Anxiety And Depression Dennis Mungall, Pharm.D. Director,Virtual Education, Non traditional Doctor...
-
Upload
lisa-reeves -
Category
Documents
-
view
220 -
download
1
Transcript of Anxiety And Depression Dennis Mungall, Pharm.D. Director,Virtual Education, Non traditional Doctor...
Anxiety And DepressionAnxiety And DepressionAnxiety And DepressionAnxiety And Depression
Dennis Mungall , Pharm.D.Director,Virtual Education, Non traditional Doctor of Pharmacy Program
Associate Professor , Pharmacy PracticeOhio State University/ College of Pharmacy
Learning ObjectivesLearning Objectives
1. Understand the various anxiety disorders , Depression and how each disorder presents
2. Understand the treatment strategies for each disorder
3. Understand the signs and symptoms of each disorder
4. Understand the consequences to the health care system of anxiety and depression
History of DepressionHistory of DepressionIt is thought that ancient man saw
mental illness as possession by supernatural forces. Ancient human skulls have been found with large holes in them, a process that has become known as trepanning. The accepted theory is that it was an attempt to let evil spirits out. We cannot be certain of this, but we do know that again and again human kind has returned to the idea of mental illness being caused by “evil forces”.
History of DepressionHistory of DepressionAnd yet in certain of these cases there is mere anger and grief and sad dejection of mind………those affected with melancholy are not every one of them affected according to one particular form but they are suspicious of poisoning or flee to the desert from misanthropy or turn superstitious or contract a hatred of life. Or if at any time a relaxation takes place, in most cases hilarity supervenes. The patients are dull or stern, dejected or unreasonably torpid……they also become peevish, dispirited and start up from a disturbed sleep.” Arateus (AD 150)
History of DepressionHistory of DepressionHippocrates (460-377 BC) lived at the time of
Hellenic enlightenment, when great advances were made in all areas of knowledge. He applied Empedocles’ theory to mental illness and was insistent that all illness or mental disorder must be explained on the basis of natural causes. Unpleasant dreams and anxiety were seen as being caused by a sudden flow of bile to the brain, melancholia was thought to be brought on by an excess of black bile4, and exaltation by a predominance of warmth and dampness in the brain. Temperament was thought to be choleric, phlegmatic, sanguine or melancholic depending on the dominating humor
History of DepressionHistory of DepressionBy the end of the fifteenth century psychological
problems were greatly entwined with legal and religious issues and were not seen alone. The devil was seen as the cause of all ills .Mental disorder was equated with sin. They also stated that where doctors could find no cause for a disease and where the disease did not respond to traditional treatment it was caused by the devil. A witch was stripped and her pubic hair was shaved before presentation to judges, so that the devil would have nowhere to hide. On being found guilty a witch would be burnt at the stake. Literally hundreds of thousands of women and children suffered this fate and probably many of the mentally ill.
History of DepressionHistory of Depression• Robert Burton’s anatomy of melancholy appeared for
the first time in 1621.2 He described in detail the psychological and social causes (such as poverty, fear and solitude) that were associated with melancholia and seemed to cause it
• In Early nineteenth century Heinroth believed that sin was the causal factor in mental illness. Not sin in the theological sense, but the offending of an individual’s morals by their own thoughts. He was referring to an internal conflict
• The man who exemplified the hard-nosed scientific feel of this era was the German psychiatrist Wilhelm Griesinger (1817-1868). For him mental diseases were somatic diseases6, and the cause of mental illness was always to be found in the brain. He firmly believed that psychiatry and neuropathology were one
History of DepressionHistory of Depression• Freud successfully realised was that
neurophysiological and psychological knowledge need not be contradictory.
• Psychoanalysis predominated until the 1970s, which was followed by renewed interest in genetic, biochemical and neuropathological causes of mental disorder which came to be known as biological psychiatry
IntroductionIntroduction
Lifetime Prevalence of Depression and Anxiety Disorders
Lifetime Prevalence of Depression and Anxiety Disorders
Comparision with Other Medical Conditions
Comparision with Other Medical Conditions
Sx Overlap of Anxiety and Depression
Sx Overlap of Anxiety and Depression
Sx Overlap ( cont.)Sx Overlap ( cont.)
Risk Of Psychiatric Disorder
PercentPercent
Kroenke et al. Kroenke et al. Arch Fam MedArch Fam Med. 1994;3:774.. 1994;3:774.
Physical Symptoms (#)Physical Symptoms (#)
Physical Symptoms
Kroenke et al. Kroenke et al. Arch Fam MedArch Fam Med. 1994;3:774.. 1994;3:774.
0 10 20 30 40 50 60 70
Fainting
Insomnia
Chest Pain
Abdominal Pain
Headache
Fatigue
Mood Disorder Anxiety Disorder
0 10 20 30 40 50 60 70
Fainting
Insomnia
Chest Pain
Abdominal Pain
Headache
Fatigue
Mood Disorder Anxiety Disorder
Somatic Symptoms In Mood And Anxiety Disorders
0123456789
10
Panic Agoraphobia SocialAnxiety
Disorder
OCD Any AnxietyDisorder
Rates
Control Alcohol-Dependent
0123456789
10
Panic Agoraphobia SocialAnxiety
Disorder
OCD Any AnxietyDisorder
Rates
Control Alcohol-Dependent
***
**
Lifetime Rates Of Anxiety Disorders InAlcohol-Dependence
Occurring Prior To Substance Dependence
Merikangas et al. Merikangas et al. Psychologic MedPsychologic Med. 1998;28:773.. 1998;28:773.
0
20
40
60
80
100
Mood Disorder Anxiety Disorder
0
20
40
60
80
100
Mood Disorder Anxiety Disorder
PercentPercent
Alcohol DependenceAlcohol Dependence Drug DependenceDrug Dependence
Mood/Anxiety Disorder
Primary Care Presentation Primary Care Presentation
Anxiety and Depression in Primary Care
Anxiety and Depression in Primary Care
Depression and GenderDepression and Gender
Days Lost from WorkDays Lost from Work
Costs of Depression in the United States
Costs of Depression in the United States
Costs of Depression in the United States Cost Center Amount ($ billion) Direct costsInpatient care 8.3Outpatient care 2.8Partial care 0.1Pharmaceuticals 1.2 Total direct costs 12.4 Indirect costsAbsenteeism 11.7Decreased productivity 2.1Suicide 7.5 Total indirect costs 31.3
Recovery RatesRecovery Rates
Relapse RatesRelapse Rates
Utilizers of Medical CareUtilizers of Medical Care
DepressionDepression
Case StudyCase Study
Depression PrevalenceDepression Prevalence
Morbidity and MortalityMorbidity and Mortality
Morbidity and MortalityMorbidity and Mortality
SuicideSuicide
Depression : DSM IVDepression : DSM IV
Major Depressive Episode:CriteriaMajor Depressive Episode:Criteria
Criteria (cont.)Criteria (cont.)
Hamilton Rating Score for Depression
Hamilton Rating Score for Depression
Interview TechniquesInterview Techniques• Depressed or
Down• Restless• Fatigued• Guilty• Inability to
Concentrate
Associated FeaturesAssociated Features
Associated Features (cont.)Associated Features (cont.)
• Prior episodes
• Family history
• Prior suicide attempts
• Female gender
• Recent childbirth
• Medical comorbidity
• Alcohol or substance abuse
• Recent separation or bereavement
Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis.Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis.Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health and Human Service,Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health and Human Service,Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0550. April 1993.Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 93-0550. April 1993.
Depression Risk Factors
• Inadequate treatment
• Poor medication compliance
• Frequent +/- multiple episodes
• Preexisting dysthymia
• Onset after age 60
• Long duration or severe index episode
• Seasonal pattern
• Familial mood disorders
• Comorbid anxiety or substance abuse disorder
Recurrent Depression Risk Factors
• Comorbid general medical/neurologic illness
• Cognitive decline
• Multiple losses/bereavement
Factors Complicating Diagnosis OfLate Life Depression
Disease ManagementDisease Management
The Five Rs
Kupfer. Kupfer. J Clin PsychiatryJ Clin Psychiatry. 1991;52(Suppl 5):28.. 1991;52(Suppl 5):28.
