Serotonin Link To Impulsivity, Decision-making, Confirmed

From: ScienceDaily.com

ScienceDaily (June 11, 2008) — New research by scientists at the University of Cambridge suggests that the neurotransmitter serotonin, which acts as a chemical messenger between nerve cells, plays a critical role in regulating emotions such as aggression during social decision-making.

Serotonin has long been associated with social behaviour, but its precise involvement in impulsive aggression has been controversial. Though many have hypothesised the link between serotonin and impulsivity, this is one of the first studies to show a causal link between the two.

Their findings highlight why some of us may become combative or aggressive when we haven't eaten. The essential amino acid necessary for the body to create serotonin can only be obtained through diet. Therefore, our serotonin levels naturally decline when we don't eat, an effect the researchers took advantage of in their experimental technique.

The research also provides insight into clinical disorders characterised by low serotonin levels, such as depression and obsessive compulsive disorder (OCD), and may help explain some of the social difficulties associated with these disorders.

This research, funded by the Wellcome Trust and the Medical Research Council, suggests that patients with depression and anxiety disorders may benefit from therapies that teach them strategies for regulating emotions during decision making, particularly in social scenarios.

The researchers were able reduce brain serotonin levels in healthy volunteers for a short time by manipulating their diet. They used a situation known as the 'Ultimatum Game' to investigate how individuals with low serotonin react to what they perceive as unfair behaviour. In this game one player proposes a way to split a sum of money with a partner. If the partner accepts, both players are paid accordingly. But if he rejects the offer, neither player is paid.

Normally, people tend to reject about half of all offers less than 20-30% of the total stake, despite the fact that this means they receive nothing - but rejection rates increased to more than 80% after serotonin reductions. Other measures showed that the volunteers with serotonin depletion were not simply depressed or hypersensitive to lost rewards.

PhD student Molly Crockett, a Gates Scholar at the University of Cambridge Behavioural and Clinical Neuroscience Institute, said: "Our results suggest that serotonin plays a critical role in social decision-making by normally keeping aggressive social responses in check. Changes in diet and stress cause our serotonin levels to fluctuate naturally, so it's important to understand how this might affect our everyday decision-making."

Where do we get Serotonin?

The only way to get the raw material for serotonin (tryptophan) is through the diet. Therefore, serotonin levels are lower when you haven't eaten, an effect that the researchers take advantage of in their experimental technique. Eating tryptophan rich foods like poultry (chicken soup) and chocolate can boost serotonin levels - some have speculated that this is why these are "feel good" foods.

Journal reference:

1. M.J. Crockett; L. Clark; T.W. Robbins, G. Tabibnia; M.D. Lieberman. Serotonin Modulates Behavioural Reactions to Unfairness. Science, 06 June 2008

Adapted from materials provided by University of Cambridge.

University of Cambridge (2008, June 11). Serotonin Link To Impulsivity, Decision-making, Confirmed. ScienceDaily. Retrieved June 22, 2008, from http://www.sciencedaily.com­ /releases/2008/06/080605150908.htm

Norepinephrine: From Arousal to Panic

From: www.enotalone.com

Norepinephrine (NE) is the neurotransmitter often associated with the “fight or flight” response to stress. Strongly linked to physical responses and reactions, it can increase heart rate and blood pressure as well as create a sense of panic and overwhelming fear/dread. This neurotransmitter is similar to adrenaline and is felt to set threshold levels to stimulation and arousal. Emotionally, anxiety and depression are related to norepinephrine levels in the brain, as this neurotransmitter seems to maintain the balance between agitation and depression.

Low levels of norepinephrine are associated with a loss of alertness, poor memory, and depression. Norepinephrine appears to be the neurotransmitter of “arousal” and for that reason, lower-than-normal levels of this neurotransmitter produce below-average levels of arousal and interest, a symptom found in several psychiatric conditions including depression and ADHD. It is for this reason that medications for depression and ADHD often target both dopamine and norepinephrine in an attempt to restore both to normal level.

Mild elevations in our norepinephrine levels produce heightened arousal, something known to be produced by stimulants. This arousal is considered pleasurable and several “street drugs” such as cocaine and amphetamines work by increasing the brains level of norepinephrine. This increased sense of arousal is pleasurable, linking these substances to their potential for addiction. Research tells us that some individuals using antidepressants develop a state of “hypomania” or emotional elation and physical arousal in this same manner. For that reason, individuals using modern antidepressants are often cautioned to notify their treating physician/psychiatrist if they become “too happy”.

Moderately high levels of norepinephrine create a sense of arousal that becomes uncomfortable. Remembering that this neurotransmitter is strongly involved in creating physical reactions, moderate increases create worry, anxiety, increased startle reflex, jumpiness, fears of crowds & tight places, impaired concentration, restless sleep, and physical changes. The physical symptoms may include rapid fatigue, muscle tension/cramps, irritability, and a sense of being on edge. Almost all anxiety disorders involve norepinephrine elevations.

Severe and sudden increases in norepinephrine are associated with panic attacks. Perhaps the best way to visualize a panic attack is to remember the association with the “flight or fight” response. The “flight or fight” response is a chemical reaction to a dramatic and threatening situation in which the brain produces excessive amounts of norepinephrine and adrenaline – giving us extra strength, increased energy/arousal, muscle tightness (for fighting or running), and a desperate sense that we must do something immediately. This animal response was activated in early man when a bear showed up at his cave or when faced with a tiger in the woods. In modern times, imagine your reaction if while calmly watching television, someone or something started trying to knock your front door in to attack you. In the “flight or fight” reaction, your brain and body chemistry prepare you to either run from the situation or fight to the death!

A panic attack is the activation of the “flight or fight” chemical reaction without a bear at the door. It’s as though the self-protection animal response is kicking-off accidentally, when no real life-threatening situation is present. Known now as panic attacks, they can surface at the grocery, at church, or when you least expect it. As norepinephrine is a fast-acting neurotransmitter, the panic attack may last less than ten minutes (feels like hours however!) but you’ll be rattled/shaken for several hours. Panic attacks are strong physical and chemical events and include the following symptoms:

· Palpitations, pounding heart or rapid heart rate

· Sweating and body temperature changes

· Trembling or shaking

· Shortness of breath of smothering sensations

· Choking sensations

· Chest pain and discomfort

· Nausea or stomach distress

· Dizziness, lightheadedness, or feeling faint

· Sense of unreality, as though you are outside yourself

· Fear of losing control or going crazy

· Fear of dying

· Numbness and tingling throughout the body

· Chills and hot flushes

If we think about the automobile example, a panic attack is the equivalent of your dashboard warning lights coming on – your stress level is too high. Panic attacks, or surges of norepinephrine, can also occur by accident as when created by the use of certain medications. The medications for certain medical conditions can cause a panic attack or increase our level of anxiety. Medications often used for asthma, for example, can create anxiety or panic attacks.

