# data[].attributes.body
We define social and emotional learning (SEL) as an integral part of education and human development. SEL is the process through which all young people and adults acquire and apply the knowledge, skills, and attitudes to develop healthy identities, manage emotions and achieve personal and collective goals, feel and show empathy for others, establish and maintain supportive relationships, and make responsible and caring decisions.

# data[].attributes.attachment_link.readable_text
We define social and emotional learning (SEL) as an integral part of education and human development. SEL is the process through which all young people and adults acquire and apply the knowledge, skills, and attitudes to develop healthy identities, manage emotions and achieve personal and collective goals, feel and show empathy for others, establish and maintain supportive relationships, and make responsible and caring decisions.

SEL advances educational equity and excellence through authentic school-family-community partnerships to establish learning environments and experiences that feature trusting and collaborative relationships, rigorous and meaningful curriculum and instruction, and ongoing evaluation. SEL can help address various forms of inequity and empower young people and adults to co-create thriving schools and contribute to safe, healthy, and just communities.

New to Social and Emotional Learning? Start here (2 min. read).

Think of a young person in your life. What skills will they need to achieve their hopes and dreams?

Chances are, you just named social and emotional skills - like staying motivated, communicating effectively, practicing curiosity, and working with others to solve problems. Social and emotional learning, or SEL, helps develop the skills we need for life.
Hear why students, parents, and educators want SEL in schools. Here are 3 things to know about social and emotional learning:

1. Social and emotional learning is a foundation for many of our most pressing priorities: SEL helps young people - and adults - learn and practice skills that set them up for academic success, fulfilling careers, healthy relationships, and responsible civic engagement.

2. The research is clear: Social and emotional learning in schools leads to positive outcomes, including better academic performance, and decreases in stress and anxiety.

3. There's no one-size-fits-all approach: Social and emotional learning brings families, schools, and communities together to make sure every child has caring relationships and what they need to learn, grow, and thrive.

Subscribe now for our expertly curated 3-part email series delivered straight to your inbox. We'll roundup the key facts from our website on SEL is, it matters, and it shows up in schools.

By submitting this form, you are consenting to receive marketing emails from: . You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact

# data[].attributes.attachment_link.description
SEL can help all young people and adults thrive personally and academically, develop and maintain positive relationships, become lifelong learners, and contribute to a more caring, just world.

# data[].attributes.body
This chapter covers various treatment approaches designed specifically to treat trauma-related symptoms, trauma-related disorders, and specific disorders of traumatic stress. The models presented do not comprise an exhaustive list, but rather, serve as examples. These models require training and supervised experience to be conducted safely and effectively. The chapter begins with a section on trauma-specific treatment models, providing a brief overview of interventions that can be delivered immediately after a trauma, as well as trauma-specific interventions for use beyond the immediate crisis. The second segment focuses on integrated care that targets trauma-specific treatment for mental, substance use, and co-occurring disorders. Even though entry-level, trauma-informed behavioral health service providers are unlikely to be in a position to use these interventions, having some knowledge of them is nevertheless important. Currently, more research is needed to tease out the most important ingredients of early interventions and their role in the prevention of more pervasive traumatic stress symptoms. More science-based evidence is available for trauma-specific treatments that occur and extend well beyond the immediate reactions to trauma. The last part of the chapter provides a brief review of selected emerging interventions that have not been covered elsewhere in this Treatment Improvement Protocol (TIP).

# data[].attributes.attachment_link.readable_text
This chapter covers various treatment approaches designed specifically to treat trauma-related symptoms, trauma-related disorders, and specific disorders of traumatic stress. The models presented do not comprise an exhaustive list, but rather, serve as examples. These models require training and supervised experience to be conducted safely and effectively. The chapter begins with a section on trauma-specific treatment models, providing a brief overview of interventions that can be delivered immediately after a trauma, as well as trauma-specific interventions for use beyond the immediate crisis. The second segment focuses on integrated care that targets trauma-specific treatment for mental, substance use, and co-occurring disorders. Even though entry-level, trauma-informed behavioral health service providers are unlikely to be in a position to use these interventions, having some knowledge of them is nevertheless important. Currently, more research is needed to tease out the most important ingredients of early interventions and their role in the prevention of more pervasive traumatic stress symptoms. More science-based evidence is available for trauma-specific treatments that occur and extend well beyond the immediate reactions to trauma. The last part of the chapter provides a brief review of selected emerging interventions that have not been covered elsewhere in this Treatment Improvement Protocol (TIP).

Introduction

Trauma-specific therapies vary in their approaches and objectives. Some are present focused, some are past focused, and some are combinations ( Najavits, 2007a). Present-focused approaches primarily address current coping skills, psychoeducation, and managing symptoms for better functioning. Past-focused approaches primarily focus on telling the trauma story to understand the impact of the trauma on how the person functions today, experiencing emotions that were too overwhelming to experience in the past, and helping clients more effectively cope in the present with their traumatic experiences. Clients participating in present-focused approaches may reveal some of their stories; past-focused approaches emphasize how understanding the past influences current behavior, emotion, and thinking, thereby helping clients cope more effectively with traumatic experiences in the present.

Trauma-Informed Care Framework in Behavioral Health Services-Trauma-Specific Services

The distinction between these approaches lies in the primary emphasis of the approach. Depending on the nature of the trauma and the specific needs of the client, one approach may be more suitable than the other. For instance, in short-term treatment for clients in early recovery from mental illness and/or substance abuse, present-focused, cognitive-behavioral, or psychoeducational approaches are generally more appropriate. For clients who are stable in their recovery and have histories of developmental trauma where much of the trauma has been repressed, a past-focused orientation may be helpful. Some clients may benefit from both types, either concurrently or sequentially.

This chapter discusses a number of treatment models, general approaches, and techniques. A treatment model is a set of practices designed to alleviate symptoms, promote psychological well-being, or restore mental health. Treatment techniques are specific procedures that can be used as part of a variety of models. Some models and techniques described in this chapter can be used with groups, some with individuals, and some with both. This chapter is selective rather than comprehensive; additional models are described in the literature. See, for example, the PILOTS database on the Web site of the National Center for PTSD (NCPTSD; http://www.ptsd.va.gov) for treatment literature related to trauma and posttraumatic stress disorder (PTSD). For an overview of models for use with both adult and child populations, refer to Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services ( Center for Mental Health Services, 2008).

Some treatments discussed in this chapter are described as evidence based. Because research on integrated treatment models is so new, many have only been examined in a few studies. Given these circumstances and the fact that an outcome study provides only limited evidence of efficacy, the term "evidence based" should be interpreted cautiously. Additional scientific study is needed to determine whether some treatments discussed herein are, in fact, evidence based. A good resource for evaluating evidence-based, trauma-specific treatment models is Effective Treatments for PTSD ( Foa, Keane, Friedman, & Cohen, 2009). Although evidence-based interventions should be a primary consideration in selecting appropriate treatment models for people with symptoms of trauma that co-occur with mental and substance use disorders (see Allen, 2001, for an indepth discussion of trauma and serious mental illness), other factors must also be weighed, including the specific treatment needs of the client; his or her history of trauma, psychosocial and cultural background, and experiences in prior trauma treatment; the overall treatment plan for the client; and the competencies of the program's clinical staff. Although behavioral health counselors can prepare to help their clients address some of the issues discussed in Chapter 5, specialized training is necessary to provide treatment for co-occurring substance use and mental disorders related to trauma.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has created the National Registry of Evidence-Based Programs and Practices (NREPP) as a resource for reviewing and identifying effective treatment programs. Programs can be nominated for consideration as co-occurring disorders programs or substance abuse prevention or treatment programs, and their quality of evidence, readiness for dissemination, and training considerations are then reviewed. For more detailed information, including details about several evidence-based co-occurring trauma treatment programs, visit the NREPP Web site ( http://www.nrepp.samhsa.gov). Program models for specialized groups, such as adolescents, can also be found on the NREPP Web site. For specific research-oriented information on trauma-specific treatments, refer to Part 3 of this TIP, which provides a literature review and links to select abstracts (available online).

Federal Agencies

Both the American Red Cross and the Federal Emergency Management Agency (FEMA) respond to disasters. Behavioral health service providers should understand the basics about these major emergency response agencies. For example, the Red Cross can respond rapidly with funding for food, shelter, and immediate needs, whereas FEMA assistance requires a period of gearing up but provides for longer-term needs. SAMHSA, along with other Federal agencies, assists FEMA in a number of areas of emergency response planning activities. See also SAMHSA's Disaster Technical Assistance Center Web site ( http://www.samhsa.gov/dtac) and Technical Assistance Publication 34, Disaster Planning Handbook for Behavioral Health Treatment Programs ( SAMHSA, 2013).

Trauma-Specific Treatment Models

Immediate Interventions

Intervention in the first 48 hours

The acute intervention period comprises the first 48 hours after a traumatic event. In a disaster, rescue operations usually begin with local agencies prior to other organizations arriving on the scene. Law enforcement is likely to take a primary role on site. Whether it is a disaster, group trauma, or individual trauma (including a trauma that affects an entire family, such as a house fire), a hierarchy of needs should be established: survival, safety, security, food, shelter, health (physical and mental), orientation of survivors to immediate local services, and communication with family, friends, and community ( National Institute of Mental Health, 2002). In this crucial time, appropriate interventions include educating survivors about resources; educating other providers, such as faith-based organizations and social service groups, to screen for increased psychological effects including use of substances; and use of a trauma response team that assists clients with their immediate needs. No formal interventions should be attempted at this time, but a professionally trained, empathic listener can offer solace and support ( Litz & Gray, 2002).

"One day I was called out of bed at 5:00 a.m. to go to a town approximately 30 miles away because a levee had broken.... By 6:00 a.m., my colleagues and I were there with many of the townspeople, with helicopters flying overhead, with trucks going in and out by the main road trying to empty the factories. When we got there, as far as you could see was farmland. By 11 a.m., you could see a 'lake' in the distance. By 2 p.m., the water was on the edge of the town. Being there, at that town, before, during, and after the water came was probably the most valuable function we performed. We were able to share in the grief of the hundreds of people as we stayed with them while their fields, houses, and workplaces were flooded. We witnessed the death of a town, and the people reacted with disbelief, anger, sadness, and numbness. Each person had a different story, but all grieved, and we provided many an opportunity to express it. People cried as the water started rising into their houses. Some had to watch. Some had to leave. At times it was utterly silent as we all waited. There was a woman whose parents sent her away during the floods of '43 and she had been angry for 50 years about it. She was determined that her children and grandchildren would see everything. I spent 12 hours that day just giving support, listening, giving information, and sometimes shedding a tear or two myself."
-Rosemary Schwartzbard, Ph.D., responder to floods along the Mississippi River in 1993

Source: Schwartzbard, 1997.

Basic needs

Basic necessities, such as shelter, food, and water, are key to survival and a sense of safety. It is important to focus on meeting these basic needs and on providing a supportive environment. Clients' access to prescribed medications may be interrupted after a trauma, particularly a disaster, so providers should identify clients' medication needs for preexisting physical and mental disorders, including methadone or other pharmacological treatment for substance use. For example, after September 11, 2001, substance abuse treatment program administrators in New York had to seek alternative methadone administration options ( Frank, Dewart, Schmeidler, & Demirjian, 2006).

Psychological first aid

The psychological first aid provided in the first 48 hours after a disaster is designed to ensure safety, provide an emotionally supportive environment and activities, identify those with high-risk reactions, and facilitate communication, including strong, reassuring leadership immediately after the event. The primary helping response of psychological first aid is to provide a calm, caring, and supportive environment to set the scene for psychological recovery. It is also essential that all those first responding to a trauma-rescue workers, medical professionals, behavioral health workers (including substance abuse counselors), journalists, and volunteers-be familiar with relevant aspects of traumatic stress. Approaching survivors with genuine respect, concern, and knowledge increases the likelihood that the caregiver can ( NCPTSD, 2002):

Answer questions about what survivors may be experiencing.

Normalize their distress by affirming that what they are experiencing is normal.

Help them learn to use effective coping strategies.

Help them be aware of possible symptoms that may require additional assistance.

Provide a positive experience that will increase their chances of seeking help if they need it in the future.

Clinical experience suggests that care be taken to respect a survivor's individual method of coping; some may want information, for example, whereas others do not. Similarly, some may want to talk about the event, but others won't. An excellent guide to providing psychological first aid is available online from the Terrorism and Disaster Branch of the National Child Traumatic Stress Network ( http://www.nctsn.org/content/psychological-first-aid).

Critical incident stress debriefing

Initially developed for work with first responders and emergency personnel, critical incident stress debriefing (CISD; Mitchell & Everly, 2001) is now widely used and encompasses various group protocols used in a variety of settings. This facilitator-led group intervention is for use soon after a traumatic event with exposed people. The goal is to provide psychological closure by encouraging participants to talk about their experiences and then giving a didactic presentation on common stress reactions and management.