RemissionRemission
xx
xxxx
SymptomsSymptoms
SyndromeSyndrome
ResponseResponse
RelapseRelapseRecoveryRecovery
RecurrenceRecurrence
Treatment PhasesTreatment Phases
Acute 6-12Acute 6-12Weeks Weeks
ContinuationContinuation4-9 Months4-9 Months
MaintenanceMaintenance 1 Year1 Year
Depression Treatment Outcome
Response to TherapyResponse to Therapy
RelapseRelapse
ComplianceCompliance
GuidelinesGuidelines
• Accurate diagnosis
• Appropriate antidepressant
• Adequate dose/duration
Criteria For An Adequate Trial Of Antidepressant Treatment
Initial Approach to RXInitial Approach to RX
Initial Approach to RXInitial Approach to RX
Initial Approach to RXInitial Approach to RX
Choosing an AntidepressantChoosing an Antidepressant
Long Term Treatment StrategiesLong Term Treatment Strategies
Rules of DosingRules of Dosing
Serotonin Side EffectsSerotonin Side Effects
Pharmacokinetics of Antidepressants
Pharmacokinetics of Antidepressants
Drug InteractionsDrug Interactions
Treatment ChoicesTreatment Choices
Treatment Choices ( cont.)Treatment Choices ( cont.)
Treatment Choices ( cont.)Treatment Choices ( cont.)
Treatment SummaryTreatment Summary
• Maximize dose• Augmentation:
– Thyroid hormone (T3 > T4) – Lithium (levels 0.7 mEq/mL)
• Combination therapy: eg, SSRI/TCA
• Other: – MAOIs - venlafaxine
– ECT
Strategies In Treatment Resistant Depression
• Common, class effect
• Affects men and women
• Reduced libido
• Dysfunctional orgasm– delayed ejaculation
– inability to ejaculate
– anorgasmia
Keller-Ashton et al. Keller-Ashton et al. J Sex Marital TherJ Sex Marital Ther. . 1997;23:165.1997;23:165.Segraves. Segraves. J Clin PsychiatryJ Clin Psychiatry. 1998;59(Suppl 4):48.. 1998;59(Suppl 4):48.
SSRIs And Sexual Dysfunction
• Tolerate sexual dysfunction in favor of optimal therapeutic response
Dose (or consider drug holiday), but monitor for relapse
• Beneficial in case reports: bupropion, buspirone, amantadine, bromocriptine, methylphenidate, yohimbine, gingko biloba
• Consider alternate antidepressant
Keller-Ashton et al. Keller-Ashton et al. J Sex Marital TherJ Sex Marital Ther. 1997;23:165. Rothschild. . 1997;23:165. Rothschild. Am J PsychiatryAm J Psychiatry. 1995;152:1514.. 1995;152:1514.Segraves. Segraves. J Clin PsychiatryJ Clin Psychiatry. 1998;59(Suppl 4):48.. 1998;59(Suppl 4):48.
Potential Management Strategies
SSRI - Related Sexual Dysfunction
• Weight gain associated with TCAs, MAOIs, SSRIs, and newer antidepressants
Appetite, weight loss associated with depression; therapeutic response may increase weight to normal
• Weight gain during SSRI therapy has not been systematically studied
Antidepressants And Weight Gain
• Sedation
• Anticholinergic effects
• Orthostatic hypotension
• Cardiac toxicity
TCAs: Enhanced Side Effects In The Elderly
Anticancer Drugs Associated With DepressionAnticancer Drugs Associated With Depression
Massie et al. J Pain Symptom Manage. 1994;9:325.
• Corticosteroids
• Interferon
• Asparaginase
• Cyproterone
• Vinblastine
• Vincristine
• Procarbazine
• Tamoxifen
Risk Factors For Suicide In Cancer PatientsRisk Factors For Suicide In Cancer Patients
Massie et al. J Pain Symptom Manage. 1994;9:325.
• Current or prior suicidality• Depression• Psychosis/irrational
thinking• Substance abuse• Recent loss• Poor social support• Older male
• Uncontrolled pain• Advanced disease• Poor prognosis• Cancer site (head/neck,
lung, GI, urogenital,breast)
• Exhaustion/fatigue
Dysthymia: CriteriaDysthymia: Criteria
Treatment of DysthymiaTreatment of Dysthymia
Generalized Anxiety Disorder: Excessive Chronic
Anxiety and Worry
Generalized Anxiety Disorder: Excessive Chronic
Anxiety and Worry
DSM IV Classification DSM IV Classification
Case Studies : GADCase Studies : GAD
Acute Anxiety
Chronic Anxiety
Uncontrolled Anxiety
Roy-Byrne et al. Roy-Byrne et al. J Clin PsychiatryJ Clin Psychiatry. 1997;58(Suppl 3):34.. 1997;58(Suppl 3):34.
• InterestInterest• AppetiteAppetite• EsteemEsteem• SuicideSuicide
DepressionDepression
• AgitationAgitation• DysphoriaDysphoria• SleepSleep• FatigueFatigue• ConcentrationConcentration
• RestlessnessRestlessness• TensionTension• IrritabilityIrritability• WorryWorry
GADGAD
Symptom Overlap In GAD And Depression
CriteriaCriteria
GABAGABA
BenzodiazepinesBenzodiazepines
Rx of GADRx of GAD
TreatmentTreatment
Rx of GADRx of GAD
Social Phobia/Social Anxiety Disorder : Fear of Scrutiny
Social Phobia/Social Anxiety Disorder : Fear of Scrutiny
Case Study: Social AnxietyCase Study: Social Anxiety
• Fear/avoidance of social situations
• Feared situations avoided or endured with intense anxiety or distress
• Fear recognized as excessive or unreasonable
• Fear/avoidance interferes with work, social, family activities
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.American Psychiatric Association, 1994.
DSM-IV Social Anxiety Disorder
* Magee et al. * Magee et al. Arch Gen PsychiatryArch Gen Psychiatry. 1996;53:159.. 1996;53:159.**Weiller et al. **Weiller et al. Br J PsychiatryBr J Psychiatry. 1996;168:169.. 1996;168:169.
13.314.4
4.5 4.9
0
5
10
15
20
General Population* Primary Care**
Lifetime Prevalance One-month Prevalence
13.314.4
4.5 4.9
0
5
10
15
20
General Population* Primary Care**
Lifetime Prevalance One-month Prevalence
PrevalencePrevalence(%)(%)
Prevalence Of Social Anxiety Disorder
Beidel. Beidel. J Clin PsychiatryJ Clin Psychiatry. 1998;59(Suppl 17):27.. 1998;59(Suppl 17):27.
PalpitationsPalpitations
Trembling/Trembling/ShakingShaking
BlushingBlushingSweatingSweating
““Butterflies”Butterflies”
Common Somatic Complaints
Social Anxiety Disorder And AgoraphobiaSocial Anxiety Disorder And AgoraphobiaDifferential Diagnosis
SocialSocialAnxietyAnxietyDisorderDisorder
DisorderDisorder
Fear of negative Fear of negative evaluation or evaluation or humiliation in social or humiliation in social or performance situationsperformance situations
Common FearCommon Fear
Public scrutinyPublic scrutiny
Key ConcernsKey Concerns
Avoids speaking, Avoids speaking, eating, drinking, eating, drinking, writing, or using writing, or using restroomsrestroomsonly in publiconly in public
ExampleExample
Agora-Agora-phobiaphobia
Fear that help won’t Fear that help won’t be available or be available or escape won’t be escape won’t be possiblepossible
Being caught in Being caught in situation where situation where escape may be escape may be difficultdifficult
Avoids being alone Avoids being alone or away from or away from home; being in a home; being in a crowd; traveling in crowd; traveling in a car, bus or a car, bus or airplane; or being airplane; or being on a bridge or in an on a bridge or in an elevatorelevator
Social Anxiety Disorder And Panic DisorderSocial Anxiety Disorder And Panic DisorderDifferential Diagnosis
SocialSocialAnxietyAnxietyDisorderDisorder
DisorderDisorder
Fear of negative Fear of negative evaluation or evaluation or humiliation in social or humiliation in social or performance situationsperformance situations
Common FearCommon Fear
Public scrutinyPublic scrutiny
Key ConcernsKey Concerns
Avoids speaking, Avoids speaking, eating, drinking, eating, drinking, writing, or using writing, or using restroomsrestroomsonly in publiconly in public
ExampleExample
PanicPanicDisorderDisorder
Fear of having a Fear of having a heart attack, dying, heart attack, dying, or “going crazy”or “going crazy”
Sudden, Sudden, unexpected unexpected panic attacks panic attacks alone or in alone or in public; not public; not exclusively exclusively limited to social limited to social situationssituations
Discrete attacks Discrete attacks about 10 minutes, about 10 minutes, including chest including chest pain, fear of dying, pain, fear of dying, or smothering or smothering sensations/avoids sensations/avoids places where places where attacks have attacks have occurredoccurred
Social Anxiety Disorder And GADSocial Anxiety Disorder And GADDifferential Diagnosis
SocialSocialAnxietyAnxietyDisorderDisorder
DisorderDisorder
Fear of negative Fear of negative evaluation or evaluation or humiliation in social or humiliation in social or performance situationsperformance situations
Common FearCommon Fear
Public scrutinyPublic scrutiny
Key ConcernsKey Concerns
Avoids speaking, Avoids speaking, eating, drinking, eating, drinking, writing, or using writing, or using restroomsrestroomsonly in publiconly in public
ExampleExample
GeneralizedGeneralizedAnxietyAnxietyDisorderDisorder
Fear of everyday Fear of everyday routine, life routine, life circumstances, e.g. circumstances, e.g. job, finances, health, job, finances, health, or minor mattersor minor matters
Anxiety/worry Anxiety/worry shifting from shifting from one concern to one concern to another - no another - no fear of social fear of social situationssituations
Worries almost Worries almost constantly about constantly about routine, everyday routine, everyday mattersmatters
• Are you afraid of being scrutinized in public?
