Posttraumatic Stress Holistic Cures

Phobia Release Program

The curative methods that are described in the 5-Day Phobia Release Course are psychologically proven and are vouched for by many phobic patients, who no longer feel the fear. Each technique is something that you can perform them on your own. Each technique is easy, described in plain, ordinary English and requires no more than a couple of minutes to do. In all, the course contains 9 exercises, organized into 5 days for your convenience. You also receive some background information about Neuro-Linguistic Programming and references for further reading on Nlp if you are interested in learning more.

Phobia Release Program Summary


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Treatment For Childhood Ptsd

Cognitive-behavioral therapy (CBT) is among the most widely investigated treatment for childhood PTSD. The theoretical model of CBT for treating PTSD draws on Mowrer's (1939) two-factor learning model, which integrates classical and operant conditioning approaches. In the classical conditioning model, neutral stimuli occur in close proximity to a traumatic event (unconditioned stimulus), which results in a series of involuntary responses, including fight-or-flight reactions (unconditioned responses). The neutral stimuli (conditioned stimuli) independently come to elicit the same involuntary responses (conditioned responses) as the traumatic event. Thus, when confronted with the conditioned stimuli, the child will experience the same fear response as during the traumatic event. Internal states, such as thoughts, memories, or feelings associated with the traumatic event, can also serve as conditioned stimuli. For example, a child hit by a car while riding his bicycle may experience...

Posttraumatic Stress Disorder Ptsd

PTSD is an emotional and behavioural syndrome following a traumatic event in the family or outside it. In the family setting, it is the result of traumas such as physical or sexual abuse, or the loss of a parent. Outside the family, it is connected with traffic accidents, natural disasters, war or terror. In childhood PTSD, the person's subjective experience of the event is at least as important as any objective characteristics of the trauma 34 . As opposed to what was thought in the past, there is evidence now that children are more likely to develop PTSD than adolescents and adults 35,36 . This tends to be more true of girls than boys, although this finding is still questionable 37,38 . Accordingly, this is a diagnosis that requires attention and should be ruled out in every case of a difficult child who is referred for evaluation. The DSM-IV category of PTSD mainly concerns adults. Scheeringa et al. 39 developed a set of alternative criteria, in which re-experiencing is expressed...

Indications for and Limitations of CBT for Treating Childhood PTSD

Results from studies implementing cognitive-behavioral interventions for childhood PTSD demonstrate reduced symptomatology in all PTSD symptom clusters and suggest that intensive, short-term individual, parent, and group treatments are efficacious and safe in treating traumatized children across a range of developmental levels. In addition, while significantly reducing PTSD symptomatology in children, some trauma-focused CBTs also have proven equally effective at diminishing peripheral psychopathology, including depression and anxiety (March et al., 1998). This is an important finding as many children with PTSD may have comorbid conditions, commonly including depression, anxiety, and attention-deficit hyperactivity disorder. While the literature examining CBT for children with PTSD has resulted in impressive findings, further empirical research is needed to better understand the differential effects of CBT as compared with other treatment modalities in order to rule out common...

Literature Review Of Cbt For Ptsd

These theoretical models led to the development of the three most widely used treatments for war-related PTSD today cognitive therapy, anxiety management therapy, and PTSD develops into a chronic disorder when individuals cognitively process the trauma in a manner that leads them to feel constant threat. This feeling of threat exists due to consistent negative appraisal of the traumatic event and to the manner in which the event is encoded and established in the memory. These cognitive distortions prevent individuals from leading productive, normal lives because they are plagued by their past. As well, these aversive cognitions produce maladaptive behaviors such as substance abuse in an attempt to control their emotions. Cognitive restructuring is one type of cognitive therapy used in the treatment of PTSD. It involves recalling the experience and verbalizing what happened and what emotions they felt at the time and subsequently. This sampling of cognitions permits the therapist and...

Posttraumatic Stress Disorder

By definition, post-traumatic stress disorder (PTSD) occurs in the aftermath of a traumatic event. The characteristic symptoms of the disorder can be divided into intrusive symptoms, avoidance and numbness symptoms, and hyperarousal symptoms. Although initially conceptualized as a normal reaction to an abnormal event, PTSD is increasingly understood as a medical disorder characterized by underlying psychobiological dysfunction 36 . After a traumatic event a range of symptoms is normative in the majority of cases these gradually diminish, but in PTSD such symptoms persist. The National Comorbidity Survey in the US found that 60.7 of males and 51.2 of females had experienced a significant traumatic event 37 . The lifetime prevalence of PTSD was 10.4 in females, and 5.0 in males. PTSD is characterized by chronicity of symptoms, significant comorbidity and substantial disability 38 . Early detection and effective treatment is therefore an important goal. PTSD in combat veterans is well...

Traumatic Stress and Posttraumatic Stress Disorder

Although many studies have examined the effects of acute, laboratory stress and chronic, naturalistic stress on immunity, relatively few have studied immune alterations in response to severe, traumatic stressors. Stressors can vary along many dimensions, including the duration of the event, the duration of threat experienced, and the duration of responding to the stressor. Therefore, distinguishing between acute and chronic stressors may be too simplistic and may not encompass the full range of stressful experiences. Sudden traumatic stressors involving life threat and direct bodily harm may be qualitatively different from other types of stress. Often, the traumatic event is acute in duration, but in some individuals distress may persist long after the event is over. A small but significant percentage of victims may develop post-traumatic stress disorder (PTSD), which is characterized by persistent reliving of the event, avoidance of situations that remind one of the event, and...

Empirical Support for CBT for Childhood PTSD

Several important treatment outcome studies have examined the efficacy of CBT for PTSD in children. In the late 1980s, following the introduction of PTSD into DSM-III (APA, 1980), Saigh (1987a,b 1989) carried out a series of single-case trials of imaginal flooding therapy for traumatized children and adolescents in Lebanon. This treatment involved children identifying and describing their traumatic experiences over a multiple baseline with outcome, measured through self-reported ratings of anxiety and depression. This and other similar treatments have been associated with a reduction in trauma-related symptoms, including exaggerated startle response, nightmares, intrusive thoughts, avoidance, impaired concentration and memory, self-reported anxiety, depression, and guilt (Saigh et al., 1996). Deblinger et al. (1990, 1999) treated 19 children and their nonoffending caretakers individually across 12 sessions using cognitive-behavioral techniques including gradual exposure, modeling,...

Epidemiology Of Ptsd In Children And Adolescents

The high prevalence of traumatic exposures in children puts them at risk of developing traumatic responses such as PTSD, as indicated by several studies. For instance, Kilpatrick et al. (2003) found that a PTSD diagnosis, according to DSM-IV criteria, was present in 15.2 of boys and 27.4 of girls who were physically abused 28.2 of boys and 29.8 of girls who had been sexually assaulted and 11.2 of boys and 20.2 of girls who had witnessed violence.

Combat Trauma and Post Traumatic Stress Disorder

In societies that have experienced war, many survivors suffer lasting psychological effects, including post-traumatic stress disorder (PTSD). The experience of battle is inherently traumatic. Isolation is central to this trauma. Civilian society's common lack of interest in hearing about war traumas, along with survivors' own denial, make healing difficult (Herman, 1992). PTSD has gone by various names in different wars, notably shell shock in World War I. Women war veterans are as prone as men to PTSD, but more men than women are exposed to combat trauma (Goldstein, 2001, pp. 259-263).

Empirical Studies A Posttraumatic Stress Disorder

Because of its claims of rapid effective treatment, EMDR has been subjected to many empirical tests and to much scientific scrutiny. It has been extensively researched in the treatment of PTSD. All but one of the research studies that used civilian participants found EMDR to be efficacious in the treatment of PTSD, and the one combat veteran study that provided a full course of treatment also revealed EMDR to be efficacious. Generally, these studies found substantial clinical effectiveness, reporting a decrease in PTSD diagnosis for 70 to 90 of the civilian participants after three or four sessions and in 78 of combat veteran participants after 12 sessions. There have been several other combat veteran EMDR studies, but these addressed only one or two memories in this multiply traumatized population, and thus their findings regarding efficacy are equivocal. Nevertheless, the effect sizes achieved in these studies were similar to those achieved in cognitive-behavioral therapy (CBT)...

Factors Influencing The Emergence And Expression Of Ptsd In Children And Adolescents

Research shows that characteristics of traumatic experiences, such as severity, duration, and proximity, impact the emergence and expression of PTSD symptoms. For example, there is evidence of a dose-response relationship between traumatic events and the development of PTSD such that events that are life-threatening are associated with greater and more severe symptoms than traumatic events that are less threatening or are experienced less directly (Davis & Siegel, 2000 Green et al., 1991). While trauma characteristics impact the emergence of PTSD, not all youth who experience traumatic events develop PTSD. There are many risk factors that influence the emergence of PTSD, such as the premorbid functioning of children and their families. Pretrauma etiological factors in children, such as age, developmental experience, intellectual ability, and psychiatric comorbidity, are associated with the development of PTSD. Studies of these factors generally indicate that children who are younger,...

