Anxiety and Stress-Related Problems

Question 1

Describe the kinds of presenting symptoms that are associated with individual anxiety and stress-based problems.

Answer 1

symptoms for anxiety
anxiety has both cognitive and physical attributes
main symptoms:
-panic attacks
-lack of appetite
-scary, uncontrollable thoughts
-thoughts about physical illness, even suicidal ideation

physical symptoms:

• muscle tension
• dry mouth
• perspiring
• trembling
• difficulty swallowing

more chronic form of anxiety:

• dizziness
• chronic fatigue
• sleeping difficulties
• rapid/irregular heartbeat
• diarrhoea or persistent need to urinate
• sexual problems
• nightmares

cognitive symptoms:
- feeling of apprehension or fear, usually resulting from the anticipation of a threatening event or situation

• 30 to 40% of individuals in Western societies develop anxiety related problem (Davey, 2017)
• up to 33.7% of the population are affected by an anxiety disorder during their lifetime (Bandelow& Michaelis, 2015)

Question 2

Describe the characteristics and diagnostic criteria of six of the important anxiety and stressor disorders.

• specific phobias*
• social anxiety disorder
• panic disorder
• generalised anxiety disorder (GAD)
• obsessive compulsive disorder (OCD)
• pos-traumatic stress disorder (PTSD)

Answer 2

Anxiety Disorder
A psychological disorder characterised by an excessive or aroused state and feelings of apprehension, uncertainty and fear.
the anxiety response may:
1)be out of proportion to the threat
2)be a state that the individual constantly finds themselves in and may not be easily attributable to any specific threat
3) persist chronically and be so disabling that it causes constant emotional distress to the individual, who is unable to plan and conduct their normal day-to-day living. this can result in an inability to hold down a job, maintain relationships, and so forth.
——————————————————————————–
SPECIFIC PHOBIAS
an excessive, unreasonable, persistent fear triggered by a specific object or situation. phobic beliefs appear to control their fears.

• A phobia is a fear-mediated avoidance that is out of proportion to the object or situation
• Phobias involve intense distress
• Phobias are disruptive

Most common phobias:
small animal phobia
social phobia
dental phobia
water phobia
height phobia
claustrophobia
blood-injury-inoculation (BII) phobia

Criteria:

• disproportionate and immediate fear relating to a specific object or situation
• objects or situations are avoided, or are tolerated with intense fear or anxiety
• symptoms cannot be explained by other mental disorders and persist for at least six months
• phobia causes significant distress and difficulty in performing social or occupational acitivites

Lifetime prevalence for specific phobias is about 7% for men and 16% for women.

DSM-5 5 subgroups of specific phobias:
- animal phobias (spiders, insects, dogs)
- natural environment phobias (heights, storms, water)
- blood-injection-injury phobias (needles, procedures)
- situational phobias (airoplanes, elevators, inclosed spaces)
- other phobias (situations leading to choking or vomiting; in children, loud sounds or costume characters)
around 10% of people will meet DSM-5 criteria for a specific phobia within their lifetime.

however there are cultural differences in the kinds of stimuli and events that can become the focus of clinical phobias.

The Aetology of Specific Phobias - where do specific phoibas come from? are phobias biologically determined through evolutionary processes or are they learnt during the individuals lifetime? explained through:
-psychoanalytic accounts*

-classical conditioning and phobias*
-Phobias as result of classical conditioning:
Little Albert: pairing the rat with an unconditioned stimulus (load noise) Popular theory but it is difficult to explain the range of phobias with conditioning theories the famous “Little Albert’ study by Watson and Rayner (1920) is an example of how phobias can be acquired through classical conditioning. (pairing rat with large noise),
also Mowrer’s two-factor model; Pairing of stimulus with aversive UCS leads to fear (Classical Conditioning) or avoidance maintained through negative reinforcement (Operant Conditioning). Avoidance reinforces fear through anxiety reduction.
Criticism includes: Not everyone who has a phobia, remembers the trauma; Not all people with pain/trauma in a situation develop a phobia; Phobias not evenly distributed (fear of knives less common than fear of heights). Classical conditioning can explain some of the phobias (e.g. dental, dogs), but not all of them.

-the role of evolution
suggest that we have an unbuilt biological predisposition to fear certain stimuli and events because these stimuli were life-threatening to our pre-technological ancestors. evolutionary accounts of phobias include biological preparedness theory and the non-associative fear acquisition model.

-neuroimaging studies
the importance of the amygdala in activating phobic fear is indicated by the fact that there is a linear relationship between subjective experience of fear and amygdala activation.

-Cognitive theory
Thought processes result in high levels of anxiety, e.g. interpret ambiguous information as threatening

-multiple pathways to phobias*
No reason why acquisition of all phobias should be explained by just one single process. Besides that possible explanations we have looked at there might be some others.
disgust: food rejection emotion.
Disease avoidance model: animal avoidance phobias to avoid diseases that might be transmitted (E.g. Comorbidity between panic disorders and phobias).
Bottom line: Specific phobias may have a number of different causes.
evidence that different phobia may be caused by different processes: some involve classical conditioning, some are caused by high disgust sensitivity, while others appear to be caused by processes similar to those that cause panic disorder.

Treatment of specific phobias:
- exposure therapy with cognitive restructuring (can be effective in as little as one 3hr sessions)
exposure is such an important feature of treatment for specific phobias because participants can experience evidence that is contrary to their dysfunctional beliefs.

Question 3

SOCIAL ANXIETY DISORDER

Answer 3

a severe and persistent fear of social or performance situations. Social anxiety disorder symptoms include physiological responses, avoidance and escaping behaviours.

lifetime prevalence rate of 4%-13% in Western societies,
prevalence of 3:2 females to males.

Criteria:

• distinct fear of social interactions, typified by anxiety around receiving negative judgement or of giving offense to others
• social interactions are avoided, or are experienced with intense fear or anxiety
• the avoidance, fear or anxiety often lasts for 6 or more months and causes significant distress and difficulty in performing social or occupational activities.
• anxiety cannot be explained by the effects of other mental or medical disorders, drug abuse or medication

Genetic Factors
there is evidence for a genetic component to social anxiety disorder, but this may be a predisposition to develop anxiety disorders generally rather than social anxiety disorders specifically.
genetic components include submissiveness, anxiousness, social avoidance and behavioural inhibition.
behavioural inhibition - a construct used to define the characteristic in some children of seeming quiet, isolated and anxious when confronted either with social situations or novelty.

Familial and Developmental Factors
offspring with SAD are more likely to have parents (particularly mothers) with SAD, and offspring with SAD parents are marginally more likely to have SAD than offspring of parents with depression

Cognitive Factors
there are a number of cognitive factors that are characteristic of social anxiety disorder, and these include a tendency:
(1) to make excessively negative predictions about future social events,
(2) to over-critically evaluate their won social performance,
(3) to shift their attention inwards on to themselves, called self-focused attention
(4) to indugle in post-event critical appraisal of their own performance.

Treatments of SAD:
•Psychoanalytic therapy attempts to uncover repressed conflicts using free association
•Behavioral approaches use graded exposure –gradually confront fears, systematic desensitization –imagine increasing exposure, and Flooding –immersed in fear. Anxiety rises, plateaus and then if avoidance doesn’t happen it gradually comes down.
•Cognitive approaches focus on altering irrational beliefs. CBT treatments include exposure therapy, social skills training, and cognitive restructuring. cognitive restructuring - challenge and replace the negative biases in information processing and the dysfunctional negative self-evaluations of social performance, and reduce self-focused attention.
•Biological approaches use drugs to try and reduce anxiety symptoms. both monoamine-oxidase inhibitors and selective serotonin reuptake inhibitors have been shown to be successful pharmacological treatments for social anxiety disorder.

More info on Behavioural Approach - Graded Exposure:
•Similar to systematic desensitisation but the exposure is done in reality, not imagination
•Both systematic desensitisation and graded exposure are effective treatments for phobic anxiety

Question 4

PANIC DISORDER AND AGORAPHOBIA

Answer 4

panic disorder: an anxiety disorder characterised by repeated panic or anxiety attacks.
it is characterised by repeated panic or anxiety attacks associated with a variety of physical symptoms, including heart palpitations, dizziness, perpiring, hyperventilation, nausea, trembling, and depersonalisation.

agoraphobia: a fear or anxiety of any place where the sufferer does not feel safe or feels trapped, and is accompanied by a strong urge to escape to a safe place (e.g. home).

criteria for a panic attack:
sudden feeling of extreme fear and distress, which can originate from either a calm or an anxious state. symptoms intensify in a short space of time and will include a range of sensations such as,
- fluctuations in heart rate
- shortness of breath or chest pain
- nausea
- dizziness
- shaking
the person may fear they are dying or 'going crazy'.

criteria for panic disorder:
repeated panic or anxiety attacks followed by at least 1 month of,
- worrying about further panic attacks and/or the consequences of a panic attack, such as loss of control
-significant, non-beneficial modification of behaviour(s), designed to avoid future attacks, such as avoidance of triggering situations.

criteria for agoraphobia:

• distinct fear of situations where the individual is outside in a crowd or open space, or in public spaces such as shops, cinemas, or buses.
• situations are avoided, or are experienced with intense fear that help will be unavailable, or that panic or other resultant symptoms will occur
• the individual experiences fear in at least two different situation types and symptoms of anxiety or avoidance will last for 6 months or more.
• fear causes difficulty in performing social or occupational activities and cannot be explained by the effects of other mental or medical disorders.

Prevlance:
the life time prevalence rate for panic disorders is between 1.5 and 3%, although prevalence rates do differ between cultures.

Biological theories of panic disorder:
hyperventilation is a common feature of panic disorder, supported by evidence from biological challenge tests (research in which panic attacks are induced by administrating CO2 enriched air or by encouraging hyperventilation), and some theorists have argued that the effect of hyperventilation on body CO2 levels is a causal factor in the development of a panic attack.
this has given rise to suffocation alarm theories - models of panic disorder in which a combination of increased CO2 intake may activate an oversensitive suffocation alarm system and give rise to the intense terror and anxiety experienced during a panic attack.

psychological theories of panic disorder: anxiety sensitivity:
Reiss & McNally (1985) proposed some individuals with panic disorder have high levels of anxiety sensitivity, which is a fear of anxiety symptoms. In order to measure the construct, Reiss, Peterson, Gursky, &McNally (1986) developed the Anxiety Sensitivity Index.

psychological theories of panic disorder - Catastrophically Misinterpretation of Bodily Sensations:
individuals who develop panic disorder tend to catastrophically misinterpret bodily sensations, and interpret them as signs of an imminent physical threat (e.g. an imminent heart attack signalled by a missed heartbeat). this cognitive bias leads to a vicious cycle which increases the anxiety symptoms that precipitate a panic attack.

psychological theories of panic disorder - the role of safety behaviours:
safety behaviours are activities that a panic disorder sufferer will deploy during a panic attack and will maintain the belief that panic attacks might have catastrophic consequences. safety behaviours include: seeking support by holding on to objects if the believed catastrophic outcome is fainting, sitting down if the outcome is a supposed heart attack, or moving slowly and looking for an escape route if the catastrophic outcomes is losing control or acting foolishly. therefore safety behaviours are a primary target for manipulation and elimination in both behavioural and cognitive therapies.

Treatments of Panic Disorders:
tricyclic antidepressants and benzodiazepines are an effective first-line treatment for panic disorder, but structured exposure therapy or CBT is as effective, if not superior, to drug treatments over the longer term.
CBT is effective specifically because they significantly reduce the tendency to react fearfully to benign bodily sensations.

Question 5

GENERALISED ANXIETY DISORDER (GAD)

Answer 5

A pervasive condition in which the sufferer experiences continual apprehension and anxiety about future events, and this leads to chronic and pathological worrying about those events.

Criteria:

• disproportionate fear or anxiety relating to areas of activity such as finances, health, and family, or work/shcool life
• the individual experiences fear relating to at least two different areas of activity and symptoms of intense anxiety or worry will last for 3 months or more, and will be present for the majority of the time during this period
• feelings of anxiety and worry will be accompanied by symptoms of restlessness, agitation or muscle tension.
• anxiety or worry are also associated with behaviours such as frequently seeking reassurance, avoidance of areas of activity that cause anxiety, or excessive procrastination or effort in preparing for activities
• symptoms cannot be explained by other mental disorders such as panic disorders

Pathological and chronic worrying is the cardinal diagnostic characteristic of GAD and accompanied by physical symptoms such as fatigue, trembling, muscle tension, headache, and nausea.

prevalence:
twice as common in women as in men, and can persist from adolescence to old age. over 5% of the population will be diagnosed with GAD at some point within their lifetime. 12% of those who attend anxiety disorder clinics will present with GAD. Considerably less is known about GAD than the other anxiety disorders. It can be difficult to distinguish GAD from panic and OCD at one end of the spectrum and from normal worrying at the other end

Biological theories of GAD:
twin studies estimate the heritable component at around 30%, but what appears to be inherited more is a vulnerability to a specific disorder such as GAD. Etkin, Prater, Hoeft, Menon & Schatzberg (2010) found reduced regulatory activity in pregenual anterior cingulate and parietal cortices in patients with GAD, suggesting a reduced capacity for emotional regulation that might be a risk factor for GAD.

Psychological theories of GAD:

• information processing biases in GAD - biases in interpreting, attending to, storing or recalling information which may give rise to dysfunctional thinking and behaving. individuals with GAD have an information processing bias which appears to maintain their hypervigilance for threat and create the opportunity to catastrophically worry about events. there is evidence that these information processing biases may actually cause anxiety generally, and can be manipulated therapeutically using attention bias modification techniques (reverse biases and neutralise them through experimental procedures).
• Beliefs, meta-beliefs and the function of worrying - it is suggested that worrying may serve a particular function, which might outweigh the negative effects of worrying. Borkovec’s cognitive model:Worry is reinforcing because it distracts from negative emotions and images, allows those with GAD to avoid more troublesome emotions and underlying anxiety never extinguishes because of avoidance
• Dispositional characteristics : intolerant of uncertainty, high on perfectionism, feelings of responsibility of negative outcomes

pharmacological treatments:
anxiolytics are useful for dealing with the anxiety symptoms exhibited by individuals with GAD, however at least 50% of GAD sufferers receive initial treatment with antidepressants such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) on the basis of their proven effectiveness in treating the symptoms of GAD in clinical trials. they control the process of worrying and challenging dysfunctional beliefs about worrying. While only around 355 are treated with benzodiazepines. lack of longitudinal studies for effectiveness of pharmacological treatments.

Psychological Treatments:
stimulus control treatment - based on the conditioning principle that the environments in which behaviours are enacted come to control their future occurrence and can act to elicit those behaviours.
CBT uses self-monitoring, relaxation techniques, cognitive reconstructuring, and behavioural rehearsal to bring the activity of worrying under control. Cognitive Behavioral methods; challenge and modify negative thoughts, increase ability to tolerate uncertainty, worry only during “scheduled” times, and focus on present moment.

Common Aspects of Treatment
•Psychological treatments emphasize exposure; face the situation or object that triggers anxiety

Risk Factors for developing anxiety disorders in general:

Personality
•Behavioral inhibition; Tendency to become agitated and cry in novel settings. Predicts symptoms of anxiety in childhood and social anxiety in adolescence.
•Neuroticism; Tendency to react to events with negative affect. High levels of neuroticism linked to both anxiety and depression.

Cognitive
•Perceived control; Individuals who believe they have little control are more vulnerable to anxiety disorders. (History of childhood trauma or punitive parenting may foster beliefs)
•Attention to threat; Tendency to notice negative environmental cues –system is sensitive to perception of threat

Social
•Negative life events; Often precede disorder onset (e.g., loss of job, end of relationship)

Question 6

OBSESSIVE COMPULSIVE DISORDER (OCD)

Answer 6

characterised by either obsessions or by compulsions. obsessions are intrusive and recurring thoughts that an individual finds disturbing and uncontrollable. these obsession can be autogenous, and that is this characteristic that helps to make obsessive thoughts distressing. compulsions are repetitive or ritualised behaviour patterns that an individual feels driven to perform in order to prevent some negative outcome happening.

Criteria:

• presence of obsessions such as repeated and unwanted thoughts, urges or images that the individual tries to ignore or suppress, and/or
• presence of compulsions where the individual feels compelled to repeat certain behaviours or mental activities.
• the individual believes that the behaviours will prevent a catastrophic event but these beliefs have no realistic connections to the imagines event, or are markedly excessive.
• obsessions and compulsions consume at least 1hr per day and cause difficulty in performing other functions
• symptoms cannot be explained by the effects of other mental or medical disorders, drug abuse or medication.

Prevalence:
lifetime prevalence is around 2.5% with a 1yr prevalence rate of between 0.7% and 2.1%, and affects women marginally more frequently than men.

Other OCD-related disorders:

1) body dysmorphic disorder - preoccupation with perceived defects or flaws in physical appearance that are not usually perceived by others. this gives rise to compulsive grooming, mirror checking, and reassurance seeking.
2) hoarding disorder - difficulty discarding or parting with possessions to the point where the individuals living area is severely congested by clutter
3) Hair-pulling disorder (trichotillomania) - compulsively pulls out own hair resulting in significant hair loss
4) skin picking disorder - recurrent picking of skin that results in skin lesions

Biological Factors:
twin studies found high concordance for OCD in MZ twins compared to DZ twins. Family relatives of individuals with OCD are also likely to have a diagnosis of OCD. OCD could be the result of genetics, or traumatic brain injury.

Psychological Factors:
1)memory deficits - doubting is a central feature of OCD., as well as less confidence in the validity of their memories. in addition to this, a deficit in the ability to distinguish between the memory of real and imagined actions.

2) clinical constructs - researchers develop constructs in order to describe the combination of thoughts, beliefs, cognitive processes and symptoms observed in individual psychopathologies. Salkovskis, Rachman, Ladouceur, Freeston, et al (1996) defined inflated responsibility as the belief that one has power to bring about or prevent subjectively crucial negative outcomes (central feature of OCD). thought-action fusion is the dysfunctional assumption that having a thought about an action is like performing it.
3) mental contamination - feelings of dirtness can be provoked without any physical contact with a contaminant, this can be caused by images, thoughts, and memories and may be associated with compulsive washing and even betrayal experiences.
4) thought suppression - defence mechanism used by individuals with obsessive thoughts to actively suppress them (using either thought suppression or distraction techniques)
5) preseveration and the role of mood - OCD is a perseverative psychopathology which is characterised by the dysfunctional perservation of certain thoughts, behaviours or activities (others include pathological worrying and chronic rumination in depression). mood-as-input hypothesis claims that people use their concurrent mood as information about whether they have successfully completed a task or not.

Treatment of OCD

• Exposure and Ritual Prevention (ERP) treatments involves graded exposure to the thoughts that trigger distress, followed by the development of behaviours designed to prevent the individuals compulsive rituals. this helps to allow anxiety to extinguish, eliminate ritualistic behaviours and contributes to the disconfirmation of dysfunctional beliefs. ERP is flexible and adaptive, and a long term effective treatment for around 75% of clients.
• CBT helps to challenge responsibility appraisals, the over-importance of thoughts, and the exaggerated perception of threat. achieve this by educating that intrusive thoughts are normal and that your thoughts about an action is not the same as performing it, focusing on changing the clients abnormal risk assessment, and providing the client with behavioural exercises that will disconfirm their dysfunctional beliefs.
• Pharmacological and neurosurgical treatments - are short term, effective and cheap way of treating OCD, although relapse is common on discontinuation of treatments. SSRIs and serotonin are the most common drugs and have the effect of increasing brain serotonin levels. however, there are criticisms to the effectiveness and relevance of the drugs. the most common procedure is cingulotomy which involves destroying cells in the cingulum, close to the corpus callosum.

Question 7

TRAUMA AND STRESS RELATED DISORDERS

Answer 7

PTSD - a set of persistent anxiety based symptoms that occurs after experiencing or witnessing an extremely fear-evoking or life-threatening traumatic event. Includes symptoms of increased arousal, numbing of emotions, flashbacks and the re-experiencing of the trauma.

acute stress disorder - a short term psychological and physical reaction to severe trauma. symptoms are very similar to those of PTSD, but the duration is much shorter (3 days to 1mnth after trauma exposure)

criteria for PTSD PG187 (too long to write down) but involves being exposed to or a witness of a traumatic experience, know someone close that has experience a traumatic experience and being subjected repeatedly to distressing details of trauma.

Criteria for acute stress disorder on PG187 too

typical symptoms:

1) instrusive - flashbacks, thoughts, reactions
2) avoidance responding - in thoughts, memories, reminders of trauma
3) negative changes in cognition and mood
4) increased arousal and reactivity - hypervigilance and exaggerated startle responses

once symptoms develop, PTSD is often a chronic condition that can last for years.

Prevalence
between 1 and 3%.
Lifetime prevalence is between 1.9% and 8.8%, but this rate doubles in populations affected by conflict and reaches more than 50% in survivors of rape.
However, (a) most people do not develop a disorder after experiencing a stressful life event, and (b) many disorders other than PTSD often develop following adversity, in particular phobias, depression, acute stress reaction and adjustment disorders.

Who Develops PTSD?
It is also clear that some individuals are more likely than others to develop PTSD following exposure to trauma. Predictive variables (risk factors) that have been identified include:
•trauma severity
•perceived threat
•dissociation during the trauma (altered mental state, “felt like I wasn’t really there”)
•prior emotional disorder (particularly depression)
There is increasing evidence that some medical events (e.g. myocardial infarction) or treatments (e.g. defibrillation) can lead to post-traumatic symptoms.

Memory function and stress
•“I can’t stop remembering what I don’t want to, yet I can’t remember what I do want to”
•Patient’s account of unwanted, intrusive, distressing recollections of trauma, together with impaired ability to remember non-trauma related material.
•Chris Brewin has recently proposed a cognitive neuroscience model of PTSD (Dual Representation theory).

Dual Representation Theory:
suggests that it may be a hybrid disorder involving two separate memory systems, the verbally accessible memory (VAM) system and the situationally accessible memory (SAM) system. Brewin proposes that VAM (verbally accessible) memories are hippocampally dependent. SAM (situationally accessible) memories are non-hippocampally dependent, and involve the amygdala. In PTSD, a considerable amount of trauma information resides solely in the SAM system, and these SAM memories are particularly vulnerable to reactivation by trauma cues, e.g. flashbacks in response to sight or smells of trauma reminders.

Helping people cope with trauma:
•Talking it through—Encourage victim to discuss and relive feelings about the incident
•Tackling avoidance—Discuss graded increase in activities, such as return to travel after a road crash
•Coping with anxiety—Anxiety management techniques (relaxation, distraction)
•Dealing with anger—Encourage discussion of incident and of feelings
•Overcoming sleep problems—Emphasise importance of regular sleep habits and avoidance of excessive alcohol and caffeine
•Treat associated depression—Antidepressant drugs, limited role for hypnotics immediately after trauma

Biological Factors:

• a relatively small or under-developed hippocampus
• failure of brain centres such as the ventromedial frontal cortex to dampen activation of the brain’s fear coordinating centre, the amygdala, which means that the individual is unable to control the activation of fear following trauma.
• genetically endowed heightened startle responses and fear relevant endocrine secretion.

Vulnerability Factors:

• a tendency to take personal responsibility for the traumatic event of others involved
• developmental factors such as early separation from parents or an unstable family life during early childhood
• a family history of PTSD
• existing high levels of anxiety or pre-existing psychological disorder

Avoidance and Dissociation:
coping styles for any traumatic event,
-avoidance coping (avoid thinking about the trauma)
-dissociation (one is detached from both mind and body, inability to recall stressful events)

there is no specific psychological model of PTSD, and current explanations include classical conditioning, emotional processing theory, mental defeat, and dual representation.

Conditioning Theory:
PTSD may be due to classical conditioning, trauma becomes associated with situational cues related to the place and time of the trauma. the conditioned model argues that such conditioned fear responses do not extinguish because the sufferer develops both cognitive and physical avoidance responses which distract them from fully processing such cues and trauma to extinguish. however classical conditioning does not provide a full explanation of PTSD.

emotional processing theory:
Foa, Steketee & Rothbaum (1989) suggested that the intense nature of the trauma in PTSD creates a representation of the trauma in memory that becomes strongly associated with other contextual details of the event.

Mental Defeat:
a specific frame of mind in which the individual sees themselves as a victim. this is a psychological factor that is important in making an individual vulnerable to PTSD (Ehlers and Clark, 2000). Ehlers & Clark (2000) suggest that such individuals only partially process their memory of the trauma because of their perceived lack of control of it, and so they do not integrate that event fully into their own autobiographical knowledge.

Treatment of PTSD:
- pharmacological - Antidepressants medication, particularly the selective serotonin re-uptake inhibitors (SSRIs) appear to be helpful. In many cases the traumatised individual may fulfil diagnostic criteria for both PTSD and major depression.

• psychological debriefing - a structured way of trying to intervene immediately after trauma in order to try to prevent the development of PTSD. includes 6 components for critical incident stress debriefing. A recent systematic review of controlled trials in this area failed to find any evidence that debriefing reduced general psychological morbidity, depression or anxiety.

-exposure therapies (effective) - client is helpedto confront and experience events and stimuli relevant to their trauma. these may include using imaginal flooding and EMDR). imaginal flooding is a technique whereby a client is asked to visualise feared, trauma-related scenes for extended periods of time. Eye Movement Desensitisation and Reprocessing (EMDR) involves clients to focus their attention on a traumatic image or memory while simultaneously visually following the therapists finger moving backwards and forwards before their eyes. It’s not clear exactly how EMDR works,but it may help you change the negative way you think about a traumatic experience.
in addition to using cognitive restructuring, the therapist can evaluate and change the extreme views they have about the world.

• CBT of PTSD: Symptoms may be maintained via overt and covert avoidance.CBT for PTSD generally involves two main elements, (a) detailed and repeated exposure to traumatic information, and (b) the modification of maladaptive beliefs about events, behaviours or symptoms. Exposure-based therapies have been shown to be particularly effective. These involve the common feature of having patients confront their fears, either via systematic desensitisation (imaginal exposure to feared stimuli while in a relaxed state, in a graded, hierarchical fashion) or exposure in vivo.