• Do you fear speaking to others?
• Do you avoid social situations or events?
Screening Questions For Social Anxiety Disorder In Primary Care
• Participating in small groups
• Eating, drinking, writing in public
• Talking to authority figures
• Performing or giving a talk
• Attending social events
• Working while being observed
• Meeting strangers or dating
• Using public bathroom
• Being center of attention
Common FearsSocial Anxiety Disorder
• Distinguishable from other anxiety disorders
• Very common, but undiagnosed, undertreated, costly
• Effectively treated with SSRIs +/- psychotherapy
• Easily screened with patient self-rated questionnaire
Social Anxiety Disorder
• Reduce anxiety/phobic avoidance
• Reduce disability
• Treat depression/other comorbidities
• Choose therapy that is tolerable over long-term
Davidson. Davidson. J Clin PsychiatryJ Clin Psychiatry. 1998;59(Suppl 17):47.. 1998;59(Suppl 17):47.
Social Anxiety Disorder Treatment Goals
TreatmentTreatment
• Can be effective• Potential problems in patients with
alcohol/substance abuse • Not effective for comorbid depression• Side effects
– disruption of cognitive function/sedation– tolerance/dependence/withdrawal
Benzodiazepine Treatment Of Social Anxiety Disorder
van Vliet et al.van Vliet et al. Psychopharmacology Psychopharmacology. 1994;115:128.. 1994;115:128.
Fluvoxamine Treatment Of Social Anxiety Disorder
50
7
0
10
20
30
40
50
60
Fluvoxamine Placebo
50
7
0
10
20
30
40
50
60
Fluvoxamine Placebo
RespondersResponders(%)(%)
Treatment Group (N = 30)Treatment Group (N = 30)
50
9
0
10
20
30
40
50
60
Sertraline Placebo
50
9
0
10
20
30
40
50
60
Sertraline Placebo
Katzelnick et al. Katzelnick et al. Am J PsychiatryAm J Psychiatry. 1995;152:1368.. 1995;152:1368.
Sertraline Treatment Of Social Anxiety Disorder
RespondersResponders(%)(%)
Treatment Group (N = 12)Treatment Group (N = 12)
* P<.001 † P=.03 ‡ P=.17* P<.001 † P=.03 ‡ P=.17Stein et al. Stein et al. JAMAJAMA. 1998;280:708.. 1998;280:708.
05
1015202530354045
Avoidance Fear/Anxiety
Social Life Work Family Life
05
1015202530354045
Avoidance Fear/Anxiety
Social Life Work Family Life
%%ImprovementImprovement
OverOverBaselineBaseline
Paroxetine (N=90)Paroxetine (N=90) Placebo (N=92)Placebo (N=92)
‡†
***
Paroxetine Treatment Of Social Anxiety Disorder
• Irreversible, nonselective– effective – poorly tolerated– hazardous
• Reversible, selective– moderate effectiveness– well tolerated– not available in US
Monoamine Oxidase Inhibitor Treatment OfSocial Anxiety Disorder
MAOI: DietMAOI: Diet
• Effective for mild, occasional performance anxiety
• Not effective in generalized social anxiety disorder
• Will not treat comorbid conditions
• Very limited role
-Blocker Treatment Of Social Anxiety Disorder
• Doubtful efficacy
• Poor side effect profile– sedation, tremor, dry mouth– effects on cognitive function– sexual dysfunction– weight gain– constipation
Tricyclic Antidepressant Treatment Of
Social Anxiety Disorder
• Frequently undiagnosed and untreated
• Presents as marked and persistent fear of social or performance situations or with physiologic symptoms
• Treatment options: psychosocial and pharmacologic– SSRIs show most promise
Conclusions: Social Anxiety Disorder
Panic Disorder: Spontaneous panic attacks
Panic Disorder: Spontaneous panic attacks
Case Study : PanicCase Study : Panic
Criteria For Panic AttacksCriteria For Panic Attacks
Other Causes of Panic SxOther Causes of Panic Sx
Other Causes of Panic SxOther Causes of Panic Sx
Rx: Panic DisorderRx: Panic Disorder
BenzodiazepinesBenzodiazepines
ClonazepamClonazepam
Benzodiazepines (cont.)Benzodiazepines (cont.)
AntidepressantsAntidepressants
Antidepressants (cont.)Antidepressants (cont.)
Post Traumatic Stress Disorder
Post Traumatic Stress Disorder
PTSD : Case StudyPTSD : Case Study
Prevalence Of PTSDPrevalence Of PTSD
0
2
4
6
8
10
12
15 - 24 25 - 34 35 - 44 45 - 54 Total
0
2
4
6
8
10
12
15 - 24 25 - 34 35 - 44 45 - 54 Total
Males Females
Core Features Of PTSD Core Features Of PTSD
• Intrusive symptoms• Avoidance behavior• Numbing• Hyperarousal
symptoms
TraumaTrauma
CriteriaCriteria
0
5
10
15
20
25
30
Rape Molestation PhysicalAttack
Accident PhysicalAbuse
0
5
10
15
20
25
30
Rape Molestation PhysicalAttack
Accident PhysicalAbuse
Non-Combat Related Trauma Associated With PTSDNon-Combat Related Trauma Associated With PTSD
Kessler et al. Kessler et al. Arch Gen PsychiatryArch Gen Psychiatry. . 1995;52:1048.1995;52:1048.
IncidenceIncidence(%)(%)
MalesMales FemalesFemales
• Must specifically ask about trauma
• Assess presence of core symptoms
• Patient self-rated scales (eg Impact of Event Scale, MINI)
• Assess comorbidity (depression, substance use disorders, anxiety disorders)
Diagnosis Of PTSD In Primary Care
• Education
• Support
• Anxiety management
– pharmacotherapy
– psychotherapy
• Lifestyle modification
Treatment Of PTSD
Non-Combat Related PTSD:Non-Combat Related PTSD:SSRI Treatment Studies
Van Der KolkVan Der Kolket al. 1994et al. 1994
AuthorAuthor
64*64*
NN
Flu vs. Pbo;Flu vs. Pbo;5 weeks5 weeks
RegimenRegimen
Significant Significant symptoms symptoms with Fluwith Flu
OutcomeOutcome
Davidson et al. Davidson et al. J Trauma StressJ Trauma Stress. 1991;4:419.. 1991;4:419.Marshall et al. Marshall et al. J Clin PsychopharmacolJ Clin Psychopharmacol. 1998;18:10.. 1998;18:10.
DavidsonDavidsonet al. 1991et al. 1991
55 Flu;Flu;8 - 32 weeks8 - 32 weeks
Intrusive and Intrusive and avoidant symptomsavoidant symptoms
RothbaumRothbaumet al. 1996et al. 1996
77 Ser;Ser;12 weeks12 weeks
Symptoms in 4/5 Symptoms in 4/5 respondersresponders
MarshallMarshallet al. 1998et al. 1998
1919 Par;Par;12 weeks12 weeks
Significant Significant all core all core symptomssymptoms
* Including 31 cases of combat related PTSD* Including 31 cases of combat related PTSD
Rothbaum et al. Rothbaum et al. J Trauma StressJ Trauma Stress. 1996;9:865.. 1996;9:865.Van Der Kolk et al. Van Der Kolk et al. J Clin PsychiatryJ Clin Psychiatry. 1994;55:517.. 1994;55:517.
TreatmentTreatment