Specific Phobia

Specific phobia refers to a persistent fear that is cued by the presence or anticipation of a specific object or situation (APA, 2000). When exposed to the situation or object, the individual experiences a panic attack or paniclike symptoms. As a result of anticipatory anxiety about experiencing further panic symptoms, the individual begins to avoid the phobic situation or endure it with great difficulty. The DSM-IV-TR (APA, 2000) identifies five subtypes that indicate the focus of fear in specific phobia animal type (fear of animals Lifetime prevalence rates for specific phobia have been found to be 11 (Kessler et al., 1994). The age of onset of specific phobias varies based on the subtype, although the majority have their onset in childhood (Lipsitz, Barlow, Mannuzza, Hofmann, & Fyer, 2002 Ost, 1987). The average age of onset is 22 years for situational phobias, 9 years for animal phobias, 14 years for natural environment phobias, and 9 years for blood-injection-injury phobias....

Animal Research in Fear and Anxiety

Using animals to measure the effects of chronic stress on neurochemical systems assumes that animal models of the anxiety disorders are directly applicable to human anxiety disorders. However, if there is any validity to our differentiation of unique disorders of anxiety and depression, then it is not possible that, regarding animal models, one size fits all.'' These limitations of animal models have to be borne in mind and are useful in guiding research in anxiety disorders. PTSD, PD, and phobic disorders have been found to have many phenomenological and neurobiological characteristics and can benefit from the application of animal models of stress.

Summary And Future Directions

Cognitive-behavioral treatments show great promise for the treatment of PTSD secondary to war experiences. Clinical interventions that involve combinations of CBT techniques such as exposure therapy, AMT, and cognitive therapy need to be examined in randomized clinical trials both alone and in conjunction with pharmacological approaches. No such trials currently exist for PTSD secondary to any type of traumatic event. There is a clear need and a demand for these clinical trials. Perhaps most important, and especially so in light of the terrorist attacks on New York and Washington on September 11, 2001, is the need for understanding how to prevent PTSD. Efforts by mental health professionals and public health professionals to deliver psychological interventions in the aftermath of trauma exposures are in their nascent stage of development. Needed now are creative efforts to intervene when mass disaster or tragedy occurs. At this point there are preliminary data available to suggest...

Applications And Exclusions

Other anxiety disorders can be similarly treated with exposure methods. Acute stress disorder, which is in many ways similar to posttraumatic stress disorder, can be successfully treated with implosion or systematic desensitization. Generalized anxiety disorder, for Exposure therapies should only be implemented by a suitably trained therapist. The therapist should not only be skilled in exposure therapy, but should have a good understanding of psychopathology and psychiatric diagnosis, and should be skilled in the psychotherapeutic interventions commonly used in conjunction with exposure therapy (e.g., cognitive therapy, social skills training, relaxation training). If the patient experiences intense anger or guilt during exposure, as sometimes happens when treating patients with posttraumatic stress disorder, it is often necessary to combine exposure with cognitive therapy The latter is used to address any dysfunctional beliefs associated with anger or guilt.

Analogue Behavioral Observation

Frequently, the behavioral assessor is not so much interested in the behavior measured by the equipment as what may be inferred from the behavior. For example, a large literature exists with regard to the psychophysio-logical measurement of responses to anxiety-eliciting stimuli. Keane and co-workers in 1998 showed that male military veterans with posttraumatic stress disorder (PTSD) exhibited greater changes in psychophysiological responding (i.e., increased heart rate, skin conductance, systolic and diastolic blood pressure) when presented a series of trauma-related cues than did veterans without PTSD. Other studies have found increased physiological responsivity in females with PTSD and increased heart rate responses to startling tones in individuals with PTSD.

Lee Hyer and Steve Sohnle

Posttraumatic stress disorder (PTSD) is a stress reaction characterized by symptoms of reexperiencing, avoidance numbing, and hyperarousal following exposure of 1 month or more to an extreme trauma. In recent years there has been a spate of studies and meta-analyses on the treatment of this disorder, involving the key curative components of exposure and assimilative techniques, as well as secondary factors of relaxation and rescripting. Generally, these studies have involved CBT, cognitive reprocessing, or eye movement desensitization and reprocessing (EMDR). Unfortunately, there have been no studies on the application of any of these methods to older people with PTSD. Additionally, there are few data with this group regarding the assessment of the client's mediating and moderating influences, implicit models of cause and treatment, the importance of education on change, the importance of the therapist, and a host of other client-treatment factors (Hyer & Sohnle, 2001).

Terence M Keane and Meredith Charney

Keywords PTSD, zone stressors, combat stressors, war veterans, military, refugees, internally displaced persons Posttraumatic stress disorder (PTSD) is a disorder characterized by intrusive thoughts about, preoccupation with, and nightmares of an extremely stressful life event. Typically these events are life threatening either to the individuals themselves or their loved ones. Initially included in the diagnostic nomenclature in the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III APA, 1980), PTSD is often a disabling condition associated with emotional avoidance and numbing, and a range of symptoms of hyperarousal including insomnia, irritability, difficulty concentrating, hypervigilance, and exaggerated startle responses. This collection of symptoms must be present for a full month if the duration of the symptoms is 3 months or less, it is referred to as acute PTSD. If the duration of symptoms exceeds 3 months, it is termed chronic...

Native American Traditional Medicine

American Indian patients have a range of diabetes causal agents traumatic events, infectious agents, transgression of cultural or supernatural norms, an imbalance of the harmonious processes of nature, an affliction of malevolent spirits, the loss of one's soul, or the malicious intent of another individual (Levy, 1983). In contrast, Choctaw

Esther Deblinger and Melissa K Runyon

Keywords child sexual abuse, child physical abuse, posttraumatic stress disorder, parenting, cognitive-behavioral therapy Empirical and clinical studies have documented a wide range of emotional, behavioral, and interpersonal difficulties, ranging from mild to severe, that are exhibited by children who have experienced CPA and or CSA. The impact on children can be similar regardless of the type of abuse suffered. Child victims commonly report emotional responses such as anger, hostility, guilt, shame, anxiety, and depression (e.g., Kendall-Tacket, Williams, & Finkelhor, 1993 Pelcovitz et al., 1994). Posttraumatic stress disorder (PTSD) has also been documented among children who have suffered abuse (Ackerman, Newton, McPherson, Jones, & Dykman, 1998 Pelcovitz et al., 1994). Recent reviews of the treatment outcome literature in the area of CSA find that cognitive-behavioral models have the strongest empirical support for the effective treatment of PTSD and related difficulties in this...

Winnie Eng and Richard G Heimberg

Behavioral techniques used in CBT are also greatly informed by the assumption that psychological difficulties are often maintained by dysfunctional patterns of behavior, including avoidance. As such, an important component of CBT is the use of exercises aimed at changing clients' expectancies about their ability to function in particular situations. For example, the key to treating a specific phobia of spiders is to actually expose the client to spiders. Through this experience, clients learn that their anxiety will habituate over time, that the terrible consequences that they associate with spiders are unlikely to occur (e.g., that the spider will have fangs that result in violent bites), and that they have the skills to deal with their anxiety in this feared situation. CBT, or components of it, have also been used for many years in the treatment of anxiety disorders. In general, CBT has been shown to be effective across the anxiety disorders. CBT is generally seen as the treatment...

Theoretical Bases

Joseph Wolpe Figura

For example, behavioral assessment with a Vietnam veteran diagnosed with posttraumatic stress disorder might identify certain conditional stimuli (e.g., the sound of a truck backfire, the whir of helicopter blades) as having a high probability of eliciting flashbacks and emotional responses because of their similarity to, or association with, aversive historical events. Operant responses may initially help the client cope with anxiety (e.g., drinking alcohol to induce intoxication and facilitate avoidance). Thus, a two-factor model of the patient's behavior incorporating both respondent and operant principles would form the basis of a functional analysis for the patient (see Mowrer's 1947 work).1 The emphasis on multimodal assessment recognizes that different response modes (e.g., behavioral, physiological, cognitive) may demonstrate different time courses, may vary in their responsiveness to hypothesized causal variables, and may differ in their response to a therapeutic...

Assessment Of The Difficult Child

Widely used scales to assess attention-deficit hyperactivity disorder (ADHD) include the Conners Rating Scale 3 and the Swanson, Nolan and Pelham Questionnaire (SNAP-IV) 4 . The Eyberg Child Behavior Inventory 5 is used to evaluate conduct disorder (CD) and oppositional defiant disorder (ODD). Common scales for the assessment of post-traumatic stress disorder (PTSD) are the Children's PTSD Inventory (CPTSDI) 6 , the Trauma Symptom Checklist for Children (TSCC) 7 , the Angie Andy Cartoon Trauma Scale (ACTS) 8 , the Pediatric Emotional Distress Scale (PEDS) 9 , the Clinician-Administered PTSD Scale for Children (CAPS-C) 10 , the Adolescent Dissociative Experience Scale (ADES) 11 , the Children's Perceptual Alteration Scale (CPAS) 12 and the Child Dissociative Checklist (CDC) 13 . The most frequently used rating scale for mood disorders is the Childhood Depression Rating Scale - Revised (CDRS-R) 14 , which is a modified version of the Hamilton Depression Rating Scale.