The widespread use of CISD has occurred despite the publication of conflicting results regarding its efficacy. Claims that single-session psychological debriefing can prevent development of chronic negative psychological sequelae are not empirically supported ( van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002). Some controlled studies suggest that it may impede natural recovery from trauma ( McNally, Bryant, & Ehlers, 2003). Other research suggests emphasizing screening to determine the need for early interventions. Mitchell and Everly (2001) point out that many of the studies showing negative results were not conducted with first responders; that is, CISD may be appropriate for some, but not all, groups. A recent study of 952 U.S. peacekeepers and CISD by the U.S. Army Research Unit-Europe ( Adler et al., 2008) found mixed results.

Advice to Counselors: Evidence Related to Immediate Interventions

Evidence related to immediate interventions suggests that:

Early, brief, focused psychotherapeutic intervention provided in an individual or group format can reduce distress in bereaved spouses, parents, and children.

Selected cognitive-behavioral approaches may help reduce the incidence, duration, and severity of acute stress disorder (ASD), PTSD, and depression in trauma survivors.

A one-session individual recital of events and expression of emotions evoked by a traumatic event does not consistently reduce risk of later developing PTSD. In fact, it may increase the risk for adverse outcomes. Perhaps CISD hinders the natural recovery mechanisms that restore pretrau-ma functioning ( Bonanno, 2004).

The focus initially should be upon screening with follow-up as indicated.

Interventions Beyond the Initial Response to Trauma

In the interest of increasing your overall familiarity with relevant approaches, the following sections review several traumatic stress treatment approaches that counselors will most likely encounter when collaborating with clinicians or agencies that specialize in trauma-specific services and treating traumatic stress.

Cognitive-behavioral therapies

Most PTSD models involve cognitive-behavioral therapy (CBT) that integrates cognitive and behavioral theories by incorporating two ideas: first, that cognitions (or thoughts) mediate between situational demands and one's attempts to respond to them effectively, and second, that behavioral change influences acceptance of altered cognitions about oneself or a situation and establishment of newly learned cognitive-behavioral interaction patterns. In practice, CBT uses a wide range of coping strategies.

There are many different varieties of CBT. CBT originated in the 1970s ( Beck, Rush, Shaw & Emery, 1979; Ellis & Harper, 1975) and has expanded since then to address various populations, including people who use substances, people who experience anxiety, people with PTSD or personality disorders, children and adolescents, individuals involved in the criminal justice system, and many others. CBT has also been expanded to include various techniques, coping skills, and approaches, such as dialectical behavior therapy (DBT; Linehan, 1993), Seeking Safety ( Najavits, 2002a), and mindfulness ( Segal, Williams, & Teasdale, 2002). Traditional CBT emphasizes symptom reduction or resolution, but recent CBT approaches have also emphasized the therapeutic relationship, a particularly important dynamic in trauma treatment ( Jackson, Nissenson, & Cloitre, 2009).

A widely accepted framework in treating trauma, substance use disorders, and mental illness categorizes therapies as single (treatment of only one disorder), sequential (treatment of one disorder first, then the other), or parallel (concurrent treatment of multiple disorders delivered by separate clinicians or in separate programs that do not necessarily address the interactions between symptoms and disorders).

CBT has been applied to the treatment of trauma and has also been widely and effectively used in the treatment of substance use. A review of efficacy research on CBT for PTSD is provided by Rothbaum, Meadows, Resick, and Foy (2000). Najavits and colleagues (2009) and O'Donnell and Cook (2006) offer an overview of CBT therapies for treating PTSD and substance abuse. In addition, a free online training resource incorporating CBT for traumatized children within the community, Trauma-Focused CBT, is available from the Medical University of South Carolina ( http://tfcbt.musc.edu/).

Cognitive processing therapy

Cognitive processing therapy (CPT) is a manualized 12-session treatment approach that can be administered in a group or individual setting ( Resick & Schnicke, 1992, 1993). CPT was developed for rape survivors and combines elements of existing treatments for PTSD, specifically exposure therapy (see the " Exposure Therapy" section later in this chapter) and cognitive therapy. The exposure therapy component of treatment consists of clients writing a detailed account of their trauma, including thoughts, sensations, and emotions that were experienced during the event. The client then reads the narrative aloud during a session and at home. The cognitive therapy aspect of CPT uses six key PTSD themes identified by McCann and Pearlman (1990): safety, trust, power, control, esteem, and intimacy. The client is guided to identify cognitive distortions in these areas, such as maladaptive beliefs.

Advice to Counselors: Relaxation Training, Biofeedback, and Breathing Retraining Strategies

Relaxation training, biofeedback, and breathing retraining strategies may help some clients cope with anxiety, a core symptom of traumatic stress. However, no evidence supports the use of relaxation and biofeedback as effective standalone PTSD treatment techniques ( Cahill, Rothbaum, Resick, & Follete, 2009). Both are sometimes used as complementary strategies to manage anxiety symptoms elicited by trauma-related stimuli. Breathing retraining uses focused or controlled breathing to reduce arousal. Breathing retraining and relaxation, along with other interventions when necessary, can help clients with ASD. An important caution in the use of breath work with trauma clients is that it can sometimes act as a trigger-for example, given its focus on the body and its potential to remind them of heavy breathing that occurred during assault. Biofeedback, which requires specialized equipment, combines stress reduction strategies (e.g., progressive muscle relaxation, guided imagery) with feedback from biological system measures (e.g., heart rate, hand temperature) that gauge levels of stress or anxiety reduction. Relaxation training, which requires no specialized equipment, encourages clients to reduce anxiety responses (including physiological responses) to trauma-related stimuli; it is often part of more comprehensive PTSD treatments (e.g., prolonged exposure and stress inoculation training [SIT]).

Results from randomized, placebo-controlled trials for the treatment of PTSD related to interpersonal violence ( Resick, 2001; Resick, Nishith, Weaver, Astin, & Feuer, 2002) support the use of CPT. CPT and prolonged exposure therapy models are equally and highly positive in treating PTSD and depression in rape survivors; CPT is superior in reducing guilt ( Nishith, Resick, & Griffin, 2002; Resick et al., 2002; Resick, Nishith, & Griffin, 2003). CPT has shown positive outcomes with refugees when administered in the refugees' native language ( Schulz, Marovic-Johnson, & Huber, 2006) and with veterans ( Monson et al., 2006). However, CPT has not been studied with high-complexity populations such as individuals with substance dependence, homelessness, current domestic violence, serious and persistent mental illness, or suicidality. CPT requires a 3-day training plus consultation ( Karlin et al., 2010). Resick and Schicke (1996) published a CPT treatment manual, Cognitive Processing Therapy for Rape Victims: A Treatment Manual.

Exposure therapy

Exposure therapy for PTSD asks clients to directly describe and explore trauma-related memories, objects, emotions, or places. Intense emotions are evoked (e.g., sadness, anxiety) but eventually decrease, desensitizing clients through repeated encounters with traumatic material. Careful monitoring of the pace and appropriateness of exposure-based interventions is necessary to prevent retraumatization (clients can become conditioned to fear the trauma-related material even more). Clients must have ample time to process their memories and integrate cognition and affect, so some sessions can last for 1.5 hours or more. For simple cases, exposure can work in as few as 9 sessions; more complex cases may require 20 or more sessions ( Foa, Hembree, & Rothbaum, 2007). Various techniques can expose the client to traumatic material. Two of the more common methods are exposure through imagery and in vivo ("real life") exposure.

Advice to Counselors: Steps for Introducing a Breathing Exercise

Use the following statements to lead clients through a breathing exercise:

Place your hands on your stomach. As you inhale, breathe deeply but slowly so that your hands rise with your stomach. As you exhale slowly, practice breathing so that your hands drop with your stomach.

Inhale slowly through your nose with your mouth closed; don't rush or force in the air.

Exhale slowly through your mouth with your lips in the whistling position.

Breathe out for twice as long as you breathe in.

The effectiveness of exposure therapy has been firmly established ( Rothbaum et al., 2000); however, adverse reactions to exposure therapy have also been noted. Some individuals who have experienced trauma exhibit an exacerbation of symptoms during or following exposure treatments. Even so, the exacerbation may depend on counselor variables during administration. Practitioners of exposure therapy need comprehensive training to master its techniques ( Karlin et al., 2010); a counselor unskilled in the methods of this treatment model can not only fail to help his or her clients, but also cause symptoms to worsen.

Exposure therapy is recommended as a first-line treatment option when the prominent trauma symptoms are intrusive thoughts, flashbacks, or trauma-related fears, panic, and avoidance. However, counselors should exercise caution when using exposure with clients who have not maintained stability in managing mental illness symptoms or abstinence from substance use disorders. Studies and routine use of exposure have consistently excluded high-complexity clients such as those with substance dependence, homelessness, current domestic violence, serious and persistent mental illness, or suicidality. The only trial of exposure therapy with a substance dependence sample found that it did not outperform standard substance abuse treatment on most variables ( Mills et al., 2012).

Prolonged exposure therapy for PTSD is listed in SAMHSA's NREPP. For reviews of exposure therapy, also see Najavits (2007a) and Institute of Medicine (2008). In addition to prolonged exposure therapy, other therapies incorporate exposure and desensitization techniques, including eye movement desensitization and reprocessing (EMDR; Shapiro, 2001), cognitive processing, and systematic desensitization therapies ( Wolpe, 1958).

Eye movement desensitization and reprocessing

EMDR ( Shapiro, 2001) is one of the most widely used therapies for trauma and PTSD. The treatment protocols of EMDR have evolved into sophisticated paradigms requiring training and, preferably, clinical supervision. EMDR draws on a variety of theoretical frameworks, including psychoneurology, CBT, information processing, and nonverbal representation of traumatic memories. The goal of this therapy is to process the experiences that are causing problems and distress. It is an effective treatment for PTSD ( Seidler & Wagner, 2006) and is accepted as an evidence-based practice by the U.S. Department of Veterans Affairs (VA), the Royal College of Psychiatrists, and the International Society for Traumatic Stress Studies ( Najavits, 2007a); numerous reviews support its effectiveness (e.g., Mills et al., 2012). EMDR values the development of "resource installation" (calming procedures) and engages in exposure work to desensitize clients to traumatic material, using external tracking techniques across the visual field to assist in processing distressing material. Training in EMDR, available through the EMDR Institute, is required before counselors use this treatment. It is listed in SAMHSA's NREPP ( EMDR Network, 2012). Thus far, there is no study examining the use of EMDR with clients in substance abuse treatment. See Part 3 of this TIP, available online, to review empirical work on EMDR.

A Brief Description of EMDR Therapy

Treatment involves three main concentrations (past memories, present disturbances, future actions) and eight phases. Counselors may work with several phases in one session. Each phase is meant to be revisited either in every session or when appropriate (e.g., the closure process is meant to be conducted at the end of every session, in preparation for the next).

Phase 1: History and Treatment Planning (1-2 sessions)

Phase 3: Assessment and Reprocessing

Source: EMDR Network, 2012.

Narrative therapy

Narrative therapy is an emerging approach to understanding human growth and change; it is founded on the premise that individuals are the experts on their own lives and can access their existing intrapsychic and interpersonal resources to reduce the impact of problems in their lives. Developed for the treatment of PTSD resulting from political or community violence, narrative therapy is based on CBT principles, particularly exposure therapy ( Neuner, Schauer, Elbert, & Roth, 2002; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). This approach views psychotherapy not as a scientific practice, but as a natural extension of healing practices that have been present throughout human history. For a trauma survivor, the narrative, as it is told and retold, expresses the traumatic experience, puts the trauma in the context of the survivor's life, and defines the options he or she has for change. Narrative structure helps clients connect events in their lives, reveals strings of events, explores alternative expressions of trauma, evokes explanations for clients' behaviors, and identifies their knowledge and skills. The use of stories in therapy, with the client as the storyteller, generally helps lessen suffering ( McLeod, 1997; White, 2004).

In the substance abuse treatment field, many clients will see a connection between narrative therapy and the process of telling their stories in 12-Step programs, in which reframing life stories of feeling trapped, despairing, and hopeless leads to stories of strength, joy, and hope. Key storytelling points at a 12-Step speaker meeting include describing what an experience was like, what happened, and what it is like now.

Skills training in affective and interpersonal regulation

Skills training in affective and interpersonal regulation (STAIR) is a two-phase cognitive-behavioral model that adapts therapies developed by others into a new package ( Cloitre, Koenen, Cohen, & Han, 2002). Phase 1 consists of eight weekly sessions of skills training in affect and interpersonal regulation derived from general CBT and DBT ( Linehan, 1993) and adapted to address trauma involving childhood abuse. Session topics are labeling and identifying feelings, emotion management, distress tolerance, acceptance of feelings, identifying trauma-based interpersonal schemas, identifying conflict between trauma-generated feelings and current interpersonal goals, role-plays on issues of power and control, and role-plays on developing flexibility in interpersonal situations. Phase 2 features eight sessions of modified prolonged exposure using a narrative approach.

STAIR Steps

Phase 1, tailored to individual clients, is called Skills Training in Affect Regulation and consists of the following components:

Psychoeducation: Describe the symptoms of PTSD and explain the treatment rationale.

Training in experiencing and identifying feelings, triggers, and thoughts, as well as training in mood regulation strategies.

Learning history: Ask the client the following questions-How did the client deal with traumas past and present? How did the client's family deal with feelings? How did the client's family life affect his or her present difficulty experiencing and identifying feeling?

