Taking on post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) often occurs following a traumatic event in a person's life. We're seeing a rise in PTSD nowadays. That's partly because of good news — due to improved medical care, we're more able to keep people alive when they encounter wars, terrorism, accidents, natural disasters, and violence. However, PTSD can haunt people for years after their traumas occur.
The vast majority of people with PTSD are best served by seeking professional help that guides them carefully through their staircase of fear. We provide a sample staircase for PTSD as an illustration, but we don't advise trying it on your own.
People can acquire PTSD by directly experiencing horrible, life-threatening events or even by witnessing such events happen to others. Amihan's story illustrates how someone can end up with PTSD from observing the aftermath of a natural disaster.
Amihan, a young nurse from the Philippines, arrives in New Orleans six months before hurricane Katrina hits. She enjoys her job in the intensive care unit and makes friends with the other nurses easily. She also feels privileged to be able to send much-needed money home to her family.
On the day of the hurricane, her hospital survives the wind and is initially able to function on auxiliary power. But when floodwaters fill the ground floor, the power goes out. That's when mayhem breaks loose. The temperature rapidly climbs into the high 90s, compounded by unbearable humidity.
Patients stream into her unit. She sees people with exposed bones, burns covering 90 percent of their bodies, horrific injuries from projectiles launched by the hurricane's winds, and some people who were savagely attacked by other survivors. Those who are conscious either moan or scream in agony. Still others lay still, barely clinging to life. The number of patients overwhelms the staff's ability to attend to them. The stench from unwashed bodies, open wounds, burned flesh, feces, urine, and sewer water gags her. She stays on the job three days without sleep or rest.
Amihan sees a psychologist a few months later for treatment of her nightmares, isolation from others, irritability, intrusive images that bombard her mind, and her inability to return to work. She's desperately fearful that she'll be deported if she can't go back to her job. Her psychologist diagnoses her with PTSD and develops a staircase of fear. Her staircase (see Figure 8-5) has a number of gruesome images and scenes. Yet, by working through the steps, she slowly but surely regains much of her emotional well-being.
Figure 8-5: Amihan's staircase of fear includes more than a dozen steps.
You should know that Figure 8-5 is a partial list of the items that Amihan dealt with. She actually went through more than 25 items, one at a time. Note that a few items involve going out with friends and don't seemingly have much to do with her trauma. That's because PTSD often causes people to avoid more than just reminders of the traumatic event itself — sometimes it includes avoiding friends and family. Treatment for severe PTSD like Amihan's often takes longer than treatment of milder anxiety disorders.
Overriding an obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) sometimes overwhelms and dominates a person's life, and the help of an experienced professional is commonly required to treat this disorder. Only attempt the strategies that we describe in this section on your own if your problems with OCD are relatively mild. Even then, you may want to enlist a friend or partner to help you. Furthermore, you may want to read Obsessive Compulsive Disorder For Dummies (Wiley), which we also wrote.
Chapter 2 discusses this disorder, which often starts with obsessive, unwanted thoughts that create anxiety. People with this problem then try to relieve the anxiety caused by their thoughts by performing one of a number of compulsive acts. Unfortunately, it seems that the relief obtained from the compulsive acts only fuels the vicious cycle and keeps it going.
Therefore, for obsessive-compulsive disorder, exposure is only the first step. Then you must do something even harder — prevent the compulsive, anxiety-relieving actions. This strategy is called exposure and response prevention (or ERP).
The first step, exposure, deals with the obsessional component of OCD — feared thoughts, images, and impulses. The exposure is often imaginary (see the earlier section "Imagining the worst"). This may be the only strategy you can use if your obsessions can't or shouldn't be acted out in real life, as in the following examples:
Thoughts that tell you to violate your personal religious beliefs
Repetitive thoughts of harm coming to a family member or loved one
Frequent worries about burning alive in a home fire
Unwanted thoughts about getting cancer or some other dreaded disease
Proceed as follows:
1. List your distressing thoughts and images, and then rate each one for the amount of distress it causes.
2. Next, select the thought that causes the least upset, and dwell on that thought over and over, ad nauseam, until your distress drops at least 50 percent.
Sometimes, listening over and over to a recorded description of your obsession is useful.
3. Then proceed to the next item on your list that causes a little more discomfort. Keep working your way up the list.
This approach is quite the opposite of what people with OCD usually do with their unwanted obsessions. Normally, they try to sweep the haunting thoughts out of their minds the moment they appear, but that only succeeds ever so briefly, and it maintains the cycle.
Give imaginary exposure enough time — keep the thoughts and images in your head long enough for your anxiety to reduce at least 50 percent before moving to the next item.
If you also suffer from compulsive acts or avoidance due to obsessive thoughts, it's now time for the more difficult, second step — response prevention. Again, make a staircase or hierarchy of feared events and situations that you typically avoid: a staircase of fear. Then proceed to put yourself in each of those situations, but don't allow yourself to perform the compulsive act.
For example, if you fear contamination from dirt and grime, go to a beach, play in the sand, and build sand castles, or go out in the garden, plant flowers, and keep yourself from washing your hands. Remain in the situation until your distress drops by 50 percent. If it doesn't drop that much, stay at least 90 minutes and try not to quit until a minimum of a third of your distress goes away. Don't proceed to the next item until you conquer the one you're working on.
Although using relaxation procedures with initial exposure attempts is a good idea, you shouldn't use relaxation with exposure and response prevention for OCD as you proceed further. That's because one of the crucial lessons is that your anxiety will come down if and only if you give exposure enough time. Furthermore, some people with OCD actually start to use relaxation as a compulsive ritual itself. Thus, it's fine if you want to practice a little relaxation for anxieties not related to your OCD, but don't use it with exposure and response prevention.
Preparing for exposure and response prevention
Prior to actual exposure and response prevention, you may find it useful to alter your compulsive rituals in ways that start to disrupt and alter their influence over you. Methods for initiating this assault on compulsions include:
Delay performing your ritual when you first feel the urge. For example, if you have a strong compulsion to wipe the doorknobs and the phones with Lysol, try putting it off for at least 30 minutes. The next day, try to delay acting on your urge for 45 minutes.
Carry out your compulsion at a much slower pace than usual. For example, if you feel compelled to arrange items in a perfect row, go ahead and do it, but lay them out with excruciating slowness.
Change your compulsion in some way. If it's a ritual, change the number of times that you do it. If it involves a sequence of checking all the door locks in the house, try doing them in a completely different order than usual.
Seeing exposure and response prevention in action
Cindy's story shows how someone with OCD begins to face he
r fears one step at a time.
Cindy obsesses incessantly about getting ill from dirt, germs, and pesticides. Whenever she imagines that she has come into contact with any of these to the slightest degree, she feels compelled to wash her hands thoroughly, first with soap containing pumice to scrape off the dirty layer of skin, and then with antibacterial soap to kill the germs. Unfortunately, this ritual leaves her hands cracked, sore, and bleeding. When she goes out into public, she wears gloves to hide the self-inflicted damage. Not only that, she's discovering that her hand-washing consumes increasing amounts of time. Her 15-minute breaks at work are too short to complete her hand-washing ritual. Cindy finally decides to do something about her problem when her supervisor at work tells her that she must take shorter breaks. Cindy prepares for her exposure and response prevention exercise by doing the following first for a week:
• She delays washing her hands for 30 minutes when she feels the urge. Later, she delays washing for 45 minutes.
• She changes her washing by using a different type of soap and starting with the rubbing alcohol instead of ending with it.
Cindy is surprised to find that these changes make her hand-washing urges a little less frequent, but they haven't exactly disappeared, and they continue to cause considerable distress. She needs to muster up the courage to do exposure and response prevention.
First, she approaches Dolores, a trusted friend, for help. She tells Dolores about her problem and asks her to coach her through the exercises by lending support and encouragement. Then she makes a staircase of fear for her exposure and response prevention that includes touching the "dirty dozen" depicted in Figure 8-6.
Dolores helps Cindy with her staircase of fear by having her start with the easiest step: touching a telephone receiver that someone else has used. She has Cindy do this a number of times and encourages her to resist the urge to wash her hands. After an hour and a half, the urge to wash drops significantly. The next day, Dolores has Cindy take on the next step.
Figure 8-6: Cindy fights her fear of illness by touching dirty objects.
Each day they tackle one new step if Cindy succeeds the previous day. When she gets to touching the cat's litter box, Cindy balks at first. Dolores says she won't "make" Cindy do it, but she thinks it just might help her. In other words, she urges her on. The cat litter box takes many attempts. Finally, Cindy manages to touch it and stay with it. However, it takes a total of three hours of repeatedly attempting to touch and finally touching the litter box numerous times for as long as ten minutes each time for her anxiety to come down by half.
Sometimes exposure and response prevention takes a while, so set plenty of time aside. In Cindy's case, the final two items didn't require as much effort because her earlier work had seemingly cracked the compulsion enough so that it lost some of its power over her.
Upping the ante
After she gets through her staircase of fear, Cindy takes one more initiative. She tackles the toughest steps again. But this time, she asks Dolores to describe scenes of Cindy getting sick and dying a slow death from some dreaded disease because of her contamination, while Cindy is actually doing the exposure task.
We call this "upping the ante." It gives you the opportunity to practice your exposure while bombarding yourself with your worst fears. Why in the world would you want to do that? Mainly because doing so reduces the grip those fears have on you. Of course, that's true if and only if you stay with the exposure, along with the dreaded outcome pictured in your mind, long enough.
If you can't do this on your own or with a friend fairly easily, please consult a professional for help. Make sure that professional is well acquainted with using exposure and response prevention for OCD (not everyone is).
If you get stuck on exposure and response prevention, you may want to carefully work through Chapters 5, 6, and 7. Pay particular attention to the section on rethinking risk. Usually, those with OCD overestimate the odds of catastrophic outcomes if they halt their compulsions, and these chapters can help you recalculate the odds.
Expecting the Impossible
Occasionally, people come to us asking for a quick fix for their anxiety problems. It's as though they think we have some magic wand we can pass over them to make everything better. That would be so nice, but it isn't realistic.
Other folks hope that with help, they'll rid themselves of all anxiety — another misconception. Some anxiety helps prepare you for action, warn you of danger, and mobilize your resources (see Chapter 3). The only people who are completely rid of anxiety are unconscious or dead.
Overcoming anxiety requires effort and some discomfort. We have no way around that. No magic wand. But we know that those who undertake the challenge, make the effort, and suffer the discomfort are rewarded with reduced anxiety and increased confidence.
Chapter 9: Considering Medications and Other Physical Treatment Options
In This Chapter
Deciding whether to take medication
Knowing what medication choices are available
Looking at supplements
Seeing some stimulating possibilities
The last several decades have witnessed an explosion in new knowledge about emotions, mental illness, and brain chemistry. Scientists recognize changes in the brain that accompany many psychological disorders. New and old drugs address these chemical imbalances, and using these drugs has both advantages and disadvantages.
This chapter helps you make an informed decision about whether or not to use medication for your anxiety. We give you information about the most widely prescribed drugs and some of their more common side effects. Only you, in consultation with your healthcare provider, can determine what's best for helping you. Next, we tell you about over-the-counter supplements for anxiety. More importantly, we share with you the latest information about their effectiveness and warn you about possible dangers and downsides. Finally, we alert you to some of the methods that involve stimulating the brain for those whose anxiety is severe and resistant to standard treatments.
Making Up Your Mind About Medications
Deciding whether to medicate your anxiety brings up a number of issues to consider. This decision isn't one to take lightly. You should consult with your therapist, if you have one, as well as your physician. Before you decide on medication, ask yourself what you've done to alleviate your anxiety. Have you challenged your anxious thoughts and beliefs (see Chapters 5, 6, and 7)? Have you faced your fears head-on (see Chapter 8)? And have you looked at lifestyle changes, relaxation strategies, or mindfulness techniques (see Part III)?
With a few important exceptions, which we review in this chapter, we recommend that you try various psychological approaches prior to adding medication. Why? Consider the following:
Some research suggests that certain medications may actually interfere with the long-term effectiveness of the most successful treatments for anxiety. That's especially true of the techniques designed to confront phobias and fears directly through exposure.
If you try psychological strategies first, you very well may discover that you don't need medication. Many of our recommended anxiety axes have the potential to cement change for the long haul as well as positively affect your entire life.
Studies show that cognitive behavioral therapy (the type of strategies we discuss throughout this book) helps prevent relapse. Many people who take medication alone experience a quick reoccurrence of symptoms when they discontinue taking medication for any reason.
The downside of medications
You need to reflect on both sides of any important decision. Medications have an upside and a downside. The negative side of the argument includes:
Addiction: Some medications can lead to physical and/or mental dependency. Getting off of those medications can be difficult, or even dangerous, if not done properly. (However, contrary to what some people think, many medications are available that do not have addictive potential.)
Long-term effects: We don't really ha
ve good information on possible long-term effects with some of the newest medications. And some medications can lead to serious problems, such as diabetes and tremors.
Philosophical aversions: Some people just feel strongly that they don't like to take medications. And that's okay, but only to a point.
Pregnancy and breast-feeding: Only a few drugs are recommended for women who are pregnant or breast-feeding. The potential effects on the baby or fetus are just too risky for most situations.
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