Jesse H Wright and D Kristen Small

The first computer programs for cognitive-behavior therapy (CBT) were developed in the 1980s by teams of investigators in the United Kingdom (Carr, Ghosh, & Marks, 1988 Ghosh, Marks, & Carr, 1984) and the United States (Selmi, Klein, Greist, & Harris, 1982 Selmi, Klein, Greist, Sorrell, & Erdman, 1990). Using the computer technology of the time, these researchers produced programs that relied on written text, checklists, and multiple-choice questions for communication with the patient. More recently developed computer tools for CBT have incorporated multimedia, virtual reality, hand-held devices, or other methods to rapidly engage the user and stimulate learning (Newman, Kenardy, Herman, & Taylor, 1997 Rothbaum et al., 1995 Rothbaum, Hodges, Ready, Graap, & Alarcon, 2001 Wright & Wright, 1997 Wright et al., 2002). Computer programs have been tested and found to be useful for a variety of Axis I disorders including depression, simple phobia, agoraphobia, and PTSD (Ghosh et al., 1984...

Empirical Studies

Most of the studies attesting to the effectiveness of aversion relief as a principal treatment have been uncontrolled case studies. Procedures based on aversion relief have been successfully applied in specific phobias, obsessive compulsive behaviors, obesity, aphonia, torticollis, writing cramp, transvestism, fetishism, and other deviant sexual interests. Results with thumb-sucking are not always positive. Nathan Azrin and his co-workers compared aversion relief therapy (using a bitter-tasting substance) with habit reversal in 32 children with thumbsucking. At three-month followup, 47 of the habit-reversal children had stopped thumb-sucking, compared to 10 of the aversion relief children. These findings suggest that aversion relief may be of little value in reducing thumbsucking. However, the parents in the aversion relief therapy were only instructed by phone, whereas the therapist saw the habit reversal children and their parents in a single session. Given this methodological flaw,...

Classical Conditioning

A more popular application of classical conditioning is the exposure therapies. These treatments are used to help people overcome specific phobias and other anxiety disorders in which excessive fear plays a prominent role, such as agoraphobia, social phobia, posttraumatic stress disorder, and obsessive-compulsive disorder. Given that exposure therapies for treating phobias are the most widely used applications of classical conditioning, these treatments and their theoretical bases will be the focus of this chapter.

Trauma In Pregnancy

Trauma remains the leading cause of nonobstetric morbidity and mortality in pregnant women. The conventional paradigm that fetal survival depends wholly on maternal stabilization and well-being is fundamentally accurate. It has become increasingly apparent, however, that especially in relatively minor traumatic events the severity of maternal injuries may be a poor predictor of fetal distress and outcome.12 and 3 Successful outcomes for both mother and fetus require a collaborative effort among the prehospital provider, emergency physician, trauma surgeon, obstetrician, and neonatologist.

The Effect Of Domestic Violence On Children

As many as 70 percent of children from violent homes witness their fathers beating their mothers. In addition, about 30 to 54 percent of reported cases of spousal abuse also report child abuse. One-quarter to one-half of children in violent homes are hurt incidentally during the violence or are injured when they try to intervene in the struggle. Several studies have documented that children exposed to violence in their homes have significant behavioral difficulties, including depression or PTSD, during childhood and later life. Several studies have documented a link between growing up in a violent home and later high-risk behaviors such as drug use, promiscuity, and criminal behaviors.

Application Of The Model Of The Neural Circuitry Of Anxiety And Fear To Anxiety Disorders

Among the most characteristic features of anxiety disorders such as PTSD and PD is that anxiogenic memories (e.g., of the traumatic experience or first panic attack) can remain indelible for years or decades and can be easily reawakened by all sorts of stimuli and stressors. The strength of traumatic memories relates, in part, to the degree to which certain neuromodula-tory systems, particularly catecholamines and gluco-corticoids, are activated by the traumatic experience. Release of these stress hormones modulates the encoding of memories of the stressful event. Experimental and clinical investigations provide evidence that memory processes remain susceptible to modulating influences after information has been acquired. Long-term alterations in these catecholaminergic and glucocorticoid systems may also be responsible for symptoms of fragmentation of memories, but also for hypermnesia, amnesia, deficits in declarative memory, delayed recall of abuse, and other aspects of the wide...

Symbolism Imagery In

After learning progressive deep muscle relaxation in the presence of pleasant imagery, patients were assisted in going back and forth from a physiologically relaxed state to an anxiety state that was induced by imaginal exposure to a hierarchy of fear-evoking stimuli. Each imaginal exposure segment was followed by relaxation until no further anxiety was reported during exposure. Imaginal flooding was also employed by behaviorists with anxious patients, which involved repeated, prolonged imaginal exposure to the feared stimuli until the anxiety response was extinguished. Variations of covert desen-sitization and imaginal flooding continue to be employed by CBT clinicians today who work with anxious patients (e.g., specific phobias, GAD, OCD, and PTSD). The use of imagery as a primary therapeutic agent in fostering emotional processing of traumatic events has been emphasized by a growing number of CBT theorists and clinicians in recent years. Since traumatic memories and their...

Exposure in Vivo Therapy versus Cognitive Therapy

In specific phobias, cognitive therapy was generally less effective than in vivo exposure. Several studies found cognitive therapy and exposure in vivo therapy with the addition of response prevention about equally effective in obsessive-compulsives. Similarly, cognitive therapy is as effective as exposure in vivo therapy alone for social phobic complaints. In general, studies find that cognitive therapy alone is of limited value for agoraphobia as compared to exposure in vivo. More recently developed cognitive approaches focusing on catastrophic cognitions are effective with respect to reduction of panic attacks in patients with panic disorder with no or limited avoidance, but less effective than exposure in vivo in severe agoraphobic patients. However, these cognitive restructuring packages contain an exposure component (i.e., behavioral experiments). Finally, exposure in vivo was as effective as cognitive therapy in hypochondriasis.

History of Neuroanatomical Modeling of Fear and Anxiety

Although technological developments have contributed to a more differentiated assessment of brain structures involved in anxiety, the past decade has seen considerable research on the role of the amygdala. This has led to hypotheses that the amgygdala plays a critical role in the elaboration of anxiety, panic, and related symptoms of arousal and fearful avoidance. However, the role of mental imagery and conscious memory recall in the development of anxiety suggests that other cortical areas, such as hippocampus and frontal cortex, must play a role in anxiety since the amygdala does not have the capacity for conscious recall, and research findings are consistent with a role for these structures in anxiety disorders. Moreover, the role of specific neurochemical systems has become clearer. Long-term dysregulation of these systems is strongly associated with the development of anxiety disorders, including PD, PTSD, and phobic disorders. In the mediation of symptoms of the anxiety...

Reactions to the CEE

Detailed review of past experiences is often a way psychotherapy begins. How such review is used subsequently in the treatment varies with patient and clinician. There is controversy about the efficacy of this method for the treatment of some disorders, given the potential risks that an attempted CEE could bring. For some patients with posttraumatic stress disorder, symptoms can worsen after reexposure to past traumas. In contrast, some recent research by Edna Foa and others shows that it can be very helpful when a patient therapeutically reexperiences past trauma. The astute clinician carefully follows the patient's state of mind in sessions and knows when reviewing certain material would be likely to help the patient.

Dissociative Disorders

Dissociative disorders occur when there is a disruption in the usually unified aspects of consciousness such as memory, affect, perception, and sense of identity. One of the most severe of these disorders is dissociative identity disorder (DID), formerly referred to as multiple personality disorder. Some of the earliest work involving NF and dissociative disorders was done with clients suffering from posttraumatic stress disorder for whom one of the symptoms was dissociation. More recently, some researchers and clinicians have reported successful treatment of DID using NF. Researchers and clinicians who have published reports of their work in this area commonly use other techniques to supplement NF. For example, Carol Manchester required subjects to learn to control body temperature through temperature biofeedback prior to NF and to use various visualization techniques. Along with other NF practitioners who work with DID clients, Manchester trained subjects to increase amplitudes of...

Pervasive Developmental Disorders PDD

Another important differential diagnosis is that between children with PDD and those suffering from PTSD. Some PTSD characteristics in infancy (overarousal and hypervigilance on the one hand, and detachment, recoiling from people and introversion on the other) are similar to those of PDD. Much further research is needed in this sphere.

Traditional Versus Virtual Reality Therapy VRT

A test of VR therapy's efficiency has been the treatment of combat-related posttraumatic stress disorders (PTSD) among Vietnam veterans (Hodges and others, 2001). Patients may develop PTSD after a traumatic change in their lives, such as a severe car accident or a sexual assault. High avoidance of retrieving past traumatic memories, sleep difficulties, nightmares, and flashbacks are some symptoms of PTSD. Combat-related PTSD affected approximately 830,000 Vietnam War veterans (Hodges and others, 2001). VR therapy can provide much needed help in facilitating retrieval of past traumatic memories. For patients suffering from PTSD, the virtual world is a place they could go to confront their fear or to confront a traumatic experience. Studies have shown that retrieval of past traumatic memories can help cure PTSD symptoms.