Emotion regulation skills: Identify the cognitive, behavioral, and social support modalities for coping. Use data gathered with self-monitoring forms to identify strengths and weaknesses in each coping modality. Teach skills such as breathing retraining, self-statements to reduce fear, and social skill training to improve social support.

Acceptance and tolerance of negative affect: Motivate clients to face distressing situations related to the trauma that are important to them. Review negative repercussions of avoidance. Discuss tolerating negative affect as a step toward achieving specific goals.

Schema therapy for improved relationships: Identify relevant schemas learned in childhood. Suggest alternative ways of viewing self and others in current relationships. Use role-playing to teach assertiveness, emphasizing response flexibility based on relative power in each relationship.

Once Phase 1 of STAIR is well learned, clients move to Phase 2, which involves exposure therapy.

Source: Mollick & Spett, 2002.

Cloitre and colleagues (2002) assigned women with PTSD related to childhood abuse randomly to STAIR or a minimal attention wait-list, excluding clients with current substance dependence as well as other complexities. STAIR participants showed significantly greater gains in affect regulation, interpersonal skills, and PTSD symptoms than the control participants. These gains were maintained through follow-up at 3 and 9 months. However, it is not clear from this study whether DBT and exposure were both needed. Phase 1 therapeutic alliance and negative mood regulation skills predicted Phase 2 exposure success in reducing PTSD, suggesting the importance of establishing a strong therapeutic relationship and emotion regulation skills before conducting exposure work with people who have chronic PTSD.

Stress inoculation training

SIT was originally developed to manage anxiety ( Meichenbaum, 1994; Meichenbaum & Deffenbacher, 1988). Kilpatrick, Veronen, and Resick (1982) modified SIT to treat rape survivors based on the idea that the anxiety and fear that rape survivors experience during their trauma generalizes to other objectively safe situations. SIT treatment components include education, skills training (muscle relaxation training, breathing retraining, role-playing, guided self-talk, assertiveness training, and thought stopping [i.e., actively and forcefully ending negative thoughts by thinking "STOP" and then redirecting thoughts in a more positive direction]), and skills application. The goal is to help clients learn to manage their anxiety and to decrease avoidant behavior by using effective coping strategies. Randomized controlled clinical trials have indicated that SIT reduces the severity of PTSD compared with waitlist controls and shows comparable efficacy to exposure therapy. At follow-up (up to 12 months after treatment), gains were maintained ( Foa et al., 1999; Foa, Rothbaum, Riggs, & Murdock, 1991).

SIT has been used to help individuals cope with the aftermath of exposure to stressful events and on a preventative basis to "inoculate" individuals to future and ongoing stressors ( Meichenbaum, 1996). This practice as a preventive strategy is similar to promoting disease resistance through immunizations.

Advice to Counselors: SIT Phases

SIT is a prevention and treatment approach that has three overlapping phases. It is often seen as a complementary approach to other interventions for traumatic stress.

Phase 1: Conceptualization and education. This phase has two main objectives. The initial goal is to develop a collaborative relationship that supports and encourages the client to confront stressors and learn new coping strategies. The next objective is to increase the client's understanding of the nature and impact of his or her stress and awareness of alternative coping skills. Many cognitive strategies are used to meet these objectives, including self-monitoring activities, Socratic questioning, identifying strengths and evidence of resilience, and modeling of coping strategies.

Phase 2: Skill acquisition and rehearsal. This phase focuses on developing coping skills and using coping skills that the individual already possesses. This process includes practice across settings, so that the individual begins to generalize the use of his or her skills across situations through rehearsal, rehearsal, and more rehearsal.

Phase 3: Implementation and following through. The main objective is to create more challenging circumstances that elicit higher stress levels for the client. By gradually increasing the challenge, the client can practice coping strategies that mimic more realistic circumstances. Through successful negotiation, the client builds a greater sense of self-efficacy. Common strategies in this phase include imagery and behavioral rehearsal, modeling, role-playing, and graded in vivo exposure.

Source: Meichenbaum, 2007.

Other therapies

Numerous interventions introduced in the past 20 years focus on traumatic stress. For some interventions, the evidence is limited, and for other others, it is evolving. One example is the traumatic incident reduction (TIR) approach. This brief memory-oriented intervention is designed for children, adolescents, and adults who have experienced traumatic stress ( Valentine & Smith, 2001). Listed in SAMHSA's NREPP, the intervention is designed to process specific traumatic incidents or problematic themes related to the trauma, including specific feelings, emotions, sensations, attitudes, or pain. It involves having clients talk through the traumatic incident repeatedly with the anticipation that changes in affect will occur throughout the repetitions. TIR is a client-centered approach.

Integrated Models for Trauma

This section covers models specifically designed to treat trauma-related symptoms along with either mental or substance use disorders at the same time. Integrated treatments help clients work on several presenting problems simultaneously throughout the treatment, a promising and recommended strategy ( Dass-Brailsford & Myrick, 2010; Najavits, 2002b; Nixon & Nearmy, 2011). Thus far, research is limited, but what is available suggests that integrated treatment models effectively reduce substance abuse, PTSD symptoms, and other mental disorder symptoms. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( Center for Substance Abuse Treatment, 2005c), offers a detailed description of integrated treatment. In contrast with integrated models, other model types include single (treatment of only one disorder), sequential (treatment of one disorder first, then the other), or parallel (concurrent treatment of multiple disorders delivered by separate clinicians or in separate programs that do not necessarily address the interactions between symptoms and disorders).

Similar to single models, integrated treatment models are designed for use in a variety of settings (e.g., outpatient, day treatment, and/or residential substance abuse and mental health clinics/programs). Most models listed are manual-based treatments that address trauma-related symptoms, mental disorders, and substance use disorders at the same time. Additional approaches and further details on the selected approaches can be found at NREPP ( http://www.nrepp.samhsa.gov).

Addiction and Trauma Recovery Integration Model

The Addiction and Trauma Recovery Integrated Model (ATRIUM; Miller & Guidry, 2001) integrates CBT and relational treatment through an emphasis on mental, physical, and spiritual health. This 12-week model for individuals and groups blends psychoeducational, process, and expressive activities, as well as information on the body's responses to addiction and traumatic stress and the impact of trauma and addiction on the mind and spirit. It helps clients explore anxiety, sexuality, self-harm, depression, anger, physical complaints and ailments, sleep difficulties, relationship challenges, and spiritual disconnection. It was designed primarily for women and focuses on developmental (childhood) trauma and interpersonal violence, but it recognizes that other types of traumatic events occur.

The ATRIUM model consists of three phases of treatment. The first stage, or "outer circle," consists of the counselor collecting data from the client about his or her trauma history, offering psychoeducation on the nature of trauma, and helping the client assess personal strengths. ATRIUM actively discourages the evocation of memories of abuse or other trauma events in this phase. The second stage, or "middle circle," allows clients and counselors to address trauma symptoms more directly and specifically encourages clients to reach out to and engage with support resources in the community. The middle circle also emphasizes learning new information about trauma and developing additional coping skills. The third stage of the program, the "inner circle," focuses on challenging old beliefs that arose as a result of the trauma. For instance, the concept of "nonprotecting bystander" is used to represent the lack of support that the traumatized person experienced at the time of the trauma. This representation is replaced with the "protective presence" of supportive others today.

ATRIUM was used in one of the nine study sites of SAMHSA's Women, Co-Occurring Disorders and Violence Study. Across all sites, trauma-specific models achieved more favorable outcomes than control sites that did not use trauma-specific models ( Morrissey et al., 2005). There has not yet been a study of ATRIUM per se, however. A manual describing the theory behind this model in greater depth, as well as how to implement it, is published under the title Addictions and Trauma Recovery: Healing the Body, Mind, and Spirit ( Miller & Guidry, 2001).

Beyond Trauma: A Healing Journey for Women

Beyond Trauma ( Covington, 2003) is a curriculum for women's services based on theory, research, and clinical experience. It was developed for use in residential, outpatient, and correctional settings; domestic violence programs; and mental health clinics. It uses behavioral techniques and expressive arts and is based on relational therapy. Although the materials are designed for trauma treatment, the connection between trauma and substance abuse in women's lives is a theme throughout. Beyond Trauma has a psychoeducational component that defines trauma by way of its process as well as its impact on the inner self (thoughts, feelings, beliefs, values) and the outer self (behavior and relationships, including parenting). Coping skills are emphasized; specific exercises develop emotional wellness.

Concurrent Treatment of PTSD and Cocaine Dependence

Concurrent Treatment of PTSD and Cocaine Dependence (CTPCD) is a 16-session, twice-weekly individual outpatient psychotherapy model designed to treat women and men with co-occurring PTSD and cocaine dependence ( Coffey, Schumacher, Brimo, & Brady, 2005). CTPCD combines imagery and in vivo exposure therapy (in which the client becomes desensitized to anxiety-producing stimuli through repeated exposure to them) for the treatment of PTSD with elements of CBT for substance dependence. To balance the dual needs of abstinence skill building and prompt trauma treatment, the first five sessions focus on coping skills for cocaine dependence. Session six transitions into exposure therapy, which begins in earnest in session seven and is combined with CBT for the treatment of substance abuse.

CTPCD helps reduce substance use and PTSD symptoms. The use of any illicit drug, as measured by urine screens, was quite low during the 16-week treatment trial and didn't escalate during the second half of treatment-when most exposure sessions occurred. PTSD symptoms dropped significantly over the course of treatment, as did self-reported depressive symptoms; however, the dropout rate was high ( Coffey, Dansky, & Brady, 2003). CTPCD was reformulated into Concurrent Prolonged Exposure (COPE; Mills et al., 2012), which was compared with treatment as usual in a high-complexity clinical sample of individuals who had PTSD and substance dependence. Both treatment conditions resulted in improvements in PTSD with no difference at 3 months (though COPE showed significantly greater improvement at 9 months); moreover, the two conditions did not differ in impact on substance use outcomes, depression, or anxiety.

Integrated CBT

Integrated CBT is a 14-session individual therapy model designed for PTSD and substance use. It incorporates elements such as psychoeducation, cognitive restructuring, and breathing retraining ( McGovern, Lamber-Harris, Alterman, Xie, & Meier, 2011). A randomized controlled trial showed that both integrated CBT and individual addiction treatment achieved improvements in substance use and other measures of psychiatric symptom severity with no difference between the treatments.

Seeking Safety

Seeking Safety is an empirically validated, present-focused treatment model that helps clients attain safety from trauma and substance abuse ( Najavits, 2002a). The Seeking Safety manual ( Najavits, 2002b) offers clinician guidelines and client handouts and is available in several languages. Training videos and other implementation materials are available online ( http://www.seekingsafety.org). Seeking Safety is flexible; it can be used for groups and individuals, with women and men, in all settings and levels of care, by all clinicians, for all types of trauma and substance abuse.

Seeking Safety covers 25 topics that address cognitive, behavioral, interpersonal, and case management domains. The topics can be conducted in any order, using as few or as many as are possible within a client's course of treatment. Each topic represents a coping skill relevant to both trauma and substance abuse, such as compassion, taking good care of yourself, healing from anger, coping with triggers, and asking for help. This treatment model builds hope through an emphasis on ideals and simple, emotionally evocative language and quotations. It attends to clinician processes and offers concrete strategies that are thought to be essential for clients dealing with concurrent substance use disorders and histories of trauma.

More than 20 published studies (which include pilot studies, randomized controlled trials, and multisite trials representing various investigators and populations) provide the evidence base for this treatment model. For more information, see SAMHSA's NREPP Web site ( http://www.nrepp.samhsa.gov) as well as the "Outcomes" section of the Seeking Safety Web site ( http://www.seekingsafety.org/3-03-06/studies.html). Study samples included people with chronic, severe trauma symptoms and substance dependence who were diverse in ethnicity and were treated in a range of settings (e.g., criminal justice, VA centers, adolescent treatment, homelessness services, public sector). Seeking Safety has shown positive outcomes on trauma symptoms, substance abuse, and other domains (e.g., suicidality, HIV risk, social functioning, problem-solving, sense of meaning); consistently outperformed treatment as usual; and achieved high satisfaction ratings from both clients and clinicians. It has been translated into seven languages, and a version for blind and/or dyslexic individuals is available.

The five key elements of Seeking Safety are:

1. Safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions).

2. Integrated treatment (working on trauma and substance abuse at the same time).

3. A focus on ideals to counteract the loss of ideals in both trauma and substance abuse.

4. Four content areas: cognitive, behavioral, interpersonal, and case management.

5. Attention to clinician processes (addressing counter transference, self-care, and other issues).

Substance Dependence PTSD Therapy

Substance Dependence PTSD Therapy ( Triffleman, 2000) was designed to help clients of both sexes cope with a broad range of traumas. It combines existing treatments for PTSD and substance abuse into a structured, 40-session (5-month, twice-weekly) individual therapy that occurs in two phases. Phase I is "Trauma-Informed, Addictions-Focused Treatment" and focuses on coping skills and cognitive interventions as well as creating a safe environment. Phase I draws on CBT models, anger management, relaxation training, HIV risk reduction, and motivational enhancement techniques. Phase II, "Trauma-Focused, Addictions-Informed Treatment," begins with psychoeducation about PTSD followed by "Anti-Avoidance I," in which a modified version of stress inoculation training is taught in two to four sessions. Following this is "Anti-Avoidance II," lasting 6 to 10 sessions, in which in vivo exposure is used.