Treating low or elevated levels of norepinephrine in the brain involve different approaches. Low levels of norepinephrine are often treated using newer antidepressants. Many new antidepressants, known as Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s) with brand names like Effexor and Serzone, treat depression by increasing levels of both serotonin and norepinephrine neurotransmitters.

Treatment for high levels of norepinephrine, as found in anxiety and panic disorders, involves decreasing neurotransmitter levels directly or using medications which increase another neurotransmitter that inhibits or decreases the action of norepinephrine. One of those inhibiting neurotransmitters is GABA, also known as Gamma-Aminobutyric Acid.

Church response to the mentally ill

From: http://www.canadianchristianity.com/christianliving/070809ill.html
By Peter Andres, CanadianChristianity.com
August 9/2007

Are people of faith with a mental illness different from those who have a physical illness? Much about mental illness still remains a mystery. That's one of the reasons people are tempted to spiritualize the problem. They hope that the person with mental illness would be able to gain spiritual strength and thus gain victory over the illness.

What remains hard for many to understand is that having a mental illness and being a strong person of faith is no different than having a serious physical illness and being a strong person of faith.

How can church leaders encourage support of people with a mental illness? What does a person with a mental illness need to help him or her feel accepted and part of the congregation? How does the Christian message and experience take on meaning under these circumstances? What exactly is mental illness, anyway?

Marja Bergen, in her book Riding the Roller Coaster (Northstone, 1999), describes her experiences living with bipolar disorder. She talks about the many important factors that helped make her life with this illness tolerable and manageable. Having a supportive husband, friends, and service systems were critical, but she also acknowledges the importance of a spiritual home.

Her church friends learned to understand her illness and provided spiritual nurture, especially during difficult times. She speaks about friendships which include a common belief as being the most valuable ones she'll have. But she also admits that she was fortunate in this regard.

Sadly, many people with mental illness who look for spiritual help during difficult times face ignorance, stigma, avoidance, and judgment. The spiritual counsel and prayer these people receive frankly do more harm than good.

Understanding mental illness, even from the professional, scientific perspective, is still very much a work in progress. Schizophrenia and its related disorders, bipolar disorder (also known as manic depression), major depression, panic and obsessive-compulsive disorders, are all considered mental illnesses. It is estimated that between 15 percent to 20 percent of North Americans will, at some time in their lives, experience a mental illness. Most of these will suffer debilitating depression.

Evidence suggests there are probably organic (biochemical) reasons for the illness, or psycho-social origins -- or a combination of the two. Treatments that deal with the symptoms include medications, psychotherapy or a blend of both.

What is clear to people working in the field is that the experience of the illness goes far beyond living with the symptoms. While a person who has a physical illness -- even cancer -- suffers discomfort and anxiety related to the illness, those who have a mental illness suffer from a constellation of additional issues. These all affect their ability to return to wellness. One of them is stigma, both internally and externally imposed. There's also the loss of self-worth and self-efficacy that might come with a loss of job, friends, marriage and the feelings of being separated from God.

How can the church assist someone in a situation as devastating as this?

1. Church leaders and church members need to know that a mental illness is not the same as a spiritual crisis. Nor is the absence of healing, especially after fervent prayer, a sign of judgment or lack of faith.

2. There should be no judgment about the use of mood altering medications. Medications are commonly needed to treat the bio-chemical causes for the disorder and radically help many keep their symptoms under control.

3. Quality of life for a person suffering from mental illness does not depend on a complete remission from the illness.

What church members need to know is that many experience a recovery which allows them to return to an active and fulfilling life -- but still continue to experience times that are difficult. Recovery from mental illness means: the return of a positive sense of self, usually through meaningful endeavour (work, vocation), a circle of meaningful relationships, a place to live that the person can call his or her own, and a spiritual life that feels a reconnection with God.

The recovering person can be experiencing personal brokenness and limitations, yet have valuable gifts to offer to the church community.

Peter Andres is a regional director for MCC Supportive Care Services, a non-profit charitable organization which supports people with disabilities -- including people with mental health issues.

Schizophrenia: Twice As Common As HIV/AIDS, But Survey Shows Americans Misinformed

From: Medical News Today

10 Jun 2008

Twice as many Americans live with schizophrenia than with HIV/AIDS, but a major report by the National Alliance on Mental Illness (NAMI) reveals most Americans are unfamiliar with the disease.

"Americans are not sure what to think about schizophrenia," said NAMI executive director Mike Fitzpatrick. "They know schizophrenia is a medical illness affecting the brain, but it is largely misunderstood. There are gaps in knowledge- and access to treatment. Misinformation, misperceptions, and misunderstanding represent a public health crisis."

The report is available at www.nami.org/schizophreniasurvey. It is based on an on-line survey conducted by Harris Interactive among the general public, caregivers and individuals living with schizophrenia.

Approximately two million Americans live with schizophrenia. Two-thirds do not receive treatment, even though the disease can be managed successfully.

The survey found the average age at onset was 21, but a nine-year gap exists between symptoms and treatment.

• 85% of Americans recognize schizophrenia as an illness, 79% believe that with treatment, people with the diagnosis can lead independent lives, but only 24% are familiar with it. Many cannot recognize symptoms or mistakenly believe they include "split" or multiple personalities (64%).
  
• 79% want friends to tell them if they have schizophrenia, but only 46% say they would themselves. Even with treatment, 49% are uncomfortable with the prospect of dating a person with schizophrenia.
  
• Among people living with schizophrenia, 49% said doctors take their medical problems less seriously, even though the report notes that the death rate from causes like heart disease or diabetes is 2-3 times that of the general population.
  
• A vast majority believe that better medications (96%) and health insurance (82%) would be most helpful to improving their condition,
  
• Caregivers agree better medications are needed. Approximately 80% have difficulty getting services for loved ones, 63% have difficulty finding time for themselves, and 41% have provided care for more than 10 years.

"We know what to do to increase recovery, but it requires public support, which depends on public attitudes," Fitzpatrick said.

The report offers five recommendations:

1. Public education
2. Closing the gap between symptoms and treatment
3. A welcoming healthcare system
4. Education and support for caregivers and individuals living with the illness
5. Greater investment in medical research

Serotonin: From Bliss to Despair

From: www.enotalone.com
by Joseph M. Carver, Ph.D.

Serotonin, first isolated in 1933, is the neurotransmitter that has been identified in multiple psychiatric disorders including depression, obsessive-compulsive disorder, anorexia, bulimia, body dysmorphic disorder (nose doesn't look perfect after ten surgeries), social anxiety, phobias, etc. Serotonin is a major regulator and is involved in bodily processes such as sleep, libido (sexual interest), body temperature, and other areas.

Perhaps the best way to think of Serotonin is again with an automobile example. Most automobiles in the United States are made to cruise at 70 miles per hour, perfect for interstate highways and that summer vacation. If we place that same automobile on a racetrack and drive day-after-day at 130 mph, two things would happen. Parts would fail and we would run the engine so hot as to evaporate or burnout the oil. Serotonin is the brain’s “oil”.

Like a normal automobile on a race track, when we find ourselves living in a high stress situation for a prolonged period of time, we use more Serotonin than is normally replaced. Imagine a list of your pressures, responsibilities, difficulties and environmental issues (difficult job, bad marriage, poor housing, rough neighborhood, etc.). Prolonged exposure to such a high level of stress gradually lowers our Serotonin level. As we continue to “hang on” we develop symptoms of a severe stress-produced depression.

An automobile can be one, two or three quarts low in oil. Using the automobile as an example, imagine that brain Serotonin can have similar stages, being low (one quart low), moderately low (two quarts low), and severely low (three quarts low). The less Serotonin available in the brain, the more severe our depression and related symptoms.

When Serotonin is low, we experience problems with concentration and attention. We become scatterbrained and poorly organized. Routine responsibilities now seem overwhelming. It takes longer to do things because of poor planning. We lose our car keys and put odd things in the refrigerator. We call people and forget why we called or go to the grocery and forget what we needed. We tell people the same thing two or three times.

As stress continues and our Serotonin level continues to drop, we become more depressed. At this point, moderately low or “two quarts” low, major changes occur in those bodily functions regulated by Serotonin. When Serotonin is moderately low, we have the following symptoms and behaviors:

· Chronic fatigue. Despite sleeping extra hours and naps, we remain tired. There is a sense of being “worn out”

· Sleep disturbance, typically we can’t go to sleep at night as our mind/thought is racing. Patients describe this as “My mind won’t shut up!” Early-morning awakening is also common, typically at 4:00 am, at which point returning to sleep is difficult, again due to the racing thoughts.

· Appetite disturbance is present, usually in two types. We experience a loss of appetite and subsequent weight loss or a craving for sweets and carbohydrates when the brain is trying to make more Serotonin.

· Total loss of sexual interest is present. In fact, there is loss of interest in everything, including those activities and interests that have been enjoyed in the past.

· Social withdrawal is common – not answering the phone, rarely leaving the house/apartment, we stop calling friends and family, and we withdraw from social events.

· Emotional sadness and frequent crying spells are common.

· Self-esteem and self-confidence are low.

· Body sensations, due to Serotonin’s role as a body regulator, include hot flushes and temperature changes, headaches, and stomach distress.

· Loss of personality – a sense that our sense of humor has left and our personality has changed.

· We begin to take everything very personally. Comments, glances, and situations are viewed personally and negatively. If someone speaks to you, it irritates you. If they don’t speak, you become angry and feel ignored.

· Your family will have the sense that you have “faded away”. You talk less, smile less, and sit for hours without noticing anyone.

· Your behavior becomes odd. Family members may find you sitting in the dark in the kitchen at 4:00 am.

Individuals can live many years moderately depressed. They develop compensations for the sleep and other symptoms, using sleeping medication or alcohol to get some sleep. While chronically unhappy and pessimistic, they explain their situation with “It’s just my life!” They may not fully recognize the depressive component.

Very low levels of Serotonin typically bring people to the attention of their family physician, their employer, or other sources of help. Severe Serotonin loss produces symptoms that are difficult to ignore. Not only are severe symptoms present, but also the brain’s ideation/thinking becomes very uncomfortable and even torturing. When Serotonin is severely low, you will experience some if not all of the following:

· Thinking speed will increase. You will have difficulty controlling your own thoughts. The brain will focus on torturing memories and you’ll find it difficult to stop thinking about these uncomfortable memories or images.

· You’ll become emotionally numb! You wouldn’t know how you feel about your life, marriage, job, family, future, significant other, etc. It’s as though all feelings have been turned off. Asked by others how you feel – your response might be “I don’t know!”

· Outbursts will begin, typically two types. Crying outbursts will surface, suddenly crying without much warning. Behavioral outbursts will also surface. If you break the lead in a pencil, you throw the pencil across the room. Temper tantrums may surface. You may storm out of offices or public places.

· Escape fantasies will begin. The most common – Hit the Road! The brain will suggest packing up your personal effects and leaving the family and community.

· Memory torture will begin. Your brain, thinking at 100 miles an hour, will search your memories for your most traumatic or unpleasant experiences. You will suddenly become preoccupied with horrible experiences that may have happened ten, twenty, or even thirty years ago. You will relive the death of loved ones, divorce, childhood abuse – whatever the brain can find to torture you with – you’ll feel like it happened yesterday.

· You’ll have Evil Thoughts. New mothers may have thoughts about smothering their infants. Thoughts of harming or killing others may appear. You may be tortured by images/pictures in your memory. It’s as though the brain finds your most uncomfortable weak spot, then terrorizes you with it.

· With Serotonin a major bodily regulator, when Serotonin is this low your body becomes unregulated. You’ll experience changes in body temperature, aches/pains, muscle cramps, bowel/bladder problems, smothering sensations, etc. The “Evil Thoughts” then tell you those symptoms are due to a terminal disease. Depressed folks never have gas – it’s colon cancer. A bruise is leukemia.

· You’ll develop a Need-for-Change Panic. You’ll begin thinking a change in lifestyle (Midlife Crisis!), a divorce, an extramarital affair, a new job, or a Corvette will change your mood. About 70 percent of jobs are lost at this time as depressed individuals gradually fade away from their life. Most extramarital affairs occur at this time.

· As low Serotonin levels are related to obsessive-compulsive disorders, you may find yourself starting to count things, become preoccupied with germs/disease, excessively worry that appliances are turned off or doors locked, worry that televisions must be turned off on an even-numbered channel, etc. You may develop rituals involving safety and counting. One auto assembly plant worker began believing his work would curse automobiles if their serial number, when each number was added, didn’t equal an even number.

· Whatever normal personality traits, quirks, or attitudes you have, they will suddenly be increased three-fold. A perfectionist will suddenly become anxiously overwhelmed by the messiness of their environment or distraught over leaves that fall each minute to land on the lawn. Penny-pinchers will suddenly become preoccupied with the electric and water consumption in the home.

· A “trigger” event may produce bizarre behavior. Already moderately low in Serotonin, an animal bite or scratch may make you suddenly preoccupied with rabies. A media story about the harmful effects of radiation may make you remember a teenage tour of the local nuclear power plant – suddenly feeling all your symptoms are now the result of exposure to radiation.

· When you reach the bottom of “severely low” Serotonin, the “garbage truck” will arrive. Everyone with severely low Serotonin is told the same thing. You will be told 1) You’re a bad spouse, parent, child, employee, etc., 2) You are a burden to those who love or depend on you, 3) You are worsening the lives of those around you, 4) Those who care about you would be better if you weren’t there, 5) You would be better if you weren’t around, and 6) You and those around you would be better off if you were totally out of the picture. At that point, you develop suicidal thoughts.

Clinical Depression is perhaps the most common mental health problem encountered in practice. One in four adults will experience clinical depression within their lifetime. Depression is the “common cold” of mental health practice – very common and much easier to treat today than in the past.