Working Model For The Neural Circuitry Of Anxiety Disorders

Neural Circuits Anxiety Disorders

Anxiety disorders are characterized by dysfunction of an interrelated neurochemical and neuroanatomical system. PTSD and PD share many biological and phenomenological similarities that allow them to be considered related. Phobic disorders and GAD are still in early stages of investigation. Although phenomen-ologically they are similar to PTSD and PD, it is premature to include them in a model for human anxiety disorders. PTSD is related more to the deleterious effects of environmental stress, whereas PD is not as clearly related to stress and may be related more to genetic variability in anxiety. In stress-related anxiety disorders (i.e., PTSD), PTSD symptoms as well as cognitive dysfunction associated with PTSD may be linked to hippocampal dysfunction. A model can be created which incorporates informatiom from animal and clinical research relevant to these disorders, keeping in mind that working models are subject to modification with new information, and that generalizations...

Christine Maguth Nezu and Michelle A Peacock

Compared to the general population, individuals with mental retardation are at increased risk for developing behavioral, psychological, and emotional disorders. Characteristics associated with mental retardation such as deficits in social-cognitive processing ability and communication skills may negatively influence their ability to cope with stress and increase their vulnerability to developing psychopathology. Environmental factors often experienced by individuals with mental retardation that may also contribute to the development of psychopathology include poor learning opportunities, transient living situations, and staff turnover. In 2000 (Rush & Frances, 2000), practical clinical guidelines based on expert consensus and relevant research for treating persons with mental retardation suffering from major mental disorders were developed to assist clinicians in treatment decision making. Applied behavior analysis, managing the environment, and client and family education were the...

Neuropsychological Testing

The clinical neuropsychological evaluation of patients with possible toxic encephalopathy necessitates that the clinician perform a careful and thorough examination of each patient. Many areas of cognitive function must be assessed so that exposure-related effects can be detected and other possible diagnoses comprehensively evaluated and ruled in or out. Because there is overlap between the behavioral effects of exposure to certain neurotoxic chemicals and those associated with developmental disorders (e.g., learning disabilities, attention deficit disorder), psychiatric conditions (e.g., posttraumatic stress disorder, bipolar disorder), neurological diseases (e.g., multiple sclerosis, cerebrovascular disease, primary progressive dementia, parkinsonism), and the exposure to ethanol, medications, and illegal drugs, the test battery must allow for consideration of these alternative or contributing conditions. they tap. Though no test is so pure that it taps only one type of cognitive...

Presenting the Treatment Rationale

Once the appropriateness of IRRT has been established, the therapist educates the patient about the nature of trauma and how PTSD develops from inadequate emotional processing of traumatic events. A brief treatment rationale is then offered to the patient (see standard treatment rationale in Smucker & Dancu, 1999, pp. 42-44). Patients are fully informed of the emotional distress and heightened state of arousal that they are likely to experience when their traumatic memories are activated in the sessions. It is also important to emphasize that the reliving of upsetting memories in a therapy session is quite different from experiencing them in one's everyday environment, that the abuse is not actually occurring at such times, and that the therapist's voice and supportive presence provides a therapeutic anchor throughout the imagery sessions. Any questions,

Stress Inoculation Training

Developed by Meichenbaum (1974), SIT is an anxiety management program that was modified for use with sexual assault survivors. SIT is made up of training in general anxiety management techniques to address the three channels of fear and anxiety (i.e., physical, behavioral, and cognitive). These techniques can then be applied in response to specific PTSD symptoms and in general. The rationale for SIT asserts that as clients are better able to use these techniques to manage their anxiety, their PTSD symptoms will be reduced. SIT programs vary somewhat in the exact techniques that are used, but are always made up of several components. The first component, psychoeducation, focuses on the nature of fear and anxiety, the three channels of fear and anxiety, the rationale for treatment, and common reactions to sexual assault. Following psychoeducation, SIT may include several of the remaining components relaxation training, breathing retraining, role-playing, covert modeling, guided...

Empirical Studies A Efficacy of Exposure

Decades of research have established that exposure therapies, particularly graded in vivo exposure and flooding, are the treatments of choice for specific phobias and play an important role in treating other anxiety disorders. These treatments produce clinically significant reductions in fear in about 60 to 80 of cases. Systematic de-sensitization is the least effective of the exposure therapies. Although it is not often used as a stand-alone treatment, this mild, undemanding intervention is a useful starting place in an exposure program for patients who are extremely phobic.

The Eight Phases of Treatment

PTSD is not the only mental disorder known to have an etiological event phobias, panic disorders, depression, dissociation, and personality disorders are sometimes related to precipitating incidents. Deficit experiences, such as neglect, rejection, or humiliation, that occur during developmental windows can function as small-t traumas. With frequent repetition of such events, the memory network becomes predominant, organizing similar experiences in associated channels of information and precipitating a continued pattern of behavior, cognition, and related identity structures. Such persons often develop rigid defenses, a limited sense of self, impaired interpersonal function, and affect dysregulation. Because of the lack of adequate assimilation of these events into the larger associative network, similar experiences in the present, including a variety of triggers implicit in the memory network, can elicit these dysfunctional affects and negative appraisals. It is further hypothesized...

Differential Diagnoses of ADHD in Early Childhood

Irritability and attention difficulties are very common in young children who have experienced trauma, yet the origins of PTSD and ADHD are entirely different, so in most cases it is easy to distinguish between the two. At the same time, in complex cases where the young child is chronically exposed to difficult experiences, diagnosis is harder.

Cognitive Challenging

A second category of automatic thoughts is irrational thinking. For example, someone with PTSD might think, I was assaulted in a parking lot therefore, parking lots are dangerous, an example of overgeneralizing. Catastrophizing, a common type of irrational thinking in anxiety, is the tendency to think that something is intolerable or unbearable. Using the panic attack example from earlier, the thought that passing out would be a horrible thing is an example of catastrophizing it might not be pleasant, but it's not as awful a possibility as the person initially assumed. Two other

Dysfunctional Beliefs

Theories of fear have become increasingly complex in recent years. Classical conditioning and many other factors are thought to be involved. Consistent with the neo-conditioning and emotional processing models, some theorists have proposed that exaggerated beliefs about the probability and severity of danger may play an important role in motivating fear and avoidance. Such dysfunctional beliefs play a prominent role in contemporary theories of agoraphobia and social phobia, and may play a more important role in these disorders compared to specific phobia. People with social phobia tend to be preoccupied with their social presentation and have heightened public self-consciousness. They also tend to be self-critical, to excessively worry about being criticized or rejected by others, and to overestimate the likelihood of aversive social events. This suggests that such dysfunctional beliefs may be important in maintaining generalized social phobia. These beliefs appear to persist because...

Recommended Readings

Anger-control problems are an often-overlooked disorder and they have received limited attention in the treatment literature. An examination of the American Psychiatric Association DSM-IV reveals nine diagnostic categories for Anxiety Disorders and ten diagnostic categories of Depressive Disorders, but only three diagnostic categories for anger-related problems, namely, Intermittent Explosive Disorders, and two Adjustment Disorders with Conduct-Disorder features. The dearth of research on anger is further highlighted by DiGiuseppe and Tafrate (2001) who noted that for every article on anger over the past 15 years, there are ten articles in the area of depression and seven articles in the area of anxiety. The absence of research activity on anger is somewhat surprising given that anger-related behaviors are one of the most common psychiatric symptoms that cut across some 19 different psychiatric conditions. Anger, hostility, and accompanying violence are often comorbid with other...

Katie M Castille and Maurice F Prout

Anxiety disorders have been identified as the most prevalent mental health problem in the United States. According to the Epidemiologic Catchment Area (ECA) study sponsored by the National Institute of Mental Health, the 1-month prevalence rate for anxiety disorders is 7.3 (Regier et al., 1998). Among anxiety disorders, phobic disorders are the most common, with a prevalence rate of 6.2 . According to the Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR American Psychiatric Association APA , 2000), phobias are classified into three categories agoraphobia with or without panic attacks, social phobia, and specific phobia. An element common to phobias is the feeling of fear that individuals experience when they encounter the phobic situation or object. Fear is a basic emotion that acts as an alarm in response to present danger (Barlow, 2002). When in a feared situation, the natural tendency is to engage in the fight-or-flight response. There arises an...

Alterations in Neurochemical Stress Response Systems in Patients with Anxiety Disorders

The stress response and are sensitive to chronic stress. The findings in PTSD and PD (most extensively studied of the anxiety disorders) are summarized in Table II. Specific alterations in cortisol and HPA axis function are associated with PTSD. An increase in neuronal CRF release is a possible explanation for the clinical findings that have been reported for this disorder, with resultant blunting of ACTH response to CRF, increased central glucocorticoid receptor responsiveness, and resultant low levels of peripheral cortisol due to enhanced negative feedback. Interestingly, nonhuman primates with variable foraging mothers (a model for early life stress) had elevated CSF and CRF and decreased CSF cortisol levels in adulthood, which is more similar to PTSD than to depression. There is extensive evidence indicating that NE plays a role in human anxiety and is dysregulated in anxiety disorders. PTSD and PD seem to have similar alterations in noradrenergic function. However, the causes of...

Stressinduced Analgesia

Stress-induced analgesia (SIA) is the phenomenon that certain stressors can induce changes in the pain threshold following the stress situation. The biological basis of SIA is not clear. Some studies showed that SIA is mediated by the opiate system ( Altier and Stewart, 1996 Starec, et al., 1006 Vaccarino, et al., 1999 Yamada, et al., 1995), by P-endorphin (Hawanko, et al., 1994 Herz, 1995, Nakagawassi et al., 1999), substance P (Altier and Stewart, 1998), corticosterone (Filaretou, et al., 1996), or by CRF and cytokines (Laiviere and Melzack, 2000). Other studies found that the effect of SIA gradually decreases over aging ( Laiviere and Melzack, 2000), implicating the hippocampus in SIA. Fish oil protects from SIA (Sutton, et al., 1994), and stressors that induced SIA also induced an increase in cholesterol level(Bernnan, et al., 1992 ). It is of interest to note that PTSD (posttraumatic stress disorder)-induced analgesia was shown to be mediated by the opiate system, but not by...

Recommended Inclusion and Exclusion Criteria

Before treatment begins, a clinical interview is conducted that includes demographic information, current life situation, family history, history of traumatic experiences, current psychological adjustment, health status, alcohol and drug use, and severity of PTSD symptoms. Individuals who have been victims of childhood trauma, and who continue to experience recurring intrusive recollections (e.g., recurring flashbacks, repetitive nightmares) of their trauma(s) are likely to be good candidates for IRRT. Before proceeding with IRRT, however, it is important to review the following recommended exclusion criteria (1) a diagnosis of schizophrenia, acute psychosis, or dissociative identity disorder (especially if the patient is dissociative during imagery sessions) (2) active involvement in substance or alcohol abuse

Consequences of Child Abuse and Neglect

Child abuse and neglect has been associated with increased risk of adverse outcomes. Not all abused and neglected children suffer immediate or lasting consequences beyond their immediate injuries. Nevertheless, abused and neglected children are at increased risk for a range of physical, mental emotional, and social behavioral difficulties. The pathways to these outcomes are currently unclear, but involve a combination of compromised brain development and long-term psychological and emotional sequelae associated with their abuse and neglect. Abused and neglected children are at increased risk of school-related difficulties resulting from cognitive and learning difficulties or from emotional adjustment problems. Abused and neglected children are at increased risk of relationship problems stemming from low-self esteem or aggressive tendencies. Abused children are also at increased risk of juvenile delinquency. Girls who have been sexually abused are at increased risk for violence in...

TABLE 2911 Common Reasons Why Physicians May Not Diagnose Domestic Violence in the Emergency Department

Another important reason for failure to diagnose is the failure to consider domestic violence in cases with nontrauma chief complaints. Battered women seek care in emergency departments for a wide variety of medical complaints, including anxiety, hyperventilation, depression, drug and alcohol intoxication, chronic pain syndromes, and symptoms suggestive of posttraumatic stress disorder (PTSD).

Wanda Grant Knight Helen Mac Donald Stephanie Clarke and Karestan Koenen

Keywords PTSD, childhood disorders, trauma Although researchers have long been interested in children's responses to natural disasters, domestic violence, abuse, and loss associated with war (Pelcovitz & Kaplan, 1996), they have only recently explored posttraumatic stress disorder (PTSD) as an outcome of these experiences. While adult PTSD, which was officially recognized in the Diagnostic and Statistical Manual of Mental Disorders Third Edition (DSM-III American Psychiatric Association, 1980), shares some symptoms with child PTSD, researchers have discovered a unique set of age-specific responses to trauma that characterize this disorder in children. Thus, age-sensitive symptoms are included in both the DSM-III and DSM-IV (APA, 1994) diagnostic criteria for PTSD (Pelcovitz & Kaplan, 1996). According to the DSM-IV, PTSD comprises three categories of symptoms that are associated with a traumatic event that is either experienced directly or witnessed. First, reexperiencing of the...

Diagnostic Considerations

Comprehensive evaluation of a patient in crisis includes considering diagnoses commensurate with acute stress reactions and posttraumatic stress diagnoses. The DMS-IV-TR (APA, 2000) identifies several diagnoses that include as a criterion exposure to a stressor. These include adjustment disorders, acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and brief reactive psychosis. Meeting the criteria for any of these disorders requires the clinician to consider ongoing treatment. Adjustment disorders present the least impairment along the continuum and include varying types of reactions (with depression, anxiety, mixed disturbance, and so on). ASD requires the patient to have experienced, witnessed, or confronted an intense stressor that involved actual or threatened death or serious injury, or even a threat of the physical integrity of the self or others. Additionally, three main clusters of symptoms must be present. These include the reexperiencing of the event (e.g.,...

The Information Processing System

The physiologically based information processing system can be compared to other body systems such as digestion in which the body extracts nutrients for health and survival. The information processing system sorts perceptions of experience and stores memories in an accessible and useful form. Information processing is essential for learning and involves the forging of associations with experiences previously stored in memory. The strong negative affect or dissociation induced by a traumatic event may impair information processing, inhibiting associative links with adaptive information in other memory networks. The memory is then dysfunctionally stored without appropriate associative connections and with negative emotion and physical sensations intact. When triggered by similar situations the memory is reexperienced, rather than simply recalled as an historical event. A prime example involves the intrusive thoughts, emotional disturbance, and negative self-referencing cognitions of...

Victoria M Follette and Alethea A A Smith

Keywords exposure, cognitive processing therapy, PTSD, stress inoculation training Exposure therapy has increasingly been found efficacious with a variety of anxiety-related disorders including phobias, generalized anxiety disorder, and posttraumatic stress disorder. Originally developed using concepts from basic learning theory, concerns about enhancing the efficacy of exposure therapy have led to the enhancement of this technique with additional components. The primary augmentation has been the integration of cognitive techniques. As cognitive conceptualizations of various forms of psy-chopathology, particularly anxiety and depressive disorders, became dominant, the integration of cognitive and exposure strategies grew to be routine practice. While exposure alone does have strong empirical support across a variety of anxiety-related disorders, there have been several consistent concerns regarding this approach. First, studies using exposure often report high attrition rates in the...

Cancer Patients Psychotherapy

The acceptance of the possibility of illness shortening life carries with it an opportunity for reevaluating life priorities. When cure is not possible, a realistic evaluation of the future can help those with life-threatening illness make the best use of remaining time. One of the costs of unrealistic optimism is the loss of time for accomplishing life projects, communicating openly with family and friends, and setting affairs in order. Facing the threat of death can aid in making the most of life. This can help patients take control of those aspects of their lives they can influence, while grieving and relinquishing those they cannot. Having a domain of control can be quite reassuring. Previous studies by Roxanne Silver, Phillip Zimbardo, and colleagues of the sequelae of past traumatic events indicate that long-term psychological distress is associated with a temporal orientation that is focused on the past rather than on the present or future. For cancer patients who are...

Anxiety Management Training AMT

AMT teaches the patient the cognitive and behavioral skills to more effectively manage the aversive emotions experienced in PTSD. Typically, the specific skills taught are relaxation training, breathing retraining, trauma education, guided self-dialogue, cognitive restructuring, and communication skills. Although frequently considered a palliative approach to treating PTSD, AMT appears to possess the capacity to influence the frequency and intensity of PTSD symptoms across different types of traumatic events (e.g., Foa et al., 1999 Resick et al., 2002). In a large-scale trial of CBT among Australian Vietnam veterans with PTSD, Creamer, Morris, Biddle, and Elliot (1999) found striking changes in PTSD among this cohort of war-traumatized veterans. This multisite effort, while not randomly controlled, suggests great promise for treating war-related PTSD among military veterans (Frueh et al., l996).

Medical Management of Terrorist Related Injuries

Of patients with urgent and salvageable life-threatening injuries (undertriage) (Frykberg 2004 Kluger 2003 Stein and Hirshberg 1999). In these circumstances, prioritization of treatment regimens is mandatory and definitive therapy should be delayed until the patient is hemodynamically stabilized damage control principles should be applied. However, identifying those critically injured patients who are candidates for damage control maneuvers, which aims to achieve hemostasis and prevent uncontrolled spillage of bowel contents and urine, is undoubtedly a challenge. Throughout the management of the event, coordination between the primary on-scene teams responsible for the primary triage and evacuation is obligatory, followed by similar close interaction between the in-hospital teams conducting the triage, the initial treatment, the surgical interventions and the intensive care, as well as between neighboring hospitals, in order to optimize utilization of the hospitals' personnel and...

Acute Care And Rehabilitation Settings

Skin-related breakdowns accompanying diabetes or paralysis may have avoidant tendencies. Some individuals may have experienced trauma that placed them at risk for anxiety problems. For example, Koch and Taylor (1995) provide an excellent review of the psychological sequelae associated with motor vehicle crashes posttraumatic stress disorder, depression, pain-related conditions, and phobic avoidance of stimuli associated with the accident. The authors emphasize the importance of assessing the nature and subjective meaning of the accident and examining the functional relationships between physical injuries and emotional disorders. Treatment issues include selecting the appropriate CBT interventions, determining the proper sequence of application, and managing complications such as litigation and medication adherence.

Testimonial Psychotherapy

The refugee population is gaining increased recognition as a population that is susceptible to the development of PTSD. Testimonial psychotherapy has been developed as a symptom-based treatment for war-related PTSD (Weine, Kulenovic, Pavkovic, & Gibbons, 1998). Employed in small groups of people who have experienced this treatment, it accesses individuals' traumatic experiences and integrates their own story into a collection of stories including all of the refugees who shared their experiences. Among refugees it encompasses an effort to piece together the history of their culture as it has survived efforts at destruction. The goal is to review in great detail the elements of the trauma history while focusing on keeping important aspects of history and culture alive. Clearly there is a strong component of exposure therapy included in testimonial therapy, but it also incorporates meaning and highlights purpose in the refugees' lives. In a clinical trial, testimonial therapy...

Jonathan D Huppert and Edna B

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by both obsessions and compulsions. Obsessions are intrusive thoughts, images, or impulses that come into one's mind for no apparent reason, are unwanted, and are distressing. Compulsions are characterized by repeated behaviors or thoughts that serve to decrease the obsessional distress. To meet criteria for OCD, obsessions and or compulsions must take up at least 1 hour a day and be distressing or interfere with the patient's functioning in life. Severe OCD is characterized by substantial frequency of obsessions and compulsions (from 4 hours a day to every minute of the patient's waking hours), substantial impairment from the OCD (usually in all domains of life including social, work, and family), poor insight into the symptoms (or how realistic the patient thinks their fears are), and or substantial comorbidity which complicates the presentation of the symptoms (e.g., posttraumatic stress disorder or...

Diverse Clinical Applications

In large-scale studies of EMDR treatment with trauma populations, direct internal comparisons were made for those with and without PTSD diagnosis. The equivalent findings on numerous affective and cognitive measures lend credence to the notion that EMDR can be effectively used to process disturbing experiences that may contribute to a variety of clinical complaints. Although positive reports have been published on the application of EMDR to the treatment of (1) personality disorders, (2) dissociative disorders, (3) various anxiety disorders, and (4) somatoform disorders, controlled research is needed to confirm the efficacy of these applications. Some of the findings are promising. For example, although body dysmorphic disorder is known to be relatively intractable to treatment, researchers in one case series study reported that five of seven patients treated with EMDR no longer met diagnostic criteria after one to three sessions.

Prevalence Of Anxiety Disorders

The American Psychiatric Association first recognized anxiety disorders in 1980 as a separate group of psychiatric disorders. The concept of neurosis (neurasthenic neurosis, anxiety neurosis, phobic neurosis, and obsessive-compulsive neurosis) in previous classifications was abandoned because it was considered too vague. Anxiety disorders now include PD, PTSD, social phobia, specific phobia, OCD, and GAD. Anxiety disorders are by far the most common of psychiatric disorders (25 ), followed by affective disorders (17 ). In the past decade, large epidemiological studies have provided information about the prevalence of anxiety disorders in the general population. A landmark epidemiological study in the United States in 1994 found lifetime prevalence rates for all anxiety disorders combined to be 19.2 for men and 30.5 for women. Phobic disorders are the most common diagnosis in broad-based assessments of psychiatric disorders in the community (affecting about 13 of individuals at any...

The Design of Cell Culture Systems and Bioreactors

These hurdles apply to all types of bioreactor, and are not necessarily limited to the final testing devices themselves. In order to succeed in a drug-testing strategy of human micro-organoids in vitro, stem cell expansion devices may be essential for cell supply. Within such cell- and tissue-manufacturing devices, both intrinsic symmetrical division as well as intrinsic and environmental asymmetric division for the expansion and differentiation of the necessary cell populations to charge the drug-testing bioreactors are mandatory. In contrast to the drug-testing bioreactors where differentiated micro-organoids are kept alive, these devices must emulate the embryonal environment or somatic stem cell niches. An additional challenge here is to prevent the induction of irreversible molecular pathways by traumatic events in stem cell fate. Thus, it is essential that a proper environment is applied, not only for the formation of differentiated human micro-organoids but also for human stem...

Cbt And The Trauma Memory

Reviews have indicated that two forms of CBT are effective in the treatment of PTSD. In 1992 in a paper on treatment studies of PTSD, Solomon, Gerrity, and Muff (1992) identified only 11 outcome studies that utilized random assignment to treatment and control groups. While none involved older people, the active therapeutic ingredients for the treatment of PTSD remain striking to this day. They include systematic desensitization and CBT, exposure therapy, and cognitive reprocessing, as well as (but less so) general factors, including support and skills training. More recently, Solomon and Johnson (2002) reviewed the treatment research and found that several forms of therapy appear to be useful in reducing the symptoms of PTSD. Strongest support is found for the treatments that combine cognitive and behavioral techniques. Imaginal exposure to trauma memories and hypnosis are techniques most likely to affect the intrusive symptoms of PTSD, while cognitive and psychodynamic approaches may...

Cognitive Behavior Therapy

Surprisingly, no randomized, controlled between-group design outcome studies examining the efficacy of CBT with children evincing anxiety disorders, other than simple or specific phobias, existed until recently. However, several controlled single-case design studies provided preliminary support for the likely efficacy of behavioral and cognitive-behavioral procedures with overanxious, separation anxious, and socially phobic children (see Ollendick & March, 2003). These early studies provided the foundation for the between-group design studies that followed in evaluating the efficacy of CBT.

Psychiatric Disorders

Psychiatric disorders are estimated to afflict up to 50 percent of the developmentally disabled population. Although mood disorders, particularly depression, are most frequent, they are relatively unlikely to precipitate ED evaluations. Instead, emergency visits are usually precipitated by aggression or extreme agitation. In such cases, benzodiazepines or low-dose, low-potency antipsychotics, such as chlorpromazine, may be acutely helpful in controlling the patient's behavior sufficiently to proceed with an evaluation. However, it is essential to try to identify the underlying etiology of these behaviors and changes in their frequency or intensity. Undiagnosed, painful medical problems, including severe constipation, often lead to exacerbation. 16 Sleep apnea can also be manifest as increased irritability. In addition, anxiety may be manifest primarily as agitation. Often environmental factors can be identified that are increasing the patient's anxiety. Such factors may include...

Aftermath of Disaster

As soon as possible, efforts should be directed toward returning the hospital to normal operations. Besides restocking and cleaning, consideration must be given to the emotional stress experienced by both prehospital and hospital staff. Short- and long-term emotional problems, including posttraumatic stress disorder, particularly among rescuers, have been reported on numerous occasions.65 A technique known as critical incident stress debriefing (CISD) was introduced in 1983, 6667 and such an intervention can assist providers in maintaining job performance and satisfaction, resulting in improved patient care. 68

An Integrativedynamic Model Of The Difficult Child

The development of the ''difficult'' child is based on an organic nucleus that is in constant interaction with other characteristics of the person carrying it. In addition, and important to the same degree, is the interaction that develops between the child and his her environment, starting with his her parents and ending with large social systems. These interactions determine the development of the difficult child's characteristics, and in fact constitute a central factor in formulating the diagnosis, whether it is ADHD, ODD CD or PTSD. Not surprisingly, in light of the complexity of these processes, it may be expected that there will be multiple diagnoses. In fact, these diagnoses are only descriptive that is, they describe symptoms, and their developmental process is common in more fundamental ways. In addition, since frequently there is a common aetiological source, the same child is likely to be diagnosed differently at different stages in his her development. Here dynamism, the...

Sheila AM Rauch and Edna B

Keywords PTSD, assault, trauma In the past 15 years we have witnessed a proliferation of publications on the efficacy of a variety of cognitive-behavioral treatments in reducing PTSD and related symptoms. Given the vast research on CBT for PTSD, a comprehensive account of studies is beyond the scope of this article. The current review will focus on presentation of (1) descriptions of the different CBT programs (2) studies demonstrating the basic efficacy of CBT for PTSD by comparing an active CBT with some control condition such as wait-list, supportive counseling, or relaxation and (3) studies comparing the outcomes of the different CBT programs with proven efficacy.

Mechanisms of Action

The findings of dismantling research are limited by methodological problems. Although component studies with clinically diagnosed PTSD subjects provide preliminary indications that an eye movement condition is more effective than control conditions, such studies have typically used small samples (e.g., 7 to 9 persons per condition) with inadequate power, and selected inappropriate controls, Truncated procedures are common one study for example, provided only 145 seconds of treatment. The results of such studies are inconclusive and comprehensive research is required.

Contributions from Neuroimaging Studies

Digital processing of magnetic resonance imaging (MRI) of the brain can quantify three-dimensional volumes of brain structures. Nonquantitive studies found evidence of abnormalities in temporal lobe in patients with PD, and one quantitative study found decreased volume in the hippocampus. A reduction in hippocampal volume has been reported in several studies in patients with PTSD (Fig. 1). This hippocampal volume reduction has been positively correlated with verbal memory deficits. Considering the role the hippocampus plays in the integration of memory elements, which are stored in primary sensory and secondary association cortical areas at the time of retrieval, these findings suggest a possible neural correlate for symptoms of memory fragmentation and dysfunction in PTSD. Pharmacologic and cognitive provocation of PTSD symptom has been used in order to identify neural correlates of PTSD symptomatology and of traumatic remembrance in PTSD. Administration of yohimbine (which increases...