Trauma Affect Regulation: Guide for Education and Therapy

Trauma Affect Regulation: Guide for Education and Therapy (TARGET; Ford & Russo, 2006; Frisman, Ford, Lin, Mallon, & Chang, 2008) uses emotion and information processing in a present-focused, strengths-based approach to education and skills training for trauma survivors with severe mental, substance use, and co-occurring disorders across diverse populations. TARGET helps trauma survivors understand how trauma changes the brain's normal stress response into an extreme survival-based alarm response that can lead to PTSD, and it teaches them a seven-step approach to making the PTSD alarm response less distressing and more adaptive (summarized by the acronym FREEDOM: Focus, Recognize triggers, Emotion self-check, Evaluate thoughts, Define goals, Options, and Make a contribution).

TARGET: The Seven-Step FREEDOM Approach

Focus: Being focused helps a person pay attention and think about what's happening right now instead of just reacting based on alarm signals tied to past trauma. This step teaches participants to use the SOS skill (Slow down, Orient, Self-check) to pay attention to body signals and the immediate environment and to use a simple scale to measure stress and control levels.

Recognize triggers: Recognizing trauma triggers enables a person to anticipate and reset alarm signals as he or she learns to distinguish between a real threat and a reminder. This step helps participants identify personal triggers, take control, and short-circuit their alarm reactions.

Emotion self-check: The goal of this skill is to identify two types of emotions. The first are "alarm" or reactive emotions such as terror, rage, shame, hopelessness, and guilt. Because these emotions are the most noticeable after trauma, they are the alarm system's way of keeping a person primed and ready to fend off further danger. The second type of emotion, "main" emotions, include positive feelings (e.g., happiness, love, comfort, compassion) and feelings that represent positive strivings (e.g., hope, interest, confidence). By balancing both kinds of emotions, a person can reflect and draw on his or her own values and hopes even when the alarm is activated.

Evaluate thoughts: When the brain is in alarm mode, thinking tends to be rigid, global, and catastrophic. Evaluating thoughts, as with identifying emotions, is about achieving a healthier balance of positive as well as negative thinking. Through a two-part process, participants learn to evaluate the situation and their options with a focus on how they choose to act-moving from reactive thoughts to "main" thoughts. This is a fundamental change from the PTSD pattern, which causes problems by taking a person straight from alarm signals to automatic survival reactions.

Define goals: Reactive goals tend to be limited to just making it through the immediate situation or away from the source of danger. These reactive goals are necessary in true emergencies but don't reflect a person's "main" goals of doing worthwhile things and ultimately achieving a good and meaningful life. This step teaches one how to create "main" goals that reflect his or her deeper hopes and values.

Options: The only options that are available when the brain's alarm is turned on and won't turn off are automatic "flight/fight" or "freeze/submit" reactive behaviors that are necessary in emergencies but often unhelpful in ordinary living. This step helps identify positive intentions often hidden by the more extreme reactive options generated by the alarm system. This opens the possibility for a greater range of options that take into consideration one's own needs and goals as well as those of others.

Make a contribution: When the brain's alarm is turned on and reacting to ordinary stressors as if they were emergencies, it is very difficult for a person to come away from experiences with a feeling that they have made a positive difference. This can lead to feelings of alienation, worthlessness, or spiritual distress. The ultimate goal of TARGET is to empower adults and young people to think clearly enough to feel in control of their alarm reactions and, as a result, to be able to recognize the contribution they are making not only to their own lives, but to others' lives as well.

Source: Advanced Trauma Solutions, 2012.

TARGET can be presented in individual therapy or gender-specific psychoeducational groups, and it has been adapted for individuals who are deaf; it has also been translated into Spanish and Dutch. TARGET is a resilience-building and recovery program not limited to individual or group psychotherapy; it is also designed to provide an educational curriculum and milieu intervention that affects all areas of practice in school, therapeutic, or correctional programs. TARGET is listed in SAMHSA's NREPP ( http://www.nrepp.samhsa.gov).

Trauma Recovery and Empowerment Model

The trauma recovery and empowerment model (TREM) of therapy ( Fallot & Harris, 2002; Harris & Community Connections Trauma Work Group, 1998) is a manualized group intervention designed for female trauma survivors with severe mental disorders. TREM addresses the complexity of long-term adaptation to trauma and attends to a range of difficulties common among survivors of sexual and physical abuse. TREM focuses mainly on developing specific recovery skills and current functioning and uses techniques that are effective in trauma recovery services. The model's content and structure, which cover 33 topics, are informed by the role of gender in women's experience of and coping with trauma.

TREM can be adapted for shorter-term residential settings and outpatient substance abuse treatment settings, among others. Adaptations of the model for men and adolescents are available. The model was used in SAMHSA's Women, Co-Occurring Disorders and Violence Study for three of the nine study sites and in SAMHSA's Homeless Families program, and it is listed in SAMHSA's NREPP. This model has been used with clients in substance abuse treatment; research by Toussaint, VanDeMark, Bornemann, and Graeber (2007) shows that women in a residential substance abuse treatment program showed significantly better trauma treatment outcomes using TREM than they did in treatment as usual, but no difference in substance use.

TREM Program Format

Each session includes an experiential exercise to promote group cohesiveness. The 33 sessions are divided into the following general topic areas:

Part I-empowerment introduces gender identity concepts, interpersonal boundaries, and self-esteem.

Part II-trauma recovery concentrates on sexual, physical, and emotional abuse and their relationship to psychiatric symptoms, substance abuse, and relational patterns and issues.

Part III-advanced trauma recovery issues addresses additional trauma issues, such as blame and the role of forgiveness.

Part IV-closing rituals allows participants to assess their progress and encourages them to plan for their continued healing, either on their own or as part of a community of other survivors.

Part V-modifications or supplements for special populations provides modifications for subgroups such as women with serious mental illness, incarcerated women, women who are parents, women who abuse substances, and male survivors.

Source: Mental Health America Centers for Technical Assistance, 2012.

Triad Women's Project

The Triad Project was developed as a part of SAMHSA's Women, Co-Occurring Disorders and Violence Study. It is a comprehensive, trauma-informed, consumer-responsive integrated model designed for female trauma survivors with co-occurring substance use and mental disorders who live in semirural areas. Triad integrates motivational enhancement for substance use disorders, DBT, and intensive case management techniques for co-occurring mental disorders. This program is a 16-week group intervention for women that uses integrated case management services, a curriculum-based treatment group, and a peer support group ( Clark & Fearday, 2003).

Emerging Interventions

New interventions are emerging to address traumatic stress symptoms and disorders. The following sections summarize a few interventions not highlighted in prior chapters; this is not an exhaustive list. In addition to specific interventions, technology is beginning to shape the delivery of care and to increase accessibility to tools that complement trauma-specific treatments. Numerous applications are available and evolving. For more information on the role of technology in the delivery of care, see the planned TIP, Using Technology-Based Therapeutic Tools in Behavioral Health Services (SAMHSA, planned g).

Couple and Family Therapy

Trauma and traumatic stress affects significant relationships, including the survivor's family. Although minimal research has targeted the effectiveness of family therapy with trauma survivors, it is important to consider the needs of the individual in the context of their relationships. Family and couples therapy may be key to recovery. Family members may experience secondary traumatization silently, lack understanding of traumatic stress symptoms or treatment, and/or have their own histories of trauma that influence their willingness to support the client in the family or to talk about anything related to trauma and its effects. Family members can engage in similar patterns of avoidance and have their own triggers related to the trauma being addressed at the time. A range of couple and family therapies have addressed traumatic stress and PTSD, but few studies exist that support or refute their value. Current couple or family therapies that have some science-based evidence include behavioral family therapy, behavioral marital therapy, cognitive-behavioral couples treatment, and lifestyle management courses ( Riggs, Monson, Glynn, & Canterino, 2009).

Mindfulness Interventions

Mindfulness is a process of learning to be present in the moment and observing internal experience (e.g., thoughts, bodily sensations) and external experience (e.g., interactions with others) in a nonjudgmental way. Mindfulness challenges limiting beliefs that arise from trauma, quells anxiety about future events, and simply helps one stay grounded in the present. It plays a significant role in helping individuals who have been traumatized observe their experiences, increase awareness, and tolerate uncomfortable emotions and cognitions.

To date, mindfulness-based interventions appear to be valuable as an adjunct to trauma-specific interventions and in decreasing arousal ( Baer, 2003). It may also help individuals tolerate discomfort during exposure-oriented and trauma processing interventions. Overall, mindfulness practices can help clients in managing traumatic stress, coping, and resilience. In a study of firefighters, mindfulness was associated with fewer PTSD symptoms, depressive symptoms, physical symptoms, and alcohol problems when controlling for other variables ( Smith et al., 2011).

Becoming an Observer and Learning To Tolerate Discomfort: The Leaf and Stream Metaphor

The following exercise, "leaves floating on a stream," is a classic. Many clinicians and authors provide renditions of this mindfulness practice. The main objectives are to stand back and observe thoughts rather than get caught up in them. Simply stated, thoughts are just thoughts. Thoughts come and go like water flowing down a stream. We don't need to react to the thoughts; instead, we can just notice them.

Conduct the mindfulness exercise for about 10 minutes, then process afterward. Take time to allow participants to visualize each sense as they imagine themselves sitting next to the stream. For example, what does it look like? What do they hear as they sit next to the stream? Don't rush the exercise. As you slowly make the statements detailed in the following two paragraphs, take time in between each statement for participants to be in the exercise without interruption; simply offer gentle guidance.

Begin to sit quietly, bringing your attention to your breath. If you feel comfortable, close your eyes. As you focus on breathing in and out, imagine that you are sitting next to a stream. In your imagination, you may clearly see and hear the stream, or you may have difficulty visualizing the stream. Follow along with the guided exercise; either way, it will work just as well.

Now begin to notice the thoughts that come into your mind. Some thoughts rush by, while others linger. Just allow yourself to notice your thoughts. As you begin to notice each thought, imagine putting those words onto a leaf as it floats by on the stream. Just let the thoughts come, watching them drift by on the leaves. If your thoughts briefly stop, continue to watch the water flow down the stream. Eventually, your thoughts will come again. Just let them come, and as they do, place them onto a leaf. Your attention may wander. Painful feelings may arise. You may feel uncomfortable or start to think that the exercise is "stupid." You may hook onto a thought-rehashing it repeatedly. That's okay; it's what our minds do. As soon as you notice your mind wandering or getting stuck, just gently bring your focus back to your thoughts, and place them onto the leaves. Now, bring your attention back to your breath for a moment, then open your eyes and become more aware of your environment.
Facilitated Questions:

What was it like for you to observe your thoughts?

Did you get distracted? Stuck?

Were you able to bring yourself back to the exercise after getting distracted?

In what ways was the exercise uncomfortable?

In what ways was the exercise comforting?

For clients and practitioners who want to develop a greater capacity for mindfulness, see Kabat-Zinn's books Wherever You Go, There You Are: Mindfulness Meditation In Everyday Life ( 1994) and Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness ( 1990). For clinical applications of mindfulness, see Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse ( Segal et al., 2002) and Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors ( Marlatt & Donovan, 2005).

Pharmacological Therapy

Pharmacotherapy for people with mental, substance use, and traumatic stress disorders needs to be carefully managed by physicians who are well versed in the treatment of each condition. Medications can help manage and control symptoms; however, they are only a part of a comprehensive treatment plan. There are no specific "antitrauma" drugs; rather, certain drugs target specific trauma symptoms. Clients receiving pharmacotherapy need careful assessment. Some clients with preexisting mental disorders may need further adjustment in medications due to the physiological effects of traumatic stress. In addition, sudden withdrawal from a pattern of self-administered substances can not only lead to dangerous levels of physical distress, but also exacerbate the emergence of more severe PTSD symptoms. Distress after trauma often lessens over time, which can sometimes make the use of medications unnecessary for some individuals. Some trauma survivors do not develop long-term psychological problems from their experiences that require medication; others may simply refuse the initiation of pharmacotherapy or the use of additional medications.

Concluding Note

Behavioral health counselors can best serve clients who have experienced trauma by providing integrated treatment that combines therapeutic models to target presenting symptoms and disorders. Doing so acknowledges that the disorders interact with each other. Some models have integrated curricula; others that address trauma alone can be combined with behavioral health techniques with which the counselor is already familiar.

In part, the choice of a treatment model or general approach will depend on the level of evidence for the model, the counselor's training, identified problems, the potential for prevention, and the client's goals and readiness for treatment. Are improved relationships with family members a goal? Will the client be satisfied if sleep problems decrease, or is the goal resolution of broader issues? Are there substance use or substance-related disorders? Is the goal abstinence? Collaborating with clients to decide on goals, eliciting what they would like from treatment, and determining what they expect to happen can provide some clues as to what treatment models or techniques might be successful in keeping clients engaged in recovery.

# data[].attributes.attachment_link.description
This chapter covers various treatment approaches designed specifically to treat trauma-related symptoms, trauma-related disorders, and specific disorders of traumatic stress. The models presented do not comprise an exhaustive list, but rather, serve as examples. These models require training and supervised experience to be conducted safely and effectively.