Treatment for depression, as might be expected, involves increasing levels of Serotonin in the brain. Since the mid-eighties, medications have been available that attempt to specifically target and increase Serotonin. Known as Selective Serotonin Reuptake Inhibitors (SSRI’s), these medications such as Prozac, Zoloft, and Paxil are felt to work by making more Serotonin available in the brain.

Like all neurotransmitters, we can have too much Serotonin. While elevated levels of Serotonin produce a sense of well-being, bliss, and “oneness with the universe” – too much Serotonin can produce a life-threatening condition known as Serotonin Syndrome (SS).

Likely to occur by accident by combining two Serotonin-increasing medications or substances, Serotonin Syndrome (SS) produces violent trembling, profuse sweating, insomnia, nausea, teeth chattering, chilling, shivering, aggressiveness, over-confidence, agitation, and malignant hyperthermia. Emergency medical treatment is required, utilizing medications that neutralize or block the action of Serotonin as the treatment for Serotonin Syndrome (SS).

Like Dopamine, Serotonin can be accidentally increased or decreased by substances. One method of birth control is known to produce severe depression as it lowers Serotonin levels. A specific medication for acne has also been linked with depression and suicidal ideation. For this reason, always inform your physicians if you are taking any medication for depression. Also avoid combining antidepressants with any herbal substances reported to be of help in Depression such as St. John’s Wort.

Fibromyalgia: New Insights Into a Misunderstood Condition

From: medscape via http://www.psychlinks.ca/forum/showthread.php?t=12326

by Jack J. Chen, PharmD, BCPS, CGP, FCPhA
American Pharmacists Association 2008 Annual Meeting
June 9, 2008

Despite the classification of fibromyalgia nearly 20 years ago, this chronic condition continues to be shrouded in controversy and skepticism. At the recent annual meeting of the American Pharmacists Association (APhA), experts provided an evidence-based discussion of the fibromyalgia syndrome. The information provided there was intended to help clinicians better understand current diagnostic and therapeutic considerations of this medical disorder.

Ironically, the lead author on the 1990 diagnostic guidelines was originally a skeptic who questioned the credibility of fibromyalgia, said Linda Krypel, PharmD, Professor of Pharmacy Practice at Drake University College of Pharmacy and Health Sciences, Des Moines, Iowa. The recent publication of treatment guidelines and the emergence of a new therapy for fibromyalgia can be viewed as trends toward increased acceptance of this condition by the medical community.

Fibromyalgia is the most common chronic pain syndrome encountered in general medicine and rheumatology. Approximately 2% to 10% of the US population (more than 6 million people) are believed to meet the current diagnostic criteria for fibromyalgia. The disorder overwhelmingly affects more females than males.

Fibromyalgia is characterized by multiple symptoms, of which chronic, widespread pain is the sine qua non. Classification criteria established by the American College of Rheumatology (ACR) include diffuse soft-tissue pain that is present for at least 3 months, and pain on palpation in at least 11 of 18 tender points. Table 1 (see attachment) outlines the symptoms of fibromyalgia and common situations or triggers that can aggravate the condition.

If a patient reports chronic widespread pain, clinicians should look for other symptoms of fibromyalgia such as non-refreshing sleep, fatigue, presence of tender or trigger points (commonly found on the elbows, inside of the knees, on or near the neck, and laterally on both hips), and cognitive problems (such as memory loss, language and learning difficulties), often referred to as "fibrofog." If fibromyalgia syndrome is suspected, the patient should be referred to a clinician familiar with treating the condition.

Neurotransmitter Dysfunction and Sensitized Nociceptive Pathways
The pathophysiology of fibromyalgia is complex and multifactorial, Dr. Kryper explained. Currently, fibromyalgia is considered a disorder of pain regulation, due in part to heightened generalized pain sensitivity that arises from pathologic processing of nociceptive stimuli. Central and peripheral sensitization of nociceptive systems and hypothalamic-pituitary-adrenal axis dysfunction are involved.

Reduced levels of bioaminergic neurotransmitters, such as dopamine, norepinephrine, and serotonin, are believed to play a major role in pathologic nociceptive sensitization. Defects in serotonin transporters and decreased dopamine and norepinephrine levels have been documented and associated with decreased delta sleep and higher than normal activity of substance P.

Additionally, sensitization of peripheral nociceptive pathways is associated with chronic sympathetic activation, resulting in muscle hypoxia and exercise intolerance. Table 2 (see attachment) provides a more extensive overview of the pathophysiologic mechanisms involved in fibromyalgia.

The Role of Nonpharmacologic Management
Evidence-based treatment guidelines for fibromyalgia have become available only recently. Raylene M. Respond, PharmD, Dean and Professor of Pharmacy Practice, Drake University, summarized the Guidelines for the Management of Fibromyalgia Syndrome Pain in Adults and Children from the American Pain Society (APS), and the European League Against Rheumatism (EULAR) recommendations for management of fibromyalgia syndrome.

Of the 2, the EULAR guidelines are more recent, and they use more restrictive criteria to analyze currently available evidence, Dr. Respond said. For instance, clinical studies must have measured pain by visual analog scale and have measured function by the Fibromyalgia Impact Questionnaire (FIQ). These guidelines also recommend agents not currently available in the United States.

Treatment recommendations in both guidelines are based upon the type of evidence available, ranging from strong (eg, consistent benefit as supported by randomized, controlled trials) to weak (eg, supported only by nonrandomized trial data) (Table 3 - see attachment). A key point of both the APS and EULAR treatment guidelines is that various nonpharmacologic and pharmacologic interventions are supported by strong levels of evidence, and the combination of both forms of therapy is encouraged.

Nonpharmacologic treatments are an important component of fibromyalgia management and should not be overlooked. Clinicians should educate patients that integrating exercise or increased physical activity into their daily routine is important and beneficial in managing fibromyalgia. The goals of increased physical activity and exercise are to improve or maintain general fitness and overall health, give the patient a feeling of control over the condition, and improve physical function and emotional well-being, which often are negatively affected by fibromyalgia.

The clinician-patient relationship provides a unique opportunity to use targeted discussions, support, and consistent follow-up to encourage fibromyalgia patients to adopt a more physically active lifestyle. Examples of beneficial exercise include strength training, aerobic conditioning, aquatic therapy, and stretches and balance exercises. Patients should start slowly with a few minutes of exercise per day and increase gradually up to 30 minutes per day. Routine exercise also reduces stress, which can exacerbate fibromyalgia symptoms.

Patients should be encouraged to seek information about fibromyalgia through organized programs and educational resources (eg, National Fibromyalgia Association, American College of Rheumatology). Finally, complementary and alternative techniques (eg, acupuncture, biofeedback) may be considered if exercise, stress reduction, and education combined with pharmacologic treatment are not achieving desired results.

Restoring Neurotransmitter Balance Through Pharmacology
According to Dr. Rospond, strong evidence has emerged to support the use of various pharmacologic agents for managing fibromyalgia symptoms (Table 4 - see attachment). These agents include cyclobenzaprine, duloxetine, gabapentin, pregabalin, tramadol, and the tricyclic antidepressants. Pregabalin is currently the only drug approved by the US Food and Drug Administration (FDA) for management of fibromyalgia.

Tricyclic Agents
Tricyclic agents (antidepressants and cyclobenzaprine) represent an older class of drugs that is still considered the first line of therapy for fibromyalgia. These agents have been clinically evaluated more than any other class of drugs. The primary agents in this class are amitriptyline (a tricyclic antidepressant) and cyclobenzaprine (a tricyclic muscle relaxant).

Amitriptyline inhibits presynaptic reuptake of serotonin (and norepinephrine to a small degree). Increases in synaptic serotonin and norepinephrine are associated with increased slow wave sleep or delta sleep, as well as increased release of endogenous endorphins. Because anticholinergic adverse effects are common with amitriptyline (and other tricyclic antidepressants), the dosage should be increased slowly to obtain maximum efficacy with minimal side effects.Amitriptyline should be initiated at low doses (eg, 5-10 mg taken 1-3 hours before bedtime and increased by 5 mg every 2 weeks until a target maintenance dose of 25-50 mg is achieved). Daily doses at this level produce clinical improvements in pain, sleep, fatigue, and overall wellbeing in 25% to 45% of patients with fibromyalgia.

Cyclobenzaprine, commonly used as a muscle relaxant in the United States, is structurally related to the tricyclic antidepressants. This drug has been shown to modify the descending nociceptive pathways by decreasing gamma and alpha efferent neuron activity originating at the brain stem. The dosage should be started at 5-10 mg taken at bedtime and increased to 20-30 mg, taken either at night or in divided doses during the day. Compared with amitriptyline, cyclobenzaprine may be associated with better patient acceptance due to fewer side effects and more rapid onset of relief.

Serotonin-Norepinephrine Reuptake Inhibitors and Selective Serotonin Reuptake Inhibitors
Currently available evidence suggests that certain serotonin-norepinephrine reuptake inhibitors (SNRIs) are effective for fibromyalgia, although more studies of specific agents within this class are needed. In April 2007, the manufacturer of duloxetine filed a new drug application for a fibromyalgia indication. Duloxetine is a reuptake inhibitor of serotonin and norepinephrine, and to a lesser extent, dopamine.

Analysis of pooled data from two 12-week randomized, placebo-controlled, double-blind clinical trials found that duloxetine 60 mg daily or 60 mg twice daily in women with fibromyalgia was superior to placebo on all efficacy measures, including pain scores, mean tender point threshold, Clinical Global Impression of Severity, and Patient Global Impression of Improvement. The results of this pooled analysis suggest that duloxetine is an effective treatment for both the pain and functional impairment associated with fibromyalgia in female patients.

However, another randomized, double-blind, placebo-controlled study did not find any difference between placebo, duloxetine 60 mg once daily, or duloxetine 120 mg once daily on the primary outcomes of pain severity and self-reported global improvement scores at the end of a 6-month treatment period.[28] While between-group differences on the primary outcomes were noted at several timepoints throughout the study, differences at 6 months were non-significant. Duloxetine-treated patients did maintain significant improvement compared with placebo on secondary measures such as mental health, clinician-rated global improvement, and fatigue scores.

This latter study was 1 of only a few long-term (ie, 6 months or longer) studies, Dr. Rospond noted, and the results raise questions about the long-term efficacy of duloxetine as well as other agents studied, because the duration of most blinded studies of fibromyalgia treatment is only up to 12 weeks long.

For the treatment of fibromyalgia, doses of duloxetine are initiated at 20 mg daily and titrated to 60 mg twice daily over a 2-week period. Titration minimizes the incidence of side effects, such as constipation, dry mouth, nausea, and sleepiness. Clinicians should also be aware that a recent FDA statement prohibits the use of duloxetine in patients with any type of hepatic insufficiency.

Some clinicians have also been treating fibromyalgia with venlafaxine, which selectively inhibits neuronal uptake of serotonin, norepinephrine, and dopamine. However, studies using 75 mg per day for 6 weeks have yielded variable results, and additional studies are warranted.

Milnacipran (not marketed in the United States) belongs to the same class of drugs as duloxetine but exhibits greater inhibition of norepinephrine reuptake. In December 2007, the manufacturers of milnacipran filed a new drug application for a fibromyalgia indication. Milnacipran doses of 100 mg once or twice daily have demonstrated significant improvement in the outcomes of pain, mood, global wellbeing, function, and fatigue. Adverse effects include anxiety, dysuria, itchiness, nausea, sweating, shivering, and vertigo.

Agents with the most selectivity and specificity for serotonin reuptake inhibition appear to be associated with lower efficacy in fibromyalgia, Dr. Rospond said. For example, citalopram, a selective serotonin-reuptake inhibitor (SSRI) with high selectivity, has shown no efficacy (in terms of the primary outcome of pain severity) in studies of patients with fibromyalgia, while fluoxetine (a lower selectivity SSRI compared with citalopram) has been found effective for fibromyalgia. However, citalopram has demonstrated improvement on secondary outcomes such as sleep, cognitive function, fatigue, and concomitant depression.

Pregabalin: First FDA-Approved Agent for Fibromyalgia
In June 2007, pregabalin became the first agent to receive FDA-approved labeling for the treatment of fibromyalgia. (Pregabalin also carries FDA-approved indications for management of partial seizures, painful diabetic peripheral neuropathy, and postherpetic neuralgia.) Unlike other agents that work by modulating serotonin and norepinephrine activity, researchers believe that pregabalin works by inhibiting excitatory inputs to the spinal cord and raising the threshold required to activate nociceptive neurons. Pregabalin also increases delta sleep.

In fibromyalgia studies, pregabalin improved outcomes of pain, fatigue, sleep, and quality of life. In an 8-week placebo-controlled study, patients with fibromyalgia were randomized to treatment with placebo or 1 of 3 pregabalin doses (150 mg, 300 mg, or 450 mg once daily). At the end of the study, the 450 mg dose was associated with a significantly greater reduction in pain severity and fatigue than placebo. In addition, a 50% reduction in pain was reported by about 30% of subjects in the 450 mg dose group compared with fewer than 15% of subjects in the placebo group. Patients treated with 150 mg and 300 mg also demonstrated significant improvement. The 2 higher doses of pregabalin were also associated with significant improvements in sleep quality.

In a second double-blind, placebo-controlled trial, monotherapy with pregabalin was found to be efficacious and safe for treatment of pain associated with fibromyalgia. Subjects were randomized to placebo or pregabalin 300 mg, 450 mg, or 600 mg per day (doses divided and taken twice daily) for 13 weeks. Patients in all of the pregabalin-treated groups showed significant improvement in pain compared with placebo, as well as improvements in assessments of sleep and patients' impressions of their global improvement.

Therapy with pregabalin should be initiated at 75 mg twice daily and increased to 150 mg twice daily over 7 days. Dr. Rospond pointed out that effects can be seen quickly (within 1 week), and recent data demonstrate sustained effectiveness for 6 months or longer. Adverse effects include blurred vision, constipation, dizziness, drowsiness, edema, and weight gain.

Although not FDA-indicated for fibromyalgia, gabapentin has also demonstrated efficacy for fibromyalgia at doses of 1200 mg to 2400 mg per day in 3 divided doses. The most frequent side effects of gabapentin include sedation and dizziness. The incidence of edema with gabapentin appears to be lower than that with pregabalin.

Analgesics
With diffuse pain being the primary symptom of fibromyalgia, it would seem logical to include analgesics in the treatment plan. Tramadol, an atypical opioid, is the only analgesic with demonstrated efficacy in treating fibromyalgia. Not only does tramadol bind to the mu-opiate receptors in the central nervous system, it also inhibits the reuptake of serotonin and norepinephrine. These latter effects on neurotransmitter activity may partially explain tramadol's effectiveness in treating fibromyalgia.

In a randomized, double-blind, placebo-controlled clinical trial, patients with fibromyalgia were first enrolled into an open-label phase and treated with tramadol 50-400 mg per day. Patients who tolerated a perceived benefit from tramadol were then randomized to continued treatment with tramadol or placebo in a 6-week double-blinded phase. The primary efficacy outcome measure was time to exit from the double-blind phase because of inadequate pain relief. Significantly more subjects in the tramadol group completed the double-blind phase compared with those in the placebo group.

Tramadol in combination with acetaminophen is also effective for fibromyalgia. In a 3-month, randomized, double-blind study, tramadol with acetaminophen (37.5 mg tramadol with 325 mg acetaminophen) administered 4 times daily was compared with placebo. At the end of the study, tramadol-treated patients recorded significantly less pain, better pain relief, and greater improvement in FIQ scores than placebo-treated patients.

To minimize dizziness and vertigo, tramadol therapy should be initiated at a dose of 25 mg per day and titrated every 3 days in 25 mg increments until a total dose of 100 mg (25 mg 4 times daily) is achieved. Doses may then be increased incrementally every 3 days to a total of 200 mg (50 mg 4 times daily). Caution must be employed to avoid prescribing more than 4 g of acetaminophen per day to reduce the risk of hepatotoxicity with chronic therapy.

Dr. Rospond reminded the audience that the evidence supporting the effectiveness of nonsteroidal anti-inflammatory agents for fibromyalgia is weak. Additionally, data are insufficient to support the use of narcotic opioids or corticosteroids to reduce fibromyalgia pain. These agents should only be considered when patients are experiencing inadequate benefit or intolerable side effects from other agents.

Miscellaneous Agents
Benzodiazepines and nonbenzodiazepine hypnotics have not demonstrated efficacy in reducing pain or improving function in fibromyalgia. However, drugs within these classes (eg, zolpidem) can be useful as add-on therapies for persistent insomnia.

Preliminary data suggest that pramipexole, a dopamine receptor agonist approved in the United States for the treatment of Parkinson's disease and restless legs syndrome, is also effective for fibromyalgia. In 1 randomized, double-blind, placebo-controlled, 14-week trial, pramipexole 4.5 mg every evening improved outcomes for pain, fatigue, and overall function. Postmarketing reports of pathologic compulsive behaviors (eg, pathologic gambling) have been reported in patients with Parkinson's disease and restless leg syndrome who were taking dopamine agonists. Whether this would occur in patients with fibromyalgia is unknown and deserves further exploration.

Tropisetron is an antiemetic that blocks the serotonin 5-HT3 receptor and increases levels of serotonin. Although not available in the United States, preliminary data suggest efficacy in treating fibromyalgia.

Although a variety of other agents hold promise for fibromyalgia therapy, several have no evidence or only weak evidence to support their use. (Table 4 - see attachment) Recombinant human growth hormone has been tested in women with fibromyalgia and low serum insulin-like growth factor (IGF) levels. In 1 trial, doses of 0.0125 mg/kg were administered subcutaneously once daily (to maintain an IGF-1 level of about 250 ng/mL) for 9 months. At the end of that period, the treated group experienced significant improvement in symptoms (as measured by the FIQ) and signs (measured by the tender point score). Although patients experienced an improvement in functional ability, complete remission of symptoms was not observed. In general there was a lag of about 6 months before patients started to note improvement.

Sodium oxybate is a commercially available preparation of naturally occurring gamma hydroxybutyrate. Doses of 6 g at bedtime have resulted in significant improvements in pain, tenderness, sleep quality, and fatigue. Other agents with no evidence or only weak evidence of efficacy in the management of fibromyalgia include calcitonin, , dehydroepiandrosterone , guaifenesin, 5-hydroxytryptamine, magnesium, melatonin, S-adenosyl-methionine , and thyroid hormones. Further study is needed with all of these agents.

Conclusion
Although fibromyalgia remains a challenging condition to manage, a number of effective therapies are available for patients (Table 5 - see attachment). Only 1 agent, pregabalin, is FDA-approved for the treatment of fibromyalgia, but clinicians should be familiar with other agents that are also effective, as supported by available scientific evidence.

Clinicians can serve as important resources for patients with fibromyalgia. They can help educate patients on the scientific mechanisms of fibromyalgia (ie, involvement of neurotransmitter and nociceptive pathways), the role of nonpharmacologic modalities, and the benefits and risks of available pharmacotherapies. Pharmacists can also assist with selection of nonprescription products for concomitant symptoms such as constipation, headache, and sleep difficulties.

SSRI
An SSRI (Selective Serotonin Reuptake In hibitor) is a newer form of antidepressant which prevent neurons (brain cells) from absorbing free serotonin (one of the major brain neurochemicals or neurotransmitters) in the synapse, thus making more serotonin available for brain function. In addition to depression, SSRIs are also used in the treatment of anxiety disorders and other mental disorders and conditions.

Fibromyalgia-New Insights Into a Misunderstood Condition.pdf

Emotional and Psychological Trauma: Recognizing the Symptoms and Getting Help

From: www.helpguide.org

If you’ve gone through a traumatic experience, you may be struggling with painful emotions, frightening memories, or a sense of constant danger that you just can’t kick. Or you may feel numb, disconnected, and unable to trust other people. But you can overcome trauma’s paralyzing hold on your present life. With treatment and support, you can heal and move on from psychological and emotional trauma, putting it in the past where it belongs.

What is emotional or psychological trauma?

Trauma is the result of extraordinarily stressful events that shatter your sense of security, making you feel helpless and vulnerable in a dangerous world. Traumatic experiences often involve a threat to life or safety, but any situation that leaves you feeling frightened and alone can be traumatic, even if it doesn’t involve physical harm. Experiences involving betrayal, verbal abuse, or any major loss can be just as traumatizing as a life-threatening catastrophe, especially when they happen during childhood.

Whether the threat is physical or psychological, trauma results when an experience is so overwhelming that you freeze, go numb, or disconnect from what’s happening. While this automatic response protects you from the terror you feel, it also prevents you from moving on. Despite being cut off from your trauma-related feelings, you can’t escape them completely. They remain outside of conscious awareness in all their original intensity, influencing the way you see the world, react to everyday situations, and relate to others.

Causes of emotional or psychological trauma

Emotional or psychological trauma results from experiences that make you feel:

Terrified Helpless

Unprepared Alone

Not all potentially traumatic events lead to lasting emotional and psychological trauma. Some people rebound quickly from even the most tragic and shocking experiences. Others are devastated by experiences that, on the surface, appear to be less upsetting. It’s not the objective facts that determine whether an event is traumatic, but your subjective emotional experience of the event. The more endangered, helpless, and unprepared you feel, the more likely you are to be traumatized.

The types of events that can cause trauma are numerous. Emotional trauma can be caused by single-blow, one-time occurrences, such as a house fire, a plane crash, a violent crime, or an earthquake. Psychological and emotional trauma can also be caused by experiences of ongoing and relentless stress, such as fighting in a war, living in a crime-ridden neighborhood, enduring chronic abuse, or struggling with a life-threatening disease.

Though, people respond differently to stressful experiences, a traumatic event is most likely to cause negative effects if it is:

Inflicted by humans Repeated and ongoing Unexpected or unpredictable

Sadistic or intentionally cruel Experienced in childhood

People are also more likely to be traumatized as adults if they have a history of childhood trauma or if they’re already under a heavy stress load.

Attachment or developmental trauma

Stressful experiences in childhood—whether a one-time event such as a car accident or an ongoing situation caused by an unavailable or abusive parent­—can be traumatizing. Childhood trauma, known as attachment or developmental trauma, results from anything that disrupts a child’s sense of safety and security. This includes such things as an unstable or unsafe environment, separation from a parent, or a serious illness. Attachment trauma is most severe, however, when it involves betrayal or harm at the hands of a caregiver.

Attachment trauma has a negative impact on a child’s physical, emotional, cognitive, and social development. Children who have been traumatized see the world as a frightening and dangerous place. When childhood trauma is not resolved, this fundamental sense of fear and helplessness can carry over into adulthood, setting the stage for further trauma.

How childhood trauma affects adult relationships

The quality of the attachment bond between mother and baby affects the child’s ability—even as an adult—to feel safe in the world, trust others, handle stress, and rebound from disappointment. Early-life trauma disrupts this important attachment bond, resulting in adult relationship difficulties.

Read: Attachment and Adult Relationships

Normal responses to traumatic events

When it comes to recognizing psychological and emotional trauma, it’s important to distinguish between normal reactions to traumatic events and symptoms of a more serious and persistent problem.

Following a traumatic event, most people experience a variety of emotions, including shock, fear, anger, and relief to be alive. Often, they can think or talk of little else other than what happened. Many others feel jumpy, detached, or depressed. Such reactions are neither a sign of weakness nor a positive indicator of lasting trouble. Rather, they represent a normal response to an abnormal event.

Common reactions to trauma:

Guilt and self-blame Anxiety and edginess Mood swings and irritability Feeling disconnected or numb Distressing memories about the event

Insomnia or bad dreams Withdrawing from others Loss of appetite Difficulty concentrating Feeling sad or hopeless

These symptoms and feelings typically last from a few days to a few months, gradually fading as you process the trauma. But even when you’re feeling better, you may be troubled from time to time bym painful meories or emotions—especially in response to triggers such as an anniversary of the event or an image, sound, or situation that reminds you of the traumatic experience.

Grieving is normal following a traumatic event

Whether or not a traumatic event involves death or physical harm, survivors must cope with the loss, at least temporarily, of their sense of safety and security. The natural reaction to this loss is grief. Like people who have lost a loved one, trauma survivors go through a grieving process. This process, while inherently painful, is easier if you turn to others for support, take care of yourself, and talk about how you feel.

Read: Coping with Grief and Loss

Recovering from a traumatic event takes time, and everyone heals at his or her own pace. But if months have passed and your symptoms aren’t letting up, you may be experiencing emotional or psychological trauma.

When to seek professional help

It’s a good idea to seek professional help from a therapist or doctor if you’re:

• Having problems at home or work
• Living in constant fear and anxiety
• Haunted by overwhelming memories or emotions
• Avoiding more and more things that remind you of the trauma

Signs and symptoms of psychological or emotional trauma

Recognizing psychological and emotional trauma may be difficult, especially if the traumatic event occurred in your childhood. Further complicating the picture, the signs and symptoms of unresolved emotional trauma are often mistaken for other metal health problems, including depression and anxiety.

Unfortunately, antidepressants, anxiety medications, and other conventional therapies and treatments won’t heal trauma-induced wounds, so it’s important to get to the root of the symptoms.

Is Emotional Trauma a Factor in Your Life?

Respond yes or no to the following to determine if you might be living with the aftermath of a traumatic event:

• Can you stand to be alone without turning on your cell phone, computer, or TV?
• Do you rely on coffee, cigarettes, or alcohol to lift and/or calm you?
• Are you plagued by physical conditions for which there appear to be no cures?
• Do you “lose it” with certain people or in certain situations?
• Do you avoid things you wish you could do?
• Do you have to be accomplishing something in order to feel good?
• Do you frequently behave in ways that you regret?
• Do you suffer from mysterious ailments that come and go?
• Do you find it impossible to focus on some things for more than a time?
• Is it hard for you to trust people?
• Do you feel depressed or anxious although you have tried conventional treatments?
• Is it difficult for you to commit to a relationship?

If you answered “yes” to 3 or more questions, you might be suffering from emotional trauma.

Source: Emotional Intelligence by Jeanne Segal

While the potential signs and symptoms of unresolved emotional trauma are numerous, the most common indicators include:

• Emotional numbness and detachment
• Inability to form close, satisfying relationships
• Sense of the world as a cold and dangerous place
• Hair trigger stress response (dizziness, pounding heart, nausea)
• Disturbing memories, nightmares, or flashbacks
• Sense of a foreshortened, limited future

Post-traumatic stress disorder (PTSD)

PTSD is the most severe form of trauma. Its primary symptoms include intrusive memories or flashbacks, avoiding things that remind you of the traumatic event, and living in a constant state of “red alert”.

Read: Post-Traumatic Stress Disorder (PTSD)

Healing from psychological or emotional trauma

In order to heal from psychological and emotional trauma, you must face and resolve the unbearable feelings and memories you’ve long avoided. Otherwise they will return again and again, unbidden and uncontrollable. The healing journey involves two interrelated steps:

1. Processing the memory of the trauma
2. Discharging pent-up “fight-or-flight” energy

Working through trauma can be scary, painful, and potentially retraumatizing. Because of the risk of retraumatization, this healing work is best done with the help of an experienced trauma specialist.

