www.ptsd.va.

gov
Posttraumatic stress disorder (PTSD) is an anxiety disorder that can occur after you have been
through a traumatic event. A traumatic event is something horrible and scary that you see or
that happens to you. During this type of event, you think that your life or others' lives are in
danger. You may feel afraid or feel that you have no control over what is happening.

Anyone who has gone through a life-threatening event can develop PTSD. These events can
include:

 Combat or military exposure

 Child sexual or physical abuse
 Terrorist attacks
 Sexual or physical assault
 Serious accidents, such as a car wreck.
 Natural disasters, such as a fire, tornado, hurricane, flood, or earthquake.
After the event, you may feel scared, confused, or angry. If these feelings don't go away or
they get worse, you may have PTSD. These symptoms may disrupt your life, making it hard to
continue with your daily activities.

How does PTSD develop?

All people with PTSD have lived through a traumatic event that caused them to fear for their
lives, see horrible things, and feel helpless. Strong emotions caused by the event create
changes in the brain that may result in PTSD.

Most people who go through a traumatic event have some symptoms at the beginning. Yet
only some will develop PTSD. It isn't clear why some people develop PTSD and others don't.
How likely you are to get PTSD depends on many things. These include:

 How intense the trauma was or how long it lasted

 If you lost someone you were close to or were hurt
 How close you were to the event
 How strong your reaction was
 How much you felt in control of events
 How much help and support you got after the event
Many people who develop PTSD get better at some time. But about 1 out of 3 people with
PTSD may continue to have some symptoms. Even if you continue to have symptoms,
treatment can help you cope. Your symptoms don't have to interfere with your everyday
activities, work, and relationships.

What are the symptoms of PTSD?

Symptoms of posttraumatic stress disorder (PTSD) can be terrifying. They may disrupt your
life and make it hard to continue with your daily activities. It may be hard just to get through
the day.

PTSD symptoms usually start soon after the traumatic event, but they may not happen until
months or years later. They also may come and go over many years. If the symptoms last
longer than 4 weeks, cause you great distress, or interfere with your work or home life, you
probably have PTSD.
There are four types of symptoms: reliving the event, avoidance, numbing, and feeling keyed
up.

1. Reliving the event (also called re-experiencing symptoms):

Bad memories of the traumatic event can come back at any time. You may feel the
same fear and horror you did when the event took place. You may have nightmares.
You even may feel like you're going through the event again. This is called a
flashback. Sometimes there is a trigger: a sound or sight that causes you to relive the
event. Triggers might include:

 Hearing a car backfire, which can bring back memories of gunfire and war for
a combat veteran
 Seeing a car accident, which can remind a crash survivor of his or her own
accident
 Seeing a news report of a sexual assault, which may bring back memories of
assault for a woman who was raped
2. Avoiding situations that remind you of the event:
You may try to avoid situations or people that trigger memories of the traumatic
event. You may even avoid talking or thinking about the event.

 A person who was in an earthquake may avoid watching television shows or

movies in which there are earthquakes
 A person who was robbed at gunpoint while ordering at a hamburger drive-in
may avoid fast-food restaurants
 Some people may keep very busy or avoid seeking help. This keeps them from
having to think or talk about the event.

3. Feeling numb:
You may find it hard to express your feelings. This is another way to avoid memories.

 You may not have positive or loving feelings toward other people and may
stay away from relationships
 You may not be interested in activities you used to enjoy
 You may forget about parts of the traumatic event or not be able to talk about
them.

4. Feeling keyed up (also called hyperarousal):

You may be jittery, or always alert and on the lookout for danger. This is known as
hyperarousal. It can cause you to:

 Suddenly become angry or irritable

 Have a hard time sleeping
 Have trouble concentrating
 Fear for your safety and always feel on guard
 Be very startled when someone surprises you
What are other common problems?
People with PTSD may also have other problems. These include:

 Drinking or drug problems

 Feelings of hopelessness, shame, or despair
 Employment problems
 Relationships problems including divorce and violence
 Physical symptoms
Can children have PTSD?
Children can have PTSD too. They may have the symptoms described above or other
symptoms depending on how old they are. As children get older their symptoms are more like
those of adults.

 Young children may become upset if their parents are not close by, have trouble
sleeping, or suddenly have trouble with toilet training or going to the bathroom
 Children who are in the first few years of elementary school (ages 6 to 9) may act out
the trauma through play, drawings, or stories. They may complain of physical
problems or become more irritable or aggressive. They also may develop fears and
anxiety that don't seem to be caused by the traumatic event.
What treatments are available?
When you have PTSD, dealing with the past can be hard. Instead of telling others how you
feel, you may keep your feelings bottled up. But treatment can help you get better.
There are good treatments available for PTSD. Cognitive-behavioral therapy (CBT) is one type
of counseling. It appears to be the most effective type of counseling for PTSD. There are
different types of cognitive behavioral therapies such as cognitive therapy and exposure
therapy. A similar kind of therapy called EMDR, or eye movement desensitization and
reprocessing, is also used for PTSD. Medications can be effective too. A type of drug known as
a selective serotonin reuptake inhibitor (SSRI), which is also used for depression, is effective
for PTSD.

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Anxiety Overview
Anxiety is a feeling of nervousness, apprehension, fear, or worry. Some fears and worries are
justified, such as worry about a loved one or in anticipation of taking a quiz, test, or other
examination. Problem anxiety interferes with the sufferer's ability to sleep or otherwise function. It
is noteworthy that teenagers are particularly susceptible to having irritability as a symptom of a
number of emotional problems, including anxiety. Anxiety may occur without a cause, or it may
occur based on a real situation but may be out of proportion to what would normally be expected.
Severe anxiety can have a serious impact on daily life.

• Anxiety can be accompanied by a variety of physical symptoms. Most commonly, these

symptoms are related to the heart, lungs, nervous, andgastrointestinal systems. You may
have upset stomach, diarrhea, troublebreathing, feel as if you may faint or are having a heart
attack.

Anxiety Causes
Problem anxiety may be caused by a mental condition, a physical condition, the effects of drugs,
or from a combination of these. The doctor's initial task is to see if your anxiety is caused by a
medical condition. Conditions as varied as anemia, asthma attack, infection, drug intoxication or
withdrawal, or a number of heart conditions are just a few examples of medical problems that can
be associated with anxiety.

• Common types of anxiety include these mental conditions:

o Panic disorder: In addition to attacks of anxiety, called panic attacks, common

symptoms of panic disorders are stomach upset, palpitations (feeling your heart
beat), dizziness, and shortness of breath. These same symptoms also can be caused
bycaffeine consumption, amphetamines ("speed" is the street slang for amphetamines
when they are not prescribed by a doctor), an overactivethyroid, abnormal heart rhythms,
and other heart abnormalities (such as mitral valve prolapse). The panic attack sufferer
may experience their mind going blank or that they somehow do not feel real, in that they
feel as if they are looking at themselves from outside of themselves. In order to qualify for
the diagnosis of panic disorder, the individual would experience repeated panic attacks
rather than just one episode.

o Generalized anxiety disorder: Those who endure this condition experience

numerous worries that are more often on the mind of the sufferer than not. Those worries
interfere with the person's ability to sleep or otherwise function.

o Phobic disorders: People with phobias experience irrational fear that may rise
to the level of panic attacks in response to a specific thing or situation. Examples of
phobias include fears of spiders, insects in general, open spaces, closed-in spaces, air
travel, heights, and social anxiety.

o Obsessive compulsive disorder: Individuals with this condition either suffer from
intrusive and distressing thoughts (obsessions) or engage in irresistible, often repetitive
behaviors (compulsions). Examples of obsessions include worries about germs or having
items in a particular order. Examples of compulsions include counting items or activities,
avoiding walking on cracks, or avoiding touching doorknobs.

o Separation anxiety disorder: Considered a disorder of children, separation

anxiety disorder can be diagnosed when a child becomes extremely anxious in response to
anticipating or being separated from one or more caregiving adults (usually a parent). The
separation may come with the child's going to school each day or going to bed each
evening, for example.

o Stress disorders

• These common external factors can cause anxiety:

o Stress at work

o Stress from school

o Stress in a personal relationship such as marriage or friendships

o Financial stress
 o Stress from an emotional trauma such as the death of a loved one, a natural
disaster, victimization by crime, physical abuse or sexual abuse (for example, acute stress
disorder or post traumatic stress disorder)

o Stress from a serious medical illness

o Side effects of medication

o Intoxication (being "high" on) with an illicit drug, such as cocaine or

amphetamines

o Withdrawal from an illicit drug, such as opiates (for example, heroin) or from
prescription drugs like Vicodin, benzodiazepines, or barbituates

o Symptoms of a medical illness

o Lack of oxygen: In circumstances as diverse as high altitude

sickness,emphysema, or pulmonary embolism (a blood clot with the vessels of the lung)

• The doctor has the often difficult task of determining which symptoms come from which
causes. For example, in a study of people with chest pain that could be heart disease but
turned out not to be heart related, 43% were found to have a panic disorder-a common form of
anxiety.

Anxiety Symptoms

• Panic disorder: recurrent episodes of panic attacks, worry about having an attack, about
what it means, or changing the way one behaves because of the panic attacks for at least a
month. Panic attacks are separate and intense periods of fear or feelings of doom developing
over a very short time frame-10 minutes-and they're associated with at least four of the
following:

o Palpitations

o Sweating

o Trembling

o Shortness of breath

o Sense of choking

o Chest pain

o Nausea or other stomach upset

o Dizziness

o A feeling of being detached from the world (derealization)

 o Being unable to think, feeling as if the mind has gone blank

o Fear of dying

o Numbness or tingling

o Chills or hot flashes

• Generalized anxiety disorder: excessive, unrealistic, and difficult to control worry over a
period of at least six months. It's associated with three of the following:

o Restlessness

o Easily tired

o Trouble concentrating

o Irritability

o Muscle tension

o Sleep problems

• Phobic disorders: intense, persistent, and recurring fear of certain objects (such as
snakes, spiders, or blood) or situations (such as heights, speaking in front of a group, or public
places). These exposures may trigger a panic attack.

• Stress disorders: anxiety (also known as post-traumatic stress disorder) caused by the
exposure to either death or near-death circumstances such as fires, floods, earthquakes,
shootings, automobile accidents, or wars, for example. Other traumatic events may not have
had the threat of death or near-death but resulted in the severe injury or threat thereof.
Examples of such trauma include victimization through physical or sexual abuse, witnessing
the abuse of another or over-xposure to inappropriate material (for example, exposure of
children to pornographic images or acts). The traumatic event is re-experienced in thoughts
and dreams. Common behaviors include the following:

o Re-experiencing the trauma, either when awake (flashbacks) or when asleep

(nightmares)

o Avoiding activities, places, or people associated with the triggering event

o Difficulty concentrating

o Difficulty sleeping

o Being hypervigilant (you closely watch your surroundings)

o Feeling a general sense of depression, irritability, doom and gloom with

diminished emotions such as loving feelings or aspirations for the future
 • Symptoms such as chest pain, shortness of breath, palpitations, dizziness,fainting, and
weakness generally should not be attributed to anxiety and require evaluation by a doctor.

When to Seek Medical Care

Call your doctor when the signs and symptoms of anxiety are not easily, quickly, and clearly
diagnosed and treated.

• If the symptoms are so severe that you believe medication may be needed

• If the symptoms are interfering with your personal, social, or professional life

• If you have chest pain, shortness of breath, headaches, palpitations, dizziness, fainting
spells, or unexplained weakness

• If you are depressed and feel suicidal or homicidal

When the signs and symptoms suggest that anxiety may have been present for a prolonged
period (more than a few days) and appear to be stable (not getting worse rapidly), you may be
able to make an appointment with your doctor for evaluation. But when the signs and symptoms
are severe and come on suddenly, they may represent a serious medical illness that needs
immediate evaluation and treatment in a hospital's emergency department.

A man hates to go to work because a meeting is scheduled the

next day. He knows that these meetings always involve co-workers talking with
each other about their current projects. Just the thought of speaking in front of co-
workers raises his anxiety. Sometimes he can't sleep the night before because of the
anticipatory anxiety that builds up. Finally, the meeting is over. A big wave of relief
spills over him as he begins to relax. But the memory of the meeting is still
uppermost in his mind. He is convinced he made a fool of himself and that everyone
in the room saw how afraid he was when he spoke, and how stupid he acted in their
presence. At next week's meeting, the boss is going to be there. Even though this
meeting is seven days away, his stomach turns raw with anxiety and fear floods over
him again. He knows that in front of the boss he'll stammer, hesitate, his face will
turn red, he won't remember what to say, and everyone will witness his
embarrassment and humiliation. He has seven miserable days of anxiety ahead of
him -- to think about it, ruminate over it, worry about it, over-exaggerate it in his
mind.......again and again and again.....

In public places, such as work, meetings, or shopping, people with social anxiety feel
that everyone is watching, staring, and judging them (even though rationally they
know this isn't true). The socially anxious person can't relax, "take it easy", and
enjoy themselves in public. In fact, they can never fully relax when other people are
around. It always feels like others are evaluating them, being critical of them, or
"judging" them in some way. The person with social anxiety knows that people don't
do this openly, of course, but they still feel the self-consciousness and
judgment while they are in the other person's presence. It's sometimes impossible to
let go, relax, and focus on anything else except the anxiety and fear. Because the
anxiety is so very painful, it's much easier just to stay away from social situations
and avoid other people altogether.

ANALYSIS BY SHRINK

Social anxiety is the third largest psychological problem in the United States today.
This type of anxiety affects 15 million Americans in any given year. Unlike some
other psychological problems, social anxiety is not well understood by the general
public or by medical and mental health care professionals, such as doctors,
psychiatrists, psychologists, therapists, social workers, and counselors. In fact,
people with social anxiety are misdiagnosed almost 90% of the time. People with
social phobia come to our anxiety clinic labeled as "schizophrenic", "manic-
depressive", "clinically depressed", "panic disordered", and "personality disordered",
among other damaging misdiagnoses.

Because few socially-anxious people have heard of their own problem, and have
never seen it discussed on any media, such as the television talk shows, they think
they are the only ones in the whole world who have these terrible symptoms.
Therefore, they must keep quiet about them. It would be awful if everyone realized
how much anxiety they experienced in daily life. Then what would people think about
them? Unfortunately, without some kind of education, knowledge, and appropriate
treatment, social phobia/social anxiety continues to wreak havoc throughout their
lives. Adding to the dilemma, when a person with social anxiety finally gets up the
nerve to seek help, the chances that they can find it are very, very slim.

Making the situation more difficult is that social anxiety does not come and go like
some other physical and psychological problems. If you have social anxiety one
day......you have it every day for the rest of your life.....

The feelings I described to you at the beginning of the article are those of people
with social anxiety disorder. That is, their symptoms apply to most social events and
functions in almost every area of life. I suffered from social anxiety myself for twenty
years before I ever saw the term or read about its symptoms in a book. (The first
book that specifically dealt with social phobia was not published until the 1990's.)

As with all problems, everyone with social anxiety has slightly different secondary
symptoms. Some people, for example, cannot write in public because they fear
people are watching and their hand will shake. Others are very introverted and they
find it too difficult to hold down a job. Still others have severe anxiety about eating
or drinking in the presence of other people. Some people with social anxiety feel that
a certain part of their body (such as the face or neck) are particularly "strange
looking" and vulnerable to being stared at. Others experience a muscle spasm
(usually around the neck and shoulders) and it becomes the center of their focus
---"it's so embarrassing that if someone sees it I will be humiliated forever!"
One thing that all socially anxious people share is the knowledge that their thoughts
and fears are basicallyirrational. That is, people with social anxiety know that others
are really not critically judging or evaluating them all the time. They understand that
people are not trying to embarrass or humiliate them. They realize that their
thoughts and feelings are somewhat exaggerated and irrational. Yet, despite this
rational knowledge, they still continue to feel differently.

It is these automatic "feelings" and thoughts that occur around social situations that
must be met and conquered in therapy. Usually these anxious feelings are tied to
thoughts that are entwined in a vicious cycle of negative expectations and negative
appraisals. It is a catch-22 situation: there is no way out without the appropriate
therapy.

Here comes the good part.

How can social anxiety be treated? Many therapeutic methods have been studied,
but cognitive-behavioral therapy is the only modality that has been shown to work
effectively. In fact, treatment of social anxiety through cognitive-behavioral methods
has the capacity to produce long-lasting, permanent relief from the anxiety-laden
world of social anxiety.

Social anxiety responds to relatively short-term therapy, depending on the severity

of the condition. I have seen significant progress in just twelve individual sessions,
although most people respond better with sixteen to twenty-four meetings. To
overcome social anxiety, completion of a behavioral therapy group is also essential
(when people feel ready for this and not before).

What socially anxious people do not need is years and years of therapy or
counseling. You can't be "counseled" out of social phobia. In fact, socially anxious
people who are taught to "analyze" and "ruminate" over their problems usually make
their social anxiety and fears much worse, which in turn leads to depression, which
just reinforces the fact that "I will never get better". (Shudder...this statement does
NOT have to be true.)

THERE IS A BETTER LIFE FOR ALL PEOPLE WITH SOCIAL ANXIETY.

Without treatment, social anxiety is a torturous and horrible emotional problem; with
treatment, its bark is worse than its bite. Add to this that current research is clear
that cognitive-behavioral therapy is highly successful in the treatment of social
anxiety. In fact, the people who are unsuccessful are the ones who are not persistent
in their practice and who won't stick with simple methods and techniques at home.
They are the ones who give up.

If a person is motivated to end the years and years of crippling anxiety, then
cognitive-behavioral treatment provides the methods, techniques, and strategies
that come together to lessen the anxiety and make the world a much more enjoyable
place. Many of us have been through the crippling fears and constant anxiety that
social phobia produces -- and have come out healthier and happier on the other side.
You can too.

---Thomas A. Richards, Ph.D.

Psychologist