# data[].attributes.body
In a short-term study, more patients using SPRAVATO® plus oral antidepressant demonstrated rapid and superior reduction in depressive symptoms at four weeks compared to those who received placebo plus an oral antidepressant

Most of the reduction in depressive symptoms was seen at 24 hours

Between 24 hours and four weeks, both groups continued to improve; the difference in improvement between the groups remained but did not appear to increase through four weeks

SPRAVATO® was also studied in a long-term

maintenance-of-effect trial

The study was designed for patients in remission to see if the effect of treatment was maintained.

The trial compared patients who stayed on SPRAVATO® and oral antidepressant vs placebo and oral antidepressant long-term

Patients who stayed on SPRAVATO® were less likely to experience a return in depressive symptoms (known as relapse)

If two or more oral antidepressants haven’t worked for you, ask your doctor if adding SPRAVATO® may be able to help.

Indications And Limitations Of Use:

SPRAVATO® is a prescription medicine, used along with an antidepressant, taken by mouth to treat:

Adults with treatment-resistant depression (TRD)

Depressive symptoms in adults with major depressive disorder (MDD) with suicidal thoughts or actions

Limitations of Use:

SPRAVATO® is not for use as a medicine to prevent or relieve pain (anesthetic). It is not known if SPRAVATO® is safe or effective as an anesthetic medicine.

It is not known if SPRAVATO® is safe and effective for use in preventing suicide or in reducing suicidal thoughts or actions. SPRAVATO® is not for use in place of hospitalization if your healthcare provider determines that hospitalization is needed, even if improvement is experienced after the first dose of SPRAVATO®.

It is not known if SPRAVATO® is safe and effective in children.

IMPORTANT SAFETY INFORMATION

What is the most important information I should know about SPRAVATO®?

SPRAVATO® can cause serious side effects, including:

Sedation and dissociation. SPRAVATO® may cause sleepiness (sedation), fainting, dizziness, spinning sensation, anxiety, or feeling disconnected from yourself, your thoughts, feelings, space and time (dissociation).

Tell your healthcare provider right away if you feel like you cannot stay awake or if you feel like you are going to pass out.

Your healthcare provider must monitor you for serious side effects for at least 2 hours after taking SPRAVATO®. Your healthcare provider will decide when you are ready to leave the healthcare setting.

Respiratory depression was observed with the use of SPRAVATO®; additionally, there were rare reports of respiratory arrest.

Your healthcare provider must monitor you for serious side effects for at least 2 hours (including pulse oximetry) after taking SPRAVATO®. Your healthcare provider will decide when you are ready to leave the healthcare setting.

Abuse and misuse. There is a risk for abuse and physical and psychological dependence with SPRAVATO® treatment. Your healthcare provider should check you for signs of abuse and dependence before and during treatment with SPRAVATO®.

Tell your healthcare provider if you have ever abused or been dependent on alcohol, prescription medicines, or street drugs.

Your healthcare provider can tell you more about the differences between physical and psychological dependence and drug addiction.

SPRAVATO® Risk Evaluation and Mitigation Strategy (REMS). Because of the risks for sedation, dissociation, respiratory depression, and abuse and misuse, SPRAVATO® is only available through a restricted program called the SPRAVATO® Risk Evaluation and Mitigation Strategy (REMS) Program. SPRAVATO® can only be administered at healthcare settings certified in the SPRAVATO® REMS Program. Patients treated in outpatient healthcare settings (e.g., medical offices and clinics) must be enrolled in the program.

Increased risk of suicidal thoughts and actions. Antidepressant medicines may increase suicidal thoughts and actions in some people 24 years of age and younger, especially within the first few months of treatment or when the dose is changed. SPRAVATO® is not for use in children.

Depression and other serious mental illnesses are the most important causes of suicidal thoughts and actions. Some people may have a higher risk of having suicidal thoughts or actions. These include people who have (or have a family history of) depression or a history of suicidal thoughts or actions.

How can I watch for and try to prevent suicidal thoughts and actions in myself or a family member?

Pay close attention to any changes, especially sudden changes, in mood, behavior, thoughts, or feelings, or if you develop suicidal thoughts or actions.

Tell your healthcare provider right away if you have any new or sudden changes in mood, behavior, thoughts, or feelings.

Keep all follow-up visits with your healthcare provider as scheduled. Call your healthcare provider between visits as needed, especially if you have concerns about symptoms.

Tell your healthcare provider right away if you or your family member have any of the following symptoms, especially if they are new, worse, or worry you:

suicide attempts

thoughts about suicide or dying

worsening depression

other unusual changes in behavior or mood

Do not take SPRAVATO® if you:

have blood vessel (aneurysmal vascular) disease (including in the brain, chest, abdominal aorta, arms and legs)

have an abnormal connection between your veins and arteries (arteriovenous malformation)

have a history of bleeding in the brain

are allergic to esketamine, ketamine, or any of the other ingredients in SPRAVATO®.

If you are not sure if you have any of the above conditions, talk to your healthcare provider before taking SPRAVATO®.

Before you take SPRAVATO®, tell your healthcare provider about all of your medical conditions, including if you:

have heart or brain problems, including:

high blood pressure (hypertension)

slow or fast heartbeats that cause shortness of breath, chest pain, lightheadedness, or fainting

# data[].attributes.attachment_link.provider_name
SPRAVATO® (esketamine) | Official Patient Website

# data[].attributes.attachment_link.title
SPRAVATO® (esketamine) | Official Patient Website

# data[].attributes.attachment_link.description
Learn about SPRAVATO® (esketamine) CIII nasal spray, a prescription medicine for two indications. See full Prescribing & Safety Info, including BOXED WARNINGS.

# data[].attributes.body
This chapter covers various treatment approaches designed specifically to treat trauma-related symptoms, trauma-related disorders, and specific disorders of traumatic stress. The models presented do not comprise an exhaustive list, but rather, serve as examples. These models require training and supervised experience to be conducted safely and effectively. The chapter begins with a section on trauma-specific treatment models, providing a brief overview of interventions that can be delivered immediately after a trauma, as well as trauma-specific interventions for use beyond the immediate crisis. The second segment focuses on integrated care that targets trauma-specific treatment for mental, substance use, and co-occurring disorders. Even though entry-level, trauma-informed behavioral health service providers are unlikely to be in a position to use these interventions, having some knowledge of them is nevertheless important. Currently, more research is needed to tease out the most important ingredients of early interventions and their role in the prevention of more pervasive traumatic stress symptoms. More science-based evidence is available for trauma-specific treatments that occur and extend well beyond the immediate reactions to trauma. The last part of the chapter provides a brief review of selected emerging interventions that have not been covered elsewhere in this Treatment Improvement Protocol (TIP).

# data[].attributes.attachment_link.readable_text
This chapter covers various treatment approaches designed specifically to treat trauma-related symptoms, trauma-related disorders, and specific disorders of traumatic stress. The models presented do not comprise an exhaustive list, but rather, serve as examples. These models require training and supervised experience to be conducted safely and effectively. The chapter begins with a section on trauma-specific treatment models, providing a brief overview of interventions that can be delivered immediately after a trauma, as well as trauma-specific interventions for use beyond the immediate crisis. The second segment focuses on integrated care that targets trauma-specific treatment for mental, substance use, and co-occurring disorders. Even though entry-level, trauma-informed behavioral health service providers are unlikely to be in a position to use these interventions, having some knowledge of them is nevertheless important. Currently, more research is needed to tease out the most important ingredients of early interventions and their role in the prevention of more pervasive traumatic stress symptoms. More science-based evidence is available for trauma-specific treatments that occur and extend well beyond the immediate reactions to trauma. The last part of the chapter provides a brief review of selected emerging interventions that have not been covered elsewhere in this Treatment Improvement Protocol (TIP).

Introduction

Trauma-specific therapies vary in their approaches and objectives. Some are present focused, some are past focused, and some are combinations ( Najavits, 2007a). Present-focused approaches primarily address current coping skills, psychoeducation, and managing symptoms for better functioning. Past-focused approaches primarily focus on telling the trauma story to understand the impact of the trauma on how the person functions today, experiencing emotions that were too overwhelming to experience in the past, and helping clients more effectively cope in the present with their traumatic experiences. Clients participating in present-focused approaches may reveal some of their stories; past-focused approaches emphasize how understanding the past influences current behavior, emotion, and thinking, thereby helping clients cope more effectively with traumatic experiences in the present.

Trauma-Informed Care Framework in Behavioral Health Services-Trauma-Specific Services

The distinction between these approaches lies in the primary emphasis of the approach. Depending on the nature of the trauma and the specific needs of the client, one approach may be more suitable than the other. For instance, in short-term treatment for clients in early recovery from mental illness and/or substance abuse, present-focused, cognitive-behavioral, or psychoeducational approaches are generally more appropriate. For clients who are stable in their recovery and have histories of developmental trauma where much of the trauma has been repressed, a past-focused orientation may be helpful. Some clients may benefit from both types, either concurrently or sequentially.

This chapter discusses a number of treatment models, general approaches, and techniques. A treatment model is a set of practices designed to alleviate symptoms, promote psychological well-being, or restore mental health. Treatment techniques are specific procedures that can be used as part of a variety of models. Some models and techniques described in this chapter can be used with groups, some with individuals, and some with both. This chapter is selective rather than comprehensive; additional models are described in the literature. See, for example, the PILOTS database on the Web site of the National Center for PTSD (NCPTSD; http://www.ptsd.va.gov) for treatment literature related to trauma and posttraumatic stress disorder (PTSD). For an overview of models for use with both adult and child populations, refer to Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services ( Center for Mental Health Services, 2008).

Some treatments discussed in this chapter are described as evidence based. Because research on integrated treatment models is so new, many have only been examined in a few studies. Given these circumstances and the fact that an outcome study provides only limited evidence of efficacy, the term "evidence based" should be interpreted cautiously. Additional scientific study is needed to determine whether some treatments discussed herein are, in fact, evidence based. A good resource for evaluating evidence-based, trauma-specific treatment models is Effective Treatments for PTSD ( Foa, Keane, Friedman, & Cohen, 2009). Although evidence-based interventions should be a primary consideration in selecting appropriate treatment models for people with symptoms of trauma that co-occur with mental and substance use disorders (see Allen, 2001, for an indepth discussion of trauma and serious mental illness), other factors must also be weighed, including the specific treatment needs of the client; his or her history of trauma, psychosocial and cultural background, and experiences in prior trauma treatment; the overall treatment plan for the client; and the competencies of the program's clinical staff. Although behavioral health counselors can prepare to help their clients address some of the issues discussed in Chapter 5, specialized training is necessary to provide treatment for co-occurring substance use and mental disorders related to trauma.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has created the National Registry of Evidence-Based Programs and Practices (NREPP) as a resource for reviewing and identifying effective treatment programs. Programs can be nominated for consideration as co-occurring disorders programs or substance abuse prevention or treatment programs, and their quality of evidence, readiness for dissemination, and training considerations are then reviewed. For more detailed information, including details about several evidence-based co-occurring trauma treatment programs, visit the NREPP Web site ( http://www.nrepp.samhsa.gov). Program models for specialized groups, such as adolescents, can also be found on the NREPP Web site. For specific research-oriented information on trauma-specific treatments, refer to Part 3 of this TIP, which provides a literature review and links to select abstracts (available online).

Federal Agencies

Both the American Red Cross and the Federal Emergency Management Agency (FEMA) respond to disasters. Behavioral health service providers should understand the basics about these major emergency response agencies. For example, the Red Cross can respond rapidly with funding for food, shelter, and immediate needs, whereas FEMA assistance requires a period of gearing up but provides for longer-term needs. SAMHSA, along with other Federal agencies, assists FEMA in a number of areas of emergency response planning activities. See also SAMHSA's Disaster Technical Assistance Center Web site ( http://www.samhsa.gov/dtac) and Technical Assistance Publication 34, Disaster Planning Handbook for Behavioral Health Treatment Programs ( SAMHSA, 2013).

Trauma-Specific Treatment Models

Immediate Interventions

Intervention in the first 48 hours

The acute intervention period comprises the first 48 hours after a traumatic event. In a disaster, rescue operations usually begin with local agencies prior to other organizations arriving on the scene. Law enforcement is likely to take a primary role on site. Whether it is a disaster, group trauma, or individual trauma (including a trauma that affects an entire family, such as a house fire), a hierarchy of needs should be established: survival, safety, security, food, shelter, health (physical and mental), orientation of survivors to immediate local services, and communication with family, friends, and community ( National Institute of Mental Health, 2002). In this crucial time, appropriate interventions include educating survivors about resources; educating other providers, such as faith-based organizations and social service groups, to screen for increased psychological effects including use of substances; and use of a trauma response team that assists clients with their immediate needs. No formal interventions should be attempted at this time, but a professionally trained, empathic listener can offer solace and support ( Litz & Gray, 2002).