Processing the memory of the trauma

Traumatic memories are very different from normal memories. Extreme stress functions like a pause button on your brain, preventing you from integrating your experience into a coherent memory of what happened. Without a “story” that you can revisit and interpret, it’s impossible to put the experience in the past.

As a result, traumatic memories are relived rather than simply remembered. They may exist only in split-off fragments—raw emotions, bodily sensations, frightening images, smells and sounds, physical pain—that feel just as real as they did during the original trauma. Reconnecting to these emotional fragments allows you to process the memory and put it in perspective at long last.

Discharging fight-or-flight energy

When confronted with a threat, your body instantly prepares for emergency action in an automatic, biological process known as the fight-or-flight response. The fight-or-flight response gives you extra energy to either fight or escape the threat. Once the danger passes, you gradually return to a relaxed and normal state.

But when a threat is so overwhelming that survival seems impossible, the natural response is to freeze. This frozen state of shock traps the intense energies of the fight-or-flight response in the body. In essence, your nervous system gets stuck in overdrive.

The symptoms of trauma are the result of your body’s attempts to control this pent-up energy. To heal from trauma, this excess energy must be discharged in a physical way, such as:

• Trembling
• Shaking
• Crying
• Sweating
• Breathing deeply
• Laughing

Treatment and therapy for emotional or psychological trauma

The following therapies are used in the treatment of emotional or psychological trauma.

• Somatic experiencing takes advantage of the body’s unique ability to heal itself. The focus of therapy is on bodily sensations, rather than thoughts and memories about the event. By concentrating on what’s happening in your body, you gradually get in touch with trauma-related energy and tension. From there, your natural survival instincts take over, safely releasing this pent-up energy through shaking, crying, and other forms of physical release.
• EMDR (Eye Movement Desensitization and Reprocessing) incorporates elements of cognitive-behavioral therapy with eye movements or other forms of rhythmic, left-right stimulation. In a typical EMDR therapy session, you focus on traumatic memories and associated negative emotions and beliefs while tracking your therapist’s moving finger with your eyes. These back-and-forth eye movements are thought to work by “unfreezing” traumatic memories, allowing you to resolve them.

To learn more, see EMDR Therapy: A Guide to Making An Informed Choice.

Find a trauma specialist

• Click here to find a somatic experiencing specialist
• Click here to find a sensorimotor psychotherapist
• Click here to find an EMDR therapist

Cognitive-behavioral therapy helps you process and evaluate your thoughts and feelings about a trauma. While cognitive-behavioral therapy doesn’t treat the physiological effects of trauma, it can be helpful when used in addition to a body-based therapy such as somatic experiencing or EMDR. Cognitive-behavioral therapy for trauma typically includes exercises and homework designed to help you challenge irrational thoughts about the traumatic event, cope with and control painful memories and emotions, and reduce stress and self-blame. Cognitive-behavioral therapy may also include education about the nature of trauma-related disorders.

To Learn More: Related Helpguide Articles

Post-traumatic Stress Disorder (PTSD): Symptoms, Help, and Treatment Coping with Grief and Loss: A Guide to Grieving and Bereavement EMDR Therapy: A Guide to Making An Informed Choice.

Rasing Emotional Intelligence: Learning to Experience Intense Emotions Defusing Stress: Finding Quick Stress Relief that Works for You Attachment and Adult Relationships: How the Attachment Bond Shapes Adult Relationships

Related links on emotional or psychological trauma

General information on emotional and psychological trauma

Coping with Trauma – Comprehensive overview of emotional and psychological trauma, including the causes, symptoms, effects, and effective treatments. (The Menninger Clinic)

Emotional Trauma Webpage – Learn how to recognize and heal from emotional or psychological trauma. Includes an overview of effective treatments. (Dr. Jeanne Segal)

What is Psychological Trauma? – In-depth introduction to emotional or psychological trauma, including the causes, symptoms, treatments, and effects. (Sidran Institute)

Dealing With Trauma: Frightening Events Can Have Lasting Effects – Learn about the causes, symptoms, and effects of emotional or psychological trauma. (National Institutes of Health)

Causes and symptoms of emotional or psychological trauma

Common Reactions After Trauma – Guide to the common symptoms, effects, and problems that can result form emotional or psychological trauma. (National Center for PTSD)

Trauma Symptoms – Extensive list of the emotional, physical, cognitive, and behavioral symptoms of psychological trauma. (University of Saskatchewan)

Trauma: Sudden Traumatic Loss – Overview of emotional or psychological trauma due to the sudden or traumatic death of a friend or family member. (Tragedy Assistance Program for Survivors)

Trauma treatment and recovery

Managing Traumatic Stress: Tips for Recovering From Disasters and other Traumatic Events – Tips for healing and recovering from natural disasters and other traumatic experiences. (American Psychological Association)

Recovering from Trauma – Article on the necessity of processing emotional trauma if we are to recover and heal. (Psychology Today)

Nature's Lessons in Healing Trauma – Article by Peter Levine, the creator of the somatic experiencing approach to trauma. Learn about the theory behind the treatment and how it works.

A Brief Description of EMDR Therapy – Covers the eight phases of EMDR therapy involved in the treatment of trauma. (EMDR Network)

Coping with psychological or emotional trauma

Self-Care and Self-Help Following Disasters – Offers coping strategies for dealing with painful experiences and healing from emotional and psychological trauma. (National Center for PTSD)

Bouncing Back: How You Can Help – Article stresses the natural resilience of human beings in the face of trauma. Includes tips on how to help someone who has gone through a recent emotional trauma. (Psychology Today)

A Recovery Bill of Rights for Trauma Survivors – When you’re feeling overwhelmed or frightened, this list of your rights as a trauma survivor may help you stay on the recovery track. (Sidran Institute)

Dealing With the Effects of Trauma: A Self-Help Guide – Guide to the healing journey, including coping strategies, where to find help for emotional trauma, and how to support recovery. (SAMHSA’s National Mental Health Information Center)

Trauma in children and adolescents

Trauma, Attachment, and Stress Disorders: Rethinking and Reworking Developmental Issues – Explains the brain-based view of emotional trauma and how it affects child development. (Trauma Resources)

Understanding Child Traumatic Stress – Learn how emotional or psychological trauma in children differs from trauma in adult. Includes causes, symptoms, and recovery factors. (The National Child Traumatic Stress Network)

Helping Children and Adolescents Cope with Violence and Disasters: What Parents Can Do – Parent’s guide to helping a child heal from emotional or psychological trauma. (National Institute of Mental Health)

Parenting in a Challenging World – Advice on how to help your child recover and heal from traumatic events. Includes clips from a documentary about families coping with the trauma of 9/11. (The National Child Traumatic Stress Network)

Helping a Child Manage Fears – Article on helping a child cope with traumatic events. Includes tips for helping your child and a list of common childhood reactions to trauma. (Sidran Institute)

Melinda Smith, M.A., Jaelline Jaffe, Ph.D., and Jeanne Segal, Ph.D. contributed to this article. Last modified on: 1/29/08