health state refers to an individual diagnosed with chronic PTSD (i.e., symptoms have lasted more than three months), who is not undergoing treatment for the disorder. Individuals with PTSD re-experience the trauma in their thoughts and feelings through nightmares or flashbacks. The individual likely avoids situations that remind them of the event, which may interfere with interpersonal functioning and potential feelings of detachment. Anniversaries of the event are particularly difficult.39 Depression, anxiety, and sleep disturbances are typical consequences of their trauma. The individual experiences painful guilt at the fact that they survived and others did not, or at the things they had to do in order to survive. They may particularly feel guilty if they had to observe the serious injury or unnatural death of another person. Hyperarousal is also typical; individuals with PTSD startle easily and have excessive alertness, are irritable, aggressive, and possibly even violent. They also experience difficulty concentrating and memory disturbances.