"One day I was called out of bed at 5:00 a.m. to go to a town approximately 30 miles away because a levee had broken.... By 6:00 a.m., my colleagues and I were there with many of the townspeople, with helicopters flying overhead, with trucks going in and out by the main road trying to empty the factories. When we got there, as far as you could see was farmland. By 11 a.m., you could see a 'lake' in the distance. By 2 p.m., the water was on the edge of the town. Being there, at that town, before, during, and after the water came was probably the most valuable function we performed. We were able to share in the grief of the hundreds of people as we stayed with them while their fields, houses, and workplaces were flooded. We witnessed the death of a town, and the people reacted with disbelief, anger, sadness, and numbness. Each person had a different story, but all grieved, and we provided many an opportunity to express it. People cried as the water started rising into their houses. Some had to watch. Some had to leave. At times it was utterly silent as we all waited. There was a woman whose parents sent her away during the floods of '43 and she had been angry for 50 years about it. She was determined that her children and grandchildren would see everything. I spent 12 hours that day just giving support, listening, giving information, and sometimes shedding a tear or two myself."
-Rosemary Schwartzbard, Ph.D., responder to floods along the Mississippi River in 1993

Source: Schwartzbard, 1997.

Basic needs

Basic necessities, such as shelter, food, and water, are key to survival and a sense of safety. It is important to focus on meeting these basic needs and on providing a supportive environment. Clients' access to prescribed medications may be interrupted after a trauma, particularly a disaster, so providers should identify clients' medication needs for preexisting physical and mental disorders, including methadone or other pharmacological treatment for substance use. For example, after September 11, 2001, substance abuse treatment program administrators in New York had to seek alternative methadone administration options ( Frank, Dewart, Schmeidler, & Demirjian, 2006).

Psychological first aid

The psychological first aid provided in the first 48 hours after a disaster is designed to ensure safety, provide an emotionally supportive environment and activities, identify those with high-risk reactions, and facilitate communication, including strong, reassuring leadership immediately after the event. The primary helping response of psychological first aid is to provide a calm, caring, and supportive environment to set the scene for psychological recovery. It is also essential that all those first responding to a trauma-rescue workers, medical professionals, behavioral health workers (including substance abuse counselors), journalists, and volunteers-be familiar with relevant aspects of traumatic stress. Approaching survivors with genuine respect, concern, and knowledge increases the likelihood that the caregiver can ( NCPTSD, 2002):

Answer questions about what survivors may be experiencing.

Normalize their distress by affirming that what they are experiencing is normal.

Help them learn to use effective coping strategies.

Help them be aware of possible symptoms that may require additional assistance.

Provide a positive experience that will increase their chances of seeking help if they need it in the future.

Clinical experience suggests that care be taken to respect a survivor's individual method of coping; some may want information, for example, whereas others do not. Similarly, some may want to talk about the event, but others won't. An excellent guide to providing psychological first aid is available online from the Terrorism and Disaster Branch of the National Child Traumatic Stress Network ( http://www.nctsn.org/content/psychological-first-aid).

Critical incident stress debriefing

Initially developed for work with first responders and emergency personnel, critical incident stress debriefing (CISD; Mitchell & Everly, 2001) is now widely used and encompasses various group protocols used in a variety of settings. This facilitator-led group intervention is for use soon after a traumatic event with exposed people. The goal is to provide psychological closure by encouraging participants to talk about their experiences and then giving a didactic presentation on common stress reactions and management.

The widespread use of CISD has occurred despite the publication of conflicting results regarding its efficacy. Claims that single-session psychological debriefing can prevent development of chronic negative psychological sequelae are not empirically supported ( van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002). Some controlled studies suggest that it may impede natural recovery from trauma ( McNally, Bryant, & Ehlers, 2003). Other research suggests emphasizing screening to determine the need for early interventions. Mitchell and Everly (2001) point out that many of the studies showing negative results were not conducted with first responders; that is, CISD may be appropriate for some, but not all, groups. A recent study of 952 U.S. peacekeepers and CISD by the U.S. Army Research Unit-Europe ( Adler et al., 2008) found mixed results.

Advice to Counselors: Evidence Related to Immediate Interventions

Evidence related to immediate interventions suggests that:

Early, brief, focused psychotherapeutic intervention provided in an individual or group format can reduce distress in bereaved spouses, parents, and children.

Selected cognitive-behavioral approaches may help reduce the incidence, duration, and severity of acute stress disorder (ASD), PTSD, and depression in trauma survivors.

A one-session individual recital of events and expression of emotions evoked by a traumatic event does not consistently reduce risk of later developing PTSD. In fact, it may increase the risk for adverse outcomes. Perhaps CISD hinders the natural recovery mechanisms that restore pretrau-ma functioning ( Bonanno, 2004).

The focus initially should be upon screening with follow-up as indicated.

Interventions Beyond the Initial Response to Trauma

In the interest of increasing your overall familiarity with relevant approaches, the following sections review several traumatic stress treatment approaches that counselors will most likely encounter when collaborating with clinicians or agencies that specialize in trauma-specific services and treating traumatic stress.

Cognitive-behavioral therapies

Most PTSD models involve cognitive-behavioral therapy (CBT) that integrates cognitive and behavioral theories by incorporating two ideas: first, that cognitions (or thoughts) mediate between situational demands and one's attempts to respond to them effectively, and second, that behavioral change influences acceptance of altered cognitions about oneself or a situation and establishment of newly learned cognitive-behavioral interaction patterns. In practice, CBT uses a wide range of coping strategies.

There are many different varieties of CBT. CBT originated in the 1970s ( Beck, Rush, Shaw & Emery, 1979; Ellis & Harper, 1975) and has expanded since then to address various populations, including people who use substances, people who experience anxiety, people with PTSD or personality disorders, children and adolescents, individuals involved in the criminal justice system, and many others. CBT has also been expanded to include various techniques, coping skills, and approaches, such as dialectical behavior therapy (DBT; Linehan, 1993), Seeking Safety ( Najavits, 2002a), and mindfulness ( Segal, Williams, & Teasdale, 2002). Traditional CBT emphasizes symptom reduction or resolution, but recent CBT approaches have also emphasized the therapeutic relationship, a particularly important dynamic in trauma treatment ( Jackson, Nissenson, & Cloitre, 2009).

A widely accepted framework in treating trauma, substance use disorders, and mental illness categorizes therapies as single (treatment of only one disorder), sequential (treatment of one disorder first, then the other), or parallel (concurrent treatment of multiple disorders delivered by separate clinicians or in separate programs that do not necessarily address the interactions between symptoms and disorders).

CBT has been applied to the treatment of trauma and has also been widely and effectively used in the treatment of substance use. A review of efficacy research on CBT for PTSD is provided by Rothbaum, Meadows, Resick, and Foy (2000). Najavits and colleagues (2009) and O'Donnell and Cook (2006) offer an overview of CBT therapies for treating PTSD and substance abuse. In addition, a free online training resource incorporating CBT for traumatized children within the community, Trauma-Focused CBT, is available from the Medical University of South Carolina ( http://tfcbt.musc.edu/).

Cognitive processing therapy

Cognitive processing therapy (CPT) is a manualized 12-session treatment approach that can be administered in a group or individual setting ( Resick & Schnicke, 1992, 1993). CPT was developed for rape survivors and combines elements of existing treatments for PTSD, specifically exposure therapy (see the " Exposure Therapy" section later in this chapter) and cognitive therapy. The exposure therapy component of treatment consists of clients writing a detailed account of their trauma, including thoughts, sensations, and emotions that were experienced during the event. The client then reads the narrative aloud during a session and at home. The cognitive therapy aspect of CPT uses six key PTSD themes identified by McCann and Pearlman (1990): safety, trust, power, control, esteem, and intimacy. The client is guided to identify cognitive distortions in these areas, such as maladaptive beliefs.

Advice to Counselors: Relaxation Training, Biofeedback, and Breathing Retraining Strategies

Relaxation training, biofeedback, and breathing retraining strategies may help some clients cope with anxiety, a core symptom of traumatic stress. However, no evidence supports the use of relaxation and biofeedback as effective standalone PTSD treatment techniques ( Cahill, Rothbaum, Resick, & Follete, 2009). Both are sometimes used as complementary strategies to manage anxiety symptoms elicited by trauma-related stimuli. Breathing retraining uses focused or controlled breathing to reduce arousal. Breathing retraining and relaxation, along with other interventions when necessary, can help clients with ASD. An important caution in the use of breath work with trauma clients is that it can sometimes act as a trigger-for example, given its focus on the body and its potential to remind them of heavy breathing that occurred during assault. Biofeedback, which requires specialized equipment, combines stress reduction strategies (e.g., progressive muscle relaxation, guided imagery) with feedback from biological system measures (e.g., heart rate, hand temperature) that gauge levels of stress or anxiety reduction. Relaxation training, which requires no specialized equipment, encourages clients to reduce anxiety responses (including physiological responses) to trauma-related stimuli; it is often part of more comprehensive PTSD treatments (e.g., prolonged exposure and stress inoculation training [SIT]).

Results from randomized, placebo-controlled trials for the treatment of PTSD related to interpersonal violence ( Resick, 2001; Resick, Nishith, Weaver, Astin, & Feuer, 2002) support the use of CPT. CPT and prolonged exposure therapy models are equally and highly positive in treating PTSD and depression in rape survivors; CPT is superior in reducing guilt ( Nishith, Resick, & Griffin, 2002; Resick et al., 2002; Resick, Nishith, & Griffin, 2003). CPT has shown positive outcomes with refugees when administered in the refugees' native language ( Schulz, Marovic-Johnson, & Huber, 2006) and with veterans ( Monson et al., 2006). However, CPT has not been studied with high-complexity populations such as individuals with substance dependence, homelessness, current domestic violence, serious and persistent mental illness, or suicidality. CPT requires a 3-day training plus consultation ( Karlin et al., 2010). Resick and Schicke (1996) published a CPT treatment manual, Cognitive Processing Therapy for Rape Victims: A Treatment Manual.

Exposure therapy

Exposure therapy for PTSD asks clients to directly describe and explore trauma-related memories, objects, emotions, or places. Intense emotions are evoked (e.g., sadness, anxiety) but eventually decrease, desensitizing clients through repeated encounters with traumatic material. Careful monitoring of the pace and appropriateness of exposure-based interventions is necessary to prevent retraumatization (clients can become conditioned to fear the trauma-related material even more). Clients must have ample time to process their memories and integrate cognition and affect, so some sessions can last for 1.5 hours or more. For simple cases, exposure can work in as few as 9 sessions; more complex cases may require 20 or more sessions ( Foa, Hembree, & Rothbaum, 2007). Various techniques can expose the client to traumatic material. Two of the more common methods are exposure through imagery and in vivo ("real life") exposure.

Advice to Counselors: Steps for Introducing a Breathing Exercise

Use the following statements to lead clients through a breathing exercise:

Place your hands on your stomach. As you inhale, breathe deeply but slowly so that your hands rise with your stomach. As you exhale slowly, practice breathing so that your hands drop with your stomach.

Inhale slowly through your nose with your mouth closed; don't rush or force in the air.

Exhale slowly through your mouth with your lips in the whistling position.

Breathe out for twice as long as you breathe in.

The effectiveness of exposure therapy has been firmly established ( Rothbaum et al., 2000); however, adverse reactions to exposure therapy have also been noted. Some individuals who have experienced trauma exhibit an exacerbation of symptoms during or following exposure treatments. Even so, the exacerbation may depend on counselor variables during administration. Practitioners of exposure therapy need comprehensive training to master its techniques ( Karlin et al., 2010); a counselor unskilled in the methods of this treatment model can not only fail to help his or her clients, but also cause symptoms to worsen.

Exposure therapy is recommended as a first-line treatment option when the prominent trauma symptoms are intrusive thoughts, flashbacks, or trauma-related fears, panic, and avoidance. However, counselors should exercise caution when using exposure with clients who have not maintained stability in managing mental illness symptoms or abstinence from substance use disorders. Studies and routine use of exposure have consistently excluded high-complexity clients such as those with substance dependence, homelessness, current domestic violence, serious and persistent mental illness, or suicidality. The only trial of exposure therapy with a substance dependence sample found that it did not outperform standard substance abuse treatment on most variables ( Mills et al., 2012).

Prolonged exposure therapy for PTSD is listed in SAMHSA's NREPP. For reviews of exposure therapy, also see Najavits (2007a) and Institute of Medicine (2008). In addition to prolonged exposure therapy, other therapies incorporate exposure and desensitization techniques, including eye movement desensitization and reprocessing (EMDR; Shapiro, 2001), cognitive processing, and systematic desensitization therapies ( Wolpe, 1958).

Eye movement desensitization and reprocessing

EMDR ( Shapiro, 2001) is one of the most widely used therapies for trauma and PTSD. The treatment protocols of EMDR have evolved into sophisticated paradigms requiring training and, preferably, clinical supervision. EMDR draws on a variety of theoretical frameworks, including psychoneurology, CBT, information processing, and nonverbal representation of traumatic memories. The goal of this therapy is to process the experiences that are causing problems and distress. It is an effective treatment for PTSD ( Seidler & Wagner, 2006) and is accepted as an evidence-based practice by the U.S. Department of Veterans Affairs (VA), the Royal College of Psychiatrists, and the International Society for Traumatic Stress Studies ( Najavits, 2007a); numerous reviews support its effectiveness (e.g., Mills et al., 2012). EMDR values the development of "resource installation" (calming procedures) and engages in exposure work to desensitize clients to traumatic material, using external tracking techniques across the visual field to assist in processing distressing material. Training in EMDR, available through the EMDR Institute, is required before counselors use this treatment. It is listed in SAMHSA's NREPP ( EMDR Network, 2012). Thus far, there is no study examining the use of EMDR with clients in substance abuse treatment. See Part 3 of this TIP, available online, to review empirical work on EMDR.

