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Prolonged in-depth psychotherapy is seldom necessary in cases of isolated stress response or adjustment disorder Supportive psychotherapy (see above) with an emphasis on the here and now and strengthening of existing coping mechanisms is a helpful approach so that time and the patient s own resiliency can restore the previous level of function In posttraumatic stress syndromes, psychological debriefing in a single session, once a mainstay in prevention of PTSD, is now considered to be ineffective and possibly harmful Posttraumatic stress syndromes respond to interventions that help patients integrate the event in an adaptive way with some sense of mastery in having survived the trauma Early cognitive behavioral therapy has been shown to speed recovery Marital problems are a major area of concern, and it is important that the clinician have available a dependable referral source when marriage counseling is indicated

Overt anxiety or an overt manifestation of a coping mechanism (such as a phobia), or both Not limited to an adjustment disorder Somatic symptoms referable to the autonomic nervous system or to a specific organ system (eg, dyspnea, palpitations, paresthesias) Not a result of physical disorders, psychiatric conditions (eg, schizophrenia), or drug abuse (eg, cocaine)

One now activates the relevant sales organizations for rebate agreements, as shown in Figure 7-23

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Judicious use of sedatives (eg, lorazepam, 1 2 mg orally daily) for a limited time and as part of an overall treatment plan can provide relief from acute anxiety symptoms Problems arise when the situation becomes chronic through inappropriate treatment or when the treatment approach supports the development of chronicity In PTSD, early treatment of anxious arousal with blockers (eg, propranolol, 80 160 mg daily) may lessen the peripheral symptoms of anxiety (eg, tremors, palpitations) and help prevent development of the disorder; however, research in this area is preliminary Antidepressant drugs particularly selective serotonin reuptake inhibitors (SSRIs) in full dosage are helpful in ameliorating depression, panic attacks, sleep disruption, and startle responses in chronic PTSD Sertraline and paroxetine are approved by the US Food and Drug Administration (FDA) for this purpose Antiseizure

Stress, fear, and anxiety all tend to be interactive The principal components of anxiety are psychological (tension, fears, difficulty in concentration, apprehension) and somatic (tachycardia, hyperventilation, palpitations, tremor, sweating) Other organ systems (eg, gastrointestinal) may be involved in multiple-system complaints Fatigue and sleep disturbances are common Sympathomimetic symptoms of anxiety are both a response to a central nervous system state and a reinforcement of further anxiety Anxiety can become self-generating, since the symptoms reinforce the reaction, causing it to spiral This is often the case when the anxiety is an epiphenomenon of other medical or psychiatric disorders Anxiety may be free-floating, resulting in acute anxiety attacks, occasionally becoming chronic When one or several

coping mechanisms (see above) are functioning, the consequences are well-known problems such as phobias, conversion reactions, dissociative states, obsessions, and compulsions Lack of structure is frequently a contributing factor, as noted in those people who have Sunday neuroses They do well during the week with a planned work schedule but cannot tolerate the unstructured weekend Planned-time activities tend to bind anxiety, and many people have increased difficulties when this is lost, as in retirement Some believe that various manifestations of anxiety are not a result of unconscious conflicts but are habits persistent patterns of nonadaptive behavior acquired by learning The habits, being nonadaptive, are unsatisfactory ways of dealing with life s problems hence the resultant anxiety Help is sought only when the anxiety becomes too painful Exogenous factors such as stimulants (eg, caffeine, cocaine) must be considered as a contributing factor

20%) results from self-treatment and is not infrequently combined with dependence on sedatives Some patients have atypical panic attacks associated with seizure-like symptoms that often include psychosensory phenomena (a history of stimulant abuse often emerges) About 25% of panic disorder patients also have obsessive-compulsive disorder (OCD)

In the obsessive-compulsive reaction, the irrational idea or the impulse persistently intrudes into awareness Obsessions (constantly recurring thoughts such as fears of exposure to germs) and compulsions (repetitive actions such as washing the hands many times) are recognized by the individual as absurd and are resisted, but anxiety is alleviated only by ritualistic performance of the action or by deliberate contemplation of the intruding idea or emotion Many patients do not mention the symptoms and must be asked about them These patients are usually predictable, orderly, conscientious, and intelligent traits that are seen in many compulsive behaviors such as food binging and purging and compulsive exercise There is an overlapping of OCD and other behaviors ( OCD spectrum ), including tics, trichotillomania (hair pulling), onychophagia (nail biting), hypochondriasis, Tourette s syndrome, and eating disorders (see 29) The 2 3% incidence of OCD in the general population is much higher than was previously recognized In addition, there is a high comorbidity of OCD and major depression; two-thirds of OCD patients will develop major depression during their lifetime Male to female ratios are similar, with the highest rates occurring in the young, divorced, separated, and unemployed (all high-stress categories) Neurologic abnormalities of fine motor coordination and involuntary movements are common Under extreme stress, these patients sometimes exhibit paranoid and delusional behaviors, often associated with depression, and can mimic schizophrenia

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