Differential Diagnosis Childhoodonset Psychosis

Children suffering from PTSD are also likely to be misleading by creating a pseudo-psychotic picture, primarily due to the dissociative characteristics that accompany this disorder. For example, children who have undergone sexual abuse frequently exhibit dissociative, sexual seductive or anxious behaviours 55,56 . These children are also likely to exhibit visual and auditory hallucinations caused by ''flashbacks'', irritability and mistrust, detachment and avoidance. These characteristics are liable to suggest the presence of a psychotic condition, especially if the clinician has not considered the possibility of physical or sexual trauma.

Prevention Prognosis and Outcome

Among geriatric trauma patients who are hospitalized, the mortality rate has been reported to be between 15 and 30 percent. These figures far exceed the mortality rate of 4 to 8 percent found in younger patients.1 In general, multiple organ failure and sepsis cause more deaths in elderly patients than in younger trauma victims. 16 Geriatric patients also are more likely to die following minor traumatic events.17

Summary And Conclusions

Phobias can be distressing and debilitating disorders. Individuals with agoraphobia, specific phobia, and social phobia experience fear in particular situations or around particular objects that often manifests itself in a panic attack or paniclike symptoms. The experience of panic leads to anticipatory anxiety about having future symptoms of panic, resulting in avoidance of the phobic situation. CBT has been found to be effective in treating these phobias through a combination of exposure, cognitive therapy, and psychopharma-cology. Continued research on treatments for phobias will help to find the most cost-effective treatments that can be generalizable across various patients and settings.

Theoretical Integration

Step they are trained rather than programmed. Tryon used the bidirectional associative memory model to satisfy all four of Jones and Barlow's and all five of Brewin, Dalgleish, and Joseph's explanatory requirements for a comprehensive understanding of posttraumatic stress disorder. NNLT accounts for the nonassociative as well as associative etiologies of phobias. NNLT provides a comprehensive understanding of how systematic desensitiza-tion and exposure therapies work. NNLT provides an integrated theoretical basis for multimodal behavior therapy NNLT provides the missing theoretical link between genetics and behavior in behavior genetic explanations. NNLT resolves the cognitive-behavioral debate, synthesizes findings from human and animal research and resolves several other long-standing schisms in psychology.

Guidelines for Using Dreams

The imaging can become part of the homework assignment arrived at between the patient and the therapist. The patient can be asked to develop a number of images that help focus on the particular symptoms currently being addressed in treatment. The therapist can, of course, utilize imagery and imaginal restructuring as a major tool for both dream-related images and waking images (Edwards, 1989). Krakow's (2004) imagery rehearsal therapy (IRT) has been developed with groups of survivors of sexual abuse suffering from posttrau-matic stress disorder (PTSD) to reduce the number, intensity, and intrusiveness of nightmares. Repeated rehearsals of alternate imagery offer the patients a feeling of mastery over the intrusive and noxious stimuli and help them sleep through the night. Improved sleep, Krakow suggests, is then instrumental in reducing other symptoms of PTSD.

Empirical Support

Since that time, many studies have been done establishing the effectiveness of flooding for the treatment of anxiety symptoms. Flooding has been found effective in treating adults with the following anxiety disorders obsessive-compulsive disorder, simple phobias, social phobia, agoraphobia, posttraumatic stress disorder, and panic disorder. For example, in a 1993 meta-analysis, George Clum, Gretchen Clum, and Rebecca Surls found that flooding was the treatment of choice for panic disorder, showing better results than other psychological techniques (such as systematic desensitiza-tion) or medications. In a 1995 review, Melinda Stanley and Samuel Turner concluded that flooding was the treatment of choice for obsessive-compulsive disorder, resulting in greater reduction of anxiety symptoms, decreased drop-out rates, and decreased relapse rates over time than other psychological techniques or pharmacological treatments. Across all anxiety disorders, flooding has been found to be effective...

Application To Older Victims

These studies apply to older trauma victims with several caveats. Chiefly older victims find the modal exposure treatments distressing to tolerate. Intensive exposure methods with older adults may be counterproductive. It increases the level of autonomic arousal, with adverse effects on cognitive performance. There are many benefits to the use of prolonged exposure, but older patients do best with dosed exposure and coping techniques. The primary therapeutic task in PTSD treatment becomes the activation of the traumatic memories while keeping autonomic nervous system arousal in the moderate range so that the secondary process program can effectively rewrite the original codes created by the automatic thinking program to classify the traumatic memories and or the secondary process program can be used to revise the meta-cognitions that the traumatic material contradict. Four therapies perform this task well. Anxiety management training, applied prior to exposure, reduces treatment...

Comparisons Among Treatments

Key studies comparing the previously discussed efficacious treatments for PTSD have found few differences in outcome between CBTs. For instance, in a study comparing SIT, exposure therapy, and their combination in a female assault sample with PTSD, only general anxiety was significantly lower in exposure therapy compared to exposure therapy SIT (Foa et al., 1999). However, there was a trend for more clients in exposure therapy (52 ) to obtain good end-state functioning (a composite of PTSD, depressive, and general anxiety symptoms) than SIT (31 ) or exposure Similarly, Marks et al. (1998) found few differences between exposure therapy, CT, and exposure therapy CT while all were superior to relaxation. All resulted in significant reductions in anxiety, PTSD symptoms, and depression compared to relaxation. However, no treatment demonstrated significantly greater reduction compared to the other treatments, including no benefit for the combined treatment compared to either CT or exposure...

Virtual Reality Cases in Health Care

VR is an effective medium of treatment for a variety of disorders. One example is the use of VR in the treatment of phobias. Patients are helped to overcome their irrational fears and apprehensions through virtual exposure to phobogenic stimuli. A controlled study by Hodges and Rothbaum showed VR to be effective in remedying acrophobic subjects' anxiety and avoidance of heights (Kooper, 1995). Besides being time-efficient and cost-effective, VR defines a very controlled environment for phobia treatment. In other words, VR phobia treatment eliminates the variables that might prevent treatment receivers from successfully identifying and addressing the stimuli of interest. It is also worth mentioning that most people with phobias prefer to undergo virtual exposure rather than being exposed to a feared situation or object in vivo. We will now examine the use of VR for treatment of phobias in more detail.

Aversion Relief

Aversion relief has also been applied in treating anxiety disorders by Solyom and colleagues, including obsessive compulsive behavior, specific phobias, and agoraphobic avoidance. Solyom detailed an aversion relief procedure in the context of agoraphobic avoidance. Patients were repeatedly guided through audio-taped self-generated narratives of phobic avoidance. The vignettes might be interspersed with short pauses after which mild electric shocks (ES) were delivered. Patients could terminate the shock by pressing a button and continuing the taped approach scenario. For a particular female patient the narrative was I am getting dressed 15 sec ES, button pressed (by patients to terminate ES) to leave my home, as I am getting prepared and put my make-up on 15 sec ES, button pressed, the bell rings 15 sec ES button pressed. My heart is beating very fast I answer the bell and my boyfriend comes in, he says 15 sec ES button pressed, let's go Mary, 15 sec ES button pressed, the party is...


Implosion involves exposing the person to intensely fear-evoking imagined stimuli, which lie at the top of the fear hierarchy. Often exposure is embellished by having the patient imagine extremely terrifying forms of the stimuli. Implosion is often used in the treatment of posttraumatic stress disorder, where the goal is to reduce the fear and associated distress associated with traumatic memories. More often, however, the feared stimuli are simply imagined in great detail, with the person imaging all the sensory aspects of the stimulus (e.g., sights, sounds, smells), along with any bodily sensations, emotions, and thoughts that might occur when the stimulus is encountered. A person who developed posttraumatic stress disorder as a result of being in a motor vehicle accident, for example, would be asked to repeatedly imagine the traumatic experience, typically for 30 to 45 minutes per treatment session over several sessions. The narrative of the experience might be spoken into a tape...


Play materials used in CBPT are similar to those found in any type of play therapy. These include, but are not limited to, crayons markers and paper, blocks, dolls, dollhouse, and puppets. Axline (1947) provided a list of toys that is still cited as a guideline for play therapy materials, despite the volumes of new toys created since the list was published. In general, the more directive techniques found in CBPT, compared especially with Axline's nondirective approach, require planning and forethought regarding choice of materials. There are certain clinical presentations (e.g., children with specific phobias) where specific play materials will be essential to the treatment. However, it is probably more

Exposure Therapy

Exposure therapy is a general term used to describe a variety of treatments that focus on confrontation of anxiety-provoking stimuli until anxiety decreases. For PTSD, these programs include confrontation of trauma-related stimuli that may include the trauma memory and or trauma-related people, place, or situations. One type of exposure therapy that has received significant empirical attention is prolonged exposure, which includes four components psychoeducation, breathing retraining, imaginal exposure, and in vivo exposure. Psycho-education focuses on common reactions to trauma and the rationale for exposure therapy. Breathing retraining teaches clients a specific technique to deescalate anxiety. During imag-inal exposure, the client relives the trauma memory in imagination for a prolonged period of time (30 to 60 minutes per session). Imaginal exposure is repeated for maximum effectiveness. In vivo exposure involves repeated, prolonged exposure to objectively safe situations that...

Cognitive Therapy Ct

As such, the rationale for CT asserts that PTSD and other anxiety symptoms result from negative and unhelpful thoughts that may fall into common dysfunctional patterns. For instance, overgeneral-ization occurs when a person reacts to a new situation based on a previous experience that does not fit. For example, a rape survivor whose assailant had a beard may believe that all men with beards are dangerous and, thus, experience anxiety and fear whenever she sees a bearded man. In CT, these unhelpful thought patterns are identified, challenged (e.g., collecting evidence, looking for alternative interpretations), and replaced by more helpful alternative thoughts. Controlled trials of CT in survivors of various types of trauma have demonstrated that CT reduced the rates of PTSD at posttreatment more than wait list and relaxation (Frank et al., 1988 Marks et al., 1998). In addition, CT has demonstrated reductions in general anxiety and depressive symptoms...


Individual CBT for childhood PTSD is characterized by distinct modules, which are fairly uniform across treatments. These components include coping, skills training, psychoeducation, cognitive restructuring, exposure to trauma-related anxiety, and relapse prevention (Cohen & Mannarino, 1993 Saigh, Yule, & Inamdar, 1996). Treatments often begin with psychoeducation, stress management, and skills training in order to equip children with techniques to cope with the initial anxiety of the behavioral exposures, which comprise an important component of cognitive-behavioral approaches. The individual treatment modality provides the most intensive intervention, which can be catered specifically to index the child's relevant traumatic event and posttraumatic symptoms, in addition to being able to work closely with the particular issues the child's parent may be experiencing in the home. 3. Parent training (PT) is a vital component of psy-chotherapeutic treatment with younger traumatized...


Exposure therapy techniques have been empirically supported for the treatment of PTSD in adults (e.g., Keane, Fairbank, Caddell, & Zimering, 1989) and have recently been extended to treat children with trauma histories (Deblinger & Heflin, 1996). These techniques expose the child to memories or reminders of the traumatic event in a safe and structured environment. Different models of 2. Cognitive interventions have proven efficacious in treating cognitive distortions in adult trauma survivors, particularly those with sexual assault histories (Foa, Rothbaum, Riggs, & Murdock, 1991). Such distortions are common in traumatized children as well and typically manifest themselves in thoughts of a foreshortened future, self-blame, survivor guilt, overgeneralization, and meaning-making of the traumatic event. The different types of cognitive therapies developed or adapted for children seek to correct cognitive errors and simultaneously hone children's coping skills. Two such interventions are...


Hundreds of studies on stress have been performed during the past decade. About a quarter of the individuals who are exposed to serious trauma go on to develop PTSD (lifetime). Current rates of PTSD in people exposed to traumatic events range from about 5 to 11 (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Norris (1992) found the lifetime exposure rate to at least one major stressor event to be 69 . Ensel (1991) showed that most older community-dwelling adults (74 ) had at least one major life event during the past 6 months that produced a negative impact. relatives and friends, physical illness and hospitalization, as well as other precipitating factors, such as war or prison camps or other retraumatizing events, do not potentiate underlying potential PTSD residual problems. The interference of aging with a sudden or brief traumatic experience, such as an accident or robbery, has yet to be corroborated. Following the DSM categories of acute and chronic stress, there are two...


The term mild head injury has been linked to other descriptors, disorders, and controversial concepts, such as minor head injury, mild traumatic brain injury, complicated mild head injury, cerebral concussion, postconcussion disorder, posttraumatic stress disorder, somatization disorder, compensation neurosis, the silent epidemic, and the miserable minority. In the early 1980s, investigators at the University of Virginia used the following criteria to define their mild head injury research population head injury with Glasgow Coma Scale greater than 12, loss of consciousness of less than 20 min, and hospitalization less than 48 hr. This research definition was later expanded to include the absence of neuroimaging evidence of cerebral lesion(s). Variations of this definition with minor modifications have been the mainstay for mild head injury and concussion research ever since.

Mood Disorders

Mood disorders in children and adolescents are often severe and liable to cause significant morbidity and mortality 42,43 . For several years childhood depression was underdiagnosed, but today we are better able to identify and diagnose it in early childhood. Mania is undergoing the same process today. In certain cases, what was defined as ADHD or behaviour disorder turns out to be a ''covert mania''. In follow-up studies of ADHD and disruptive behaviours, a high frequency of mood disorders (including bipolar disorder) has been observed, which were diagnosed at a later stage in the child's life. Therefore, the greater our ability to refine the clinical criteria of mania in children and develop suitable scales, the better will we be able to identify maniform conditions at a younger age and differentiate them from ADHD and behaviour disorders. However, bipolar disorder, ADHD, disruptive behaviours and drug abuse are also likely to co-occur in the same subjects 44 . These subjects are...

Major Depression

PTSD is also characterized by a high prevalence of depressive symptoms. Many children who exhibit clinical depression conceal a history of acute or chronic trauma. In addition, these children are liable to be ''many-layered'' i.e. depression may be the most prominent clinical feature, and only a more in-depth evaluation will make it possible to locate the old trauma and other characteristics of PTSD, which are hiding beneath the behavioural turmoil. This combination of PTSD and depression is one of the most challenging and difficult to decipher conditions among those included under the heading of ''the difficult child''.


Excessive fears, which are a central component of many anxiety disorders, such as specific phobia, social phobia, panic disorder and agoraphobia, obsessive-compulsive disorder, and posttraumatic stress disorder. During exposure therapy, the person is presented with a fear-evoking stimuli in a controlled, prolonged fashion, until the fear diminishes. Treatment is collaborative, with the patient and therapist working together to decide how and when exposure will take place. Exposure duration depends on many factors, including the type of feared stimuli and the severity of the person's fears. Typically, an exposure session lasts 20 to 90 minutes, and sessions are repeated until the fear is eliminated. Sessions may be either therapist-assisted or may be completed by the patient as a form of homework assignment. Implosion similarly involves exposing the person to intensely fear-evoking stimuli, but in this case the stimuli are imagined. Often exposure is embellished by having the patient...


According to the ICSD (1997), nightmares are frightening dreams that usually awaken an individual from REM sleep. The DSM-IV indicates that nightmares are characterized by repeated awakenings from a sleep period with comprehensive recall of extremely frightening dreams. Themes usually involve threats to survival, security, or self-esteem. Estimates are that 10-50 of children between 3 and 5 years old have nightmares that may disturb their parents and approximately 75 of individuals can remember one or more nightmares in the course of their childhood. While 50 of adults report having at least an occasional nightmare, the condition of frequent nightmares (1+ per week) occurs in only 1 of the population. The most common causes of nightmares are anxiety or stress, the death of a loved one, adverse reaction or withdrawal from drugs and or alcohol, or other sleep disorders. When assessing nightmares, it is important to distinguish between night terror disorder, delirium, posttraumatic...


SAD is often comorbid with many of the anxiety disorders, including specific phobias, generalized anxiety disorder, agoraphobia, and panic disorder. According to the NCS, 56.7 of people diagnosed with SAD also met criteria for another anxiety disorder (Kessler et al., 1994). SAD is also highly comorbid with depression, with 37.2 of those diagnosed with SAD also meeting criteria for major depressive disorder in the NCS. Finally, SAD often co-occurs with alcoholism, with 34.8 of those diagnosed with SAD meeting criteria for either alcohol abuse or dependence in the NCS study.

Generalized Epilepsy

The parasomnias refer to clinical disorders consisting of undesirable physical phenomena that occur predominantly during sleep (DCSC, 1990). They have been classified based on the stage of sleep from which they originate. They include both normal and abnormal phenomena. Included in the category of NREM parasomnias are hypnic jerks and hypnic imagery, considered to be normal, in addition to confusional arousals, sleep terrors (pavor nocturnus), and sleepwalking (somnambulism), referred to as disorders of arousal. These all originate from deep NREM sleep, stages 3 and 4. They are all common in childhood and decrease in frequency as age increases. These individuals tend to have a family history of similar disorders. REM parasomnias include nightmares and REM behavior disorder (RBD). A third group consists of disorders that may occur during any or all sleep stages and includes bruxism, enuresis, rhythmic movement disorder (including head-banging), sleep talking (somniloquy), and...


Panic disorder is closely associated with other psychiatric and medical conditions. Comorbid psychiatric disorders include depression in up to 50 to 65 percent, other mood disorders, substance abuse and dependence, posttraumatic stress disorder, other anxiety disorders, and personality disorders. 5 Certain medical conditions have been associated with panic disorder but are unrelated to its etiology. Panic disorder has well-documented associations with mitral valve prolapse and asthma. 5 Other medical conditions such as idiopathic cardiomyopathy, hypertension, atypical chest pain without evidence of coronary artery disease, irritable bowel syndrome, chronic obstructive pulmonary disease, Parkinson's disease, and migraine headaches have also been associated with panic attacks. 17

Final Discussion

Blair I don't know when rats are doing their pain sounds naturally. When Sheila King was doing her work on post-traumatic stress disorder (PTSD), she was inducing the pain in animal, but it could be that rats only express this noise when they are being eaten by something, and it is a warning to others in the group. It could have a communicatory function, but it would be surprising if it was a weird automatic noise given that all the other noises do serve some sort of purpose to provide information to close group members.