A Brief Description of EMDR Therapy

Treatment involves three main concentrations (past memories, present disturbances, future actions) and eight phases. Counselors may work with several phases in one session. Each phase is meant to be revisited either in every session or when appropriate (e.g., the closure process is meant to be conducted at the end of every session, in preparation for the next).

Phase 1: History and Treatment Planning (1-2 sessions)

Phase 3: Assessment and Reprocessing

Source: EMDR Network, 2012.

Narrative therapy

Narrative therapy is an emerging approach to understanding human growth and change; it is founded on the premise that individuals are the experts on their own lives and can access their existing intrapsychic and interpersonal resources to reduce the impact of problems in their lives. Developed for the treatment of PTSD resulting from political or community violence, narrative therapy is based on CBT principles, particularly exposure therapy ( Neuner, Schauer, Elbert, & Roth, 2002; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). This approach views psychotherapy not as a scientific practice, but as a natural extension of healing practices that have been present throughout human history. For a trauma survivor, the narrative, as it is told and retold, expresses the traumatic experience, puts the trauma in the context of the survivor's life, and defines the options he or she has for change. Narrative structure helps clients connect events in their lives, reveals strings of events, explores alternative expressions of trauma, evokes explanations for clients' behaviors, and identifies their knowledge and skills. The use of stories in therapy, with the client as the storyteller, generally helps lessen suffering ( McLeod, 1997; White, 2004).

In the substance abuse treatment field, many clients will see a connection between narrative therapy and the process of telling their stories in 12-Step programs, in which reframing life stories of feeling trapped, despairing, and hopeless leads to stories of strength, joy, and hope. Key storytelling points at a 12-Step speaker meeting include describing what an experience was like, what happened, and what it is like now.

Skills training in affective and interpersonal regulation

Skills training in affective and interpersonal regulation (STAIR) is a two-phase cognitive-behavioral model that adapts therapies developed by others into a new package ( Cloitre, Koenen, Cohen, & Han, 2002). Phase 1 consists of eight weekly sessions of skills training in affect and interpersonal regulation derived from general CBT and DBT ( Linehan, 1993) and adapted to address trauma involving childhood abuse. Session topics are labeling and identifying feelings, emotion management, distress tolerance, acceptance of feelings, identifying trauma-based interpersonal schemas, identifying conflict between trauma-generated feelings and current interpersonal goals, role-plays on issues of power and control, and role-plays on developing flexibility in interpersonal situations. Phase 2 features eight sessions of modified prolonged exposure using a narrative approach.

STAIR Steps

Phase 1, tailored to individual clients, is called Skills Training in Affect Regulation and consists of the following components:

Psychoeducation: Describe the symptoms of PTSD and explain the treatment rationale.

Training in experiencing and identifying feelings, triggers, and thoughts, as well as training in mood regulation strategies.

Learning history: Ask the client the following questions-How did the client deal with traumas past and present? How did the client's family deal with feelings? How did the client's family life affect his or her present difficulty experiencing and identifying feeling?

Emotion regulation skills: Identify the cognitive, behavioral, and social support modalities for coping. Use data gathered with self-monitoring forms to identify strengths and weaknesses in each coping modality. Teach skills such as breathing retraining, self-statements to reduce fear, and social skill training to improve social support.

Acceptance and tolerance of negative affect: Motivate clients to face distressing situations related to the trauma that are important to them. Review negative repercussions of avoidance. Discuss tolerating negative affect as a step toward achieving specific goals.

Schema therapy for improved relationships: Identify relevant schemas learned in childhood. Suggest alternative ways of viewing self and others in current relationships. Use role-playing to teach assertiveness, emphasizing response flexibility based on relative power in each relationship.

Once Phase 1 of STAIR is well learned, clients move to Phase 2, which involves exposure therapy.

Source: Mollick & Spett, 2002.

Cloitre and colleagues (2002) assigned women with PTSD related to childhood abuse randomly to STAIR or a minimal attention wait-list, excluding clients with current substance dependence as well as other complexities. STAIR participants showed significantly greater gains in affect regulation, interpersonal skills, and PTSD symptoms than the control participants. These gains were maintained through follow-up at 3 and 9 months. However, it is not clear from this study whether DBT and exposure were both needed. Phase 1 therapeutic alliance and negative mood regulation skills predicted Phase 2 exposure success in reducing PTSD, suggesting the importance of establishing a strong therapeutic relationship and emotion regulation skills before conducting exposure work with people who have chronic PTSD.

Stress inoculation training

SIT was originally developed to manage anxiety ( Meichenbaum, 1994; Meichenbaum & Deffenbacher, 1988). Kilpatrick, Veronen, and Resick (1982) modified SIT to treat rape survivors based on the idea that the anxiety and fear that rape survivors experience during their trauma generalizes to other objectively safe situations. SIT treatment components include education, skills training (muscle relaxation training, breathing retraining, role-playing, guided self-talk, assertiveness training, and thought stopping [i.e., actively and forcefully ending negative thoughts by thinking "STOP" and then redirecting thoughts in a more positive direction]), and skills application. The goal is to help clients learn to manage their anxiety and to decrease avoidant behavior by using effective coping strategies. Randomized controlled clinical trials have indicated that SIT reduces the severity of PTSD compared with waitlist controls and shows comparable efficacy to exposure therapy. At follow-up (up to 12 months after treatment), gains were maintained ( Foa et al., 1999; Foa, Rothbaum, Riggs, & Murdock, 1991).

SIT has been used to help individuals cope with the aftermath of exposure to stressful events and on a preventative basis to "inoculate" individuals to future and ongoing stressors ( Meichenbaum, 1996). This practice as a preventive strategy is similar to promoting disease resistance through immunizations.

Advice to Counselors: SIT Phases

SIT is a prevention and treatment approach that has three overlapping phases. It is often seen as a complementary approach to other interventions for traumatic stress.

Phase 1: Conceptualization and education. This phase has two main objectives. The initial goal is to develop a collaborative relationship that supports and encourages the client to confront stressors and learn new coping strategies. The next objective is to increase the client's understanding of the nature and impact of his or her stress and awareness of alternative coping skills. Many cognitive strategies are used to meet these objectives, including self-monitoring activities, Socratic questioning, identifying strengths and evidence of resilience, and modeling of coping strategies.

Phase 2: Skill acquisition and rehearsal. This phase focuses on developing coping skills and using coping skills that the individual already possesses. This process includes practice across settings, so that the individual begins to generalize the use of his or her skills across situations through rehearsal, rehearsal, and more rehearsal.

Phase 3: Implementation and following through. The main objective is to create more challenging circumstances that elicit higher stress levels for the client. By gradually increasing the challenge, the client can practice coping strategies that mimic more realistic circumstances. Through successful negotiation, the client builds a greater sense of self-efficacy. Common strategies in this phase include imagery and behavioral rehearsal, modeling, role-playing, and graded in vivo exposure.

Source: Meichenbaum, 2007.

Other therapies

Numerous interventions introduced in the past 20 years focus on traumatic stress. For some interventions, the evidence is limited, and for other others, it is evolving. One example is the traumatic incident reduction (TIR) approach. This brief memory-oriented intervention is designed for children, adolescents, and adults who have experienced traumatic stress ( Valentine & Smith, 2001). Listed in SAMHSA's NREPP, the intervention is designed to process specific traumatic incidents or problematic themes related to the trauma, including specific feelings, emotions, sensations, attitudes, or pain. It involves having clients talk through the traumatic incident repeatedly with the anticipation that changes in affect will occur throughout the repetitions. TIR is a client-centered approach.

Integrated Models for Trauma

This section covers models specifically designed to treat trauma-related symptoms along with either mental or substance use disorders at the same time. Integrated treatments help clients work on several presenting problems simultaneously throughout the treatment, a promising and recommended strategy ( Dass-Brailsford & Myrick, 2010; Najavits, 2002b; Nixon & Nearmy, 2011). Thus far, research is limited, but what is available suggests that integrated treatment models effectively reduce substance abuse, PTSD symptoms, and other mental disorder symptoms. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( Center for Substance Abuse Treatment, 2005c), offers a detailed description of integrated treatment. In contrast with integrated models, other model types include single (treatment of only one disorder), sequential (treatment of one disorder first, then the other), or parallel (concurrent treatment of multiple disorders delivered by separate clinicians or in separate programs that do not necessarily address the interactions between symptoms and disorders).

Similar to single models, integrated treatment models are designed for use in a variety of settings (e.g., outpatient, day treatment, and/or residential substance abuse and mental health clinics/programs). Most models listed are manual-based treatments that address trauma-related symptoms, mental disorders, and substance use disorders at the same time. Additional approaches and further details on the selected approaches can be found at NREPP ( http://www.nrepp.samhsa.gov).

Addiction and Trauma Recovery Integration Model

The Addiction and Trauma Recovery Integrated Model (ATRIUM; Miller & Guidry, 2001) integrates CBT and relational treatment through an emphasis on mental, physical, and spiritual health. This 12-week model for individuals and groups blends psychoeducational, process, and expressive activities, as well as information on the body's responses to addiction and traumatic stress and the impact of trauma and addiction on the mind and spirit. It helps clients explore anxiety, sexuality, self-harm, depression, anger, physical complaints and ailments, sleep difficulties, relationship challenges, and spiritual disconnection. It was designed primarily for women and focuses on developmental (childhood) trauma and interpersonal violence, but it recognizes that other types of traumatic events occur.

The ATRIUM model consists of three phases of treatment. The first stage, or "outer circle," consists of the counselor collecting data from the client about his or her trauma history, offering psychoeducation on the nature of trauma, and helping the client assess personal strengths. ATRIUM actively discourages the evocation of memories of abuse or other trauma events in this phase. The second stage, or "middle circle," allows clients and counselors to address trauma symptoms more directly and specifically encourages clients to reach out to and engage with support resources in the community. The middle circle also emphasizes learning new information about trauma and developing additional coping skills. The third stage of the program, the "inner circle," focuses on challenging old beliefs that arose as a result of the trauma. For instance, the concept of "nonprotecting bystander" is used to represent the lack of support that the traumatized person experienced at the time of the trauma. This representation is replaced with the "protective presence" of supportive others today.

ATRIUM was used in one of the nine study sites of SAMHSA's Women, Co-Occurring Disorders and Violence Study. Across all sites, trauma-specific models achieved more favorable outcomes than control sites that did not use trauma-specific models ( Morrissey et al., 2005). There has not yet been a study of ATRIUM per se, however. A manual describing the theory behind this model in greater depth, as well as how to implement it, is published under the title Addictions and Trauma Recovery: Healing the Body, Mind, and Spirit ( Miller & Guidry, 2001).

Beyond Trauma: A Healing Journey for Women

Beyond Trauma ( Covington, 2003) is a curriculum for women's services based on theory, research, and clinical experience. It was developed for use in residential, outpatient, and correctional settings; domestic violence programs; and mental health clinics. It uses behavioral techniques and expressive arts and is based on relational therapy. Although the materials are designed for trauma treatment, the connection between trauma and substance abuse in women's lives is a theme throughout. Beyond Trauma has a psychoeducational component that defines trauma by way of its process as well as its impact on the inner self (thoughts, feelings, beliefs, values) and the outer self (behavior and relationships, including parenting). Coping skills are emphasized; specific exercises develop emotional wellness.

Concurrent Treatment of PTSD and Cocaine Dependence

Concurrent Treatment of PTSD and Cocaine Dependence (CTPCD) is a 16-session, twice-weekly individual outpatient psychotherapy model designed to treat women and men with co-occurring PTSD and cocaine dependence ( Coffey, Schumacher, Brimo, & Brady, 2005). CTPCD combines imagery and in vivo exposure therapy (in which the client becomes desensitized to anxiety-producing stimuli through repeated exposure to them) for the treatment of PTSD with elements of CBT for substance dependence. To balance the dual needs of abstinence skill building and prompt trauma treatment, the first five sessions focus on coping skills for cocaine dependence. Session six transitions into exposure therapy, which begins in earnest in session seven and is combined with CBT for the treatment of substance abuse.

CTPCD helps reduce substance use and PTSD symptoms. The use of any illicit drug, as measured by urine screens, was quite low during the 16-week treatment trial and didn't escalate during the second half of treatment-when most exposure sessions occurred. PTSD symptoms dropped significantly over the course of treatment, as did self-reported depressive symptoms; however, the dropout rate was high ( Coffey, Dansky, & Brady, 2003). CTPCD was reformulated into Concurrent Prolonged Exposure (COPE; Mills et al., 2012), which was compared with treatment as usual in a high-complexity clinical sample of individuals who had PTSD and substance dependence. Both treatment conditions resulted in improvements in PTSD with no difference at 3 months (though COPE showed significantly greater improvement at 9 months); moreover, the two conditions did not differ in impact on substance use outcomes, depression, or anxiety.

Integrated CBT

Integrated CBT is a 14-session individual therapy model designed for PTSD and substance use. It incorporates elements such as psychoeducation, cognitive restructuring, and breathing retraining ( McGovern, Lamber-Harris, Alterman, Xie, & Meier, 2011). A randomized controlled trial showed that both integrated CBT and individual addiction treatment achieved improvements in substance use and other measures of psychiatric symptom severity with no difference between the treatments.

Seeking Safety

Seeking Safety is an empirically validated, present-focused treatment model that helps clients attain safety from trauma and substance abuse ( Najavits, 2002a). The Seeking Safety manual ( Najavits, 2002b) offers clinician guidelines and client handouts and is available in several languages. Training videos and other implementation materials are available online ( http://www.seekingsafety.org). Seeking Safety is flexible; it can be used for groups and individuals, with women and men, in all settings and levels of care, by all clinicians, for all types of trauma and substance abuse.

Seeking Safety covers 25 topics that address cognitive, behavioral, interpersonal, and case management domains. The topics can be conducted in any order, using as few or as many as are possible within a client's course of treatment. Each topic represents a coping skill relevant to both trauma and substance abuse, such as compassion, taking good care of yourself, healing from anger, coping with triggers, and asking for help. This treatment model builds hope through an emphasis on ideals and simple, emotionally evocative language and quotations. It attends to clinician processes and offers concrete strategies that are thought to be essential for clients dealing with concurrent substance use disorders and histories of trauma.

More than 20 published studies (which include pilot studies, randomized controlled trials, and multisite trials representing various investigators and populations) provide the evidence base for this treatment model. For more information, see SAMHSA's NREPP Web site ( http://www.nrepp.samhsa.gov) as well as the "Outcomes" section of the Seeking Safety Web site ( http://www.seekingsafety.org/3-03-06/studies.html). Study samples included people with chronic, severe trauma symptoms and substance dependence who were diverse in ethnicity and were treated in a range of settings (e.g., criminal justice, VA centers, adolescent treatment, homelessness services, public sector). Seeking Safety has shown positive outcomes on trauma symptoms, substance abuse, and other domains (e.g., suicidality, HIV risk, social functioning, problem-solving, sense of meaning); consistently outperformed treatment as usual; and achieved high satisfaction ratings from both clients and clinicians. It has been translated into seven languages, and a version for blind and/or dyslexic individuals is available.

The five key elements of Seeking Safety are:

1. Safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions).

2. Integrated treatment (working on trauma and substance abuse at the same time).

3. A focus on ideals to counteract the loss of ideals in both trauma and substance abuse.

4. Four content areas: cognitive, behavioral, interpersonal, and case management.

5. Attention to clinician processes (addressing counter transference, self-care, and other issues).

Substance Dependence PTSD Therapy

Substance Dependence PTSD Therapy ( Triffleman, 2000) was designed to help clients of both sexes cope with a broad range of traumas. It combines existing treatments for PTSD and substance abuse into a structured, 40-session (5-month, twice-weekly) individual therapy that occurs in two phases. Phase I is "Trauma-Informed, Addictions-Focused Treatment" and focuses on coping skills and cognitive interventions as well as creating a safe environment. Phase I draws on CBT models, anger management, relaxation training, HIV risk reduction, and motivational enhancement techniques. Phase II, "Trauma-Focused, Addictions-Informed Treatment," begins with psychoeducation about PTSD followed by "Anti-Avoidance I," in which a modified version of stress inoculation training is taught in two to four sessions. Following this is "Anti-Avoidance II," lasting 6 to 10 sessions, in which in vivo exposure is used.

Trauma Affect Regulation: Guide for Education and Therapy

Trauma Affect Regulation: Guide for Education and Therapy (TARGET; Ford & Russo, 2006; Frisman, Ford, Lin, Mallon, & Chang, 2008) uses emotion and information processing in a present-focused, strengths-based approach to education and skills training for trauma survivors with severe mental, substance use, and co-occurring disorders across diverse populations. TARGET helps trauma survivors understand how trauma changes the brain's normal stress response into an extreme survival-based alarm response that can lead to PTSD, and it teaches them a seven-step approach to making the PTSD alarm response less distressing and more adaptive (summarized by the acronym FREEDOM: Focus, Recognize triggers, Emotion self-check, Evaluate thoughts, Define goals, Options, and Make a contribution).

TARGET: The Seven-Step FREEDOM Approach

Focus: Being focused helps a person pay attention and think about what's happening right now instead of just reacting based on alarm signals tied to past trauma. This step teaches participants to use the SOS skill (Slow down, Orient, Self-check) to pay attention to body signals and the immediate environment and to use a simple scale to measure stress and control levels.

Recognize triggers: Recognizing trauma triggers enables a person to anticipate and reset alarm signals as he or she learns to distinguish between a real threat and a reminder. This step helps participants identify personal triggers, take control, and short-circuit their alarm reactions.

Emotion self-check: The goal of this skill is to identify two types of emotions. The first are "alarm" or reactive emotions such as terror, rage, shame, hopelessness, and guilt. Because these emotions are the most noticeable after trauma, they are the alarm system's way of keeping a person primed and ready to fend off further danger. The second type of emotion, "main" emotions, include positive feelings (e.g., happiness, love, comfort, compassion) and feelings that represent positive strivings (e.g., hope, interest, confidence). By balancing both kinds of emotions, a person can reflect and draw on his or her own values and hopes even when the alarm is activated.

Evaluate thoughts: When the brain is in alarm mode, thinking tends to be rigid, global, and catastrophic. Evaluating thoughts, as with identifying emotions, is about achieving a healthier balance of positive as well as negative thinking. Through a two-part process, participants learn to evaluate the situation and their options with a focus on how they choose to act-moving from reactive thoughts to "main" thoughts. This is a fundamental change from the PTSD pattern, which causes problems by taking a person straight from alarm signals to automatic survival reactions.

Define goals: Reactive goals tend to be limited to just making it through the immediate situation or away from the source of danger. These reactive goals are necessary in true emergencies but don't reflect a person's "main" goals of doing worthwhile things and ultimately achieving a good and meaningful life. This step teaches one how to create "main" goals that reflect his or her deeper hopes and values.

Options: The only options that are available when the brain's alarm is turned on and won't turn off are automatic "flight/fight" or "freeze/submit" reactive behaviors that are necessary in emergencies but often unhelpful in ordinary living. This step helps identify positive intentions often hidden by the more extreme reactive options generated by the alarm system. This opens the possibility for a greater range of options that take into consideration one's own needs and goals as well as those of others.

Make a contribution: When the brain's alarm is turned on and reacting to ordinary stressors as if they were emergencies, it is very difficult for a person to come away from experiences with a feeling that they have made a positive difference. This can lead to feelings of alienation, worthlessness, or spiritual distress. The ultimate goal of TARGET is to empower adults and young people to think clearly enough to feel in control of their alarm reactions and, as a result, to be able to recognize the contribution they are making not only to their own lives, but to others' lives as well.

Source: Advanced Trauma Solutions, 2012.

TARGET can be presented in individual therapy or gender-specific psychoeducational groups, and it has been adapted for individuals who are deaf; it has also been translated into Spanish and Dutch. TARGET is a resilience-building and recovery program not limited to individual or group psychotherapy; it is also designed to provide an educational curriculum and milieu intervention that affects all areas of practice in school, therapeutic, or correctional programs. TARGET is listed in SAMHSA's NREPP ( http://www.nrepp.samhsa.gov).

Trauma Recovery and Empowerment Model

The trauma recovery and empowerment model (TREM) of therapy ( Fallot & Harris, 2002; Harris & Community Connections Trauma Work Group, 1998) is a manualized group intervention designed for female trauma survivors with severe mental disorders. TREM addresses the complexity of long-term adaptation to trauma and attends to a range of difficulties common among survivors of sexual and physical abuse. TREM focuses mainly on developing specific recovery skills and current functioning and uses techniques that are effective in trauma recovery services. The model's content and structure, which cover 33 topics, are informed by the role of gender in women's experience of and coping with trauma.

TREM can be adapted for shorter-term residential settings and outpatient substance abuse treatment settings, among others. Adaptations of the model for men and adolescents are available. The model was used in SAMHSA's Women, Co-Occurring Disorders and Violence Study for three of the nine study sites and in SAMHSA's Homeless Families program, and it is listed in SAMHSA's NREPP. This model has been used with clients in substance abuse treatment; research by Toussaint, VanDeMark, Bornemann, and Graeber (2007) shows that women in a residential substance abuse treatment program showed significantly better trauma treatment outcomes using TREM than they did in treatment as usual, but no difference in substance use.

TREM Program Format

Each session includes an experiential exercise to promote group cohesiveness. The 33 sessions are divided into the following general topic areas:

Part I-empowerment introduces gender identity concepts, interpersonal boundaries, and self-esteem.

Part II-trauma recovery concentrates on sexual, physical, and emotional abuse and their relationship to psychiatric symptoms, substance abuse, and relational patterns and issues.

Part III-advanced trauma recovery issues addresses additional trauma issues, such as blame and the role of forgiveness.

Part IV-closing rituals allows participants to assess their progress and encourages them to plan for their continued healing, either on their own or as part of a community of other survivors.

Part V-modifications or supplements for special populations provides modifications for subgroups such as women with serious mental illness, incarcerated women, women who are parents, women who abuse substances, and male survivors.

Source: Mental Health America Centers for Technical Assistance, 2012.

Triad Women's Project

The Triad Project was developed as a part of SAMHSA's Women, Co-Occurring Disorders and Violence Study. It is a comprehensive, trauma-informed, consumer-responsive integrated model designed for female trauma survivors with co-occurring substance use and mental disorders who live in semirural areas. Triad integrates motivational enhancement for substance use disorders, DBT, and intensive case management techniques for co-occurring mental disorders. This program is a 16-week group intervention for women that uses integrated case management services, a curriculum-based treatment group, and a peer support group ( Clark & Fearday, 2003).

Emerging Interventions

New interventions are emerging to address traumatic stress symptoms and disorders. The following sections summarize a few interventions not highlighted in prior chapters; this is not an exhaustive list. In addition to specific interventions, technology is beginning to shape the delivery of care and to increase accessibility to tools that complement trauma-specific treatments. Numerous applications are available and evolving. For more information on the role of technology in the delivery of care, see the planned TIP, Using Technology-Based Therapeutic Tools in Behavioral Health Services (SAMHSA, planned g).

Couple and Family Therapy

Trauma and traumatic stress affects significant relationships, including the survivor's family. Although minimal research has targeted the effectiveness of family therapy with trauma survivors, it is important to consider the needs of the individual in the context of their relationships. Family and couples therapy may be key to recovery. Family members may experience secondary traumatization silently, lack understanding of traumatic stress symptoms or treatment, and/or have their own histories of trauma that influence their willingness to support the client in the family or to talk about anything related to trauma and its effects. Family members can engage in similar patterns of avoidance and have their own triggers related to the trauma being addressed at the time. A range of couple and family therapies have addressed traumatic stress and PTSD, but few studies exist that support or refute their value. Current couple or family therapies that have some science-based evidence include behavioral family therapy, behavioral marital therapy, cognitive-behavioral couples treatment, and lifestyle management courses ( Riggs, Monson, Glynn, & Canterino, 2009).

Mindfulness Interventions

Mindfulness is a process of learning to be present in the moment and observing internal experience (e.g., thoughts, bodily sensations) and external experience (e.g., interactions with others) in a nonjudgmental way. Mindfulness challenges limiting beliefs that arise from trauma, quells anxiety about future events, and simply helps one stay grounded in the present. It plays a significant role in helping individuals who have been traumatized observe their experiences, increase awareness, and tolerate uncomfortable emotions and cognitions.

To date, mindfulness-based interventions appear to be valuable as an adjunct to trauma-specific interventions and in decreasing arousal ( Baer, 2003). It may also help individuals tolerate discomfort during exposure-oriented and trauma processing interventions. Overall, mindfulness practices can help clients in managing traumatic stress, coping, and resilience. In a study of firefighters, mindfulness was associated with fewer PTSD symptoms, depressive symptoms, physical symptoms, and alcohol problems when controlling for other variables ( Smith et al., 2011).

Becoming an Observer and Learning To Tolerate Discomfort: The Leaf and Stream Metaphor

The following exercise, "leaves floating on a stream," is a classic. Many clinicians and authors provide renditions of this mindfulness practice. The main objectives are to stand back and observe thoughts rather than get caught up in them. Simply stated, thoughts are just thoughts. Thoughts come and go like water flowing down a stream. We don't need to react to the thoughts; instead, we can just notice them.

Conduct the mindfulness exercise for about 10 minutes, then process afterward. Take time to allow participants to visualize each sense as they imagine themselves sitting next to the stream. For example, what does it look like? What do they hear as they sit next to the stream? Don't rush the exercise. As you slowly make the statements detailed in the following two paragraphs, take time in between each statement for participants to be in the exercise without interruption; simply offer gentle guidance.

Begin to sit quietly, bringing your attention to your breath. If you feel comfortable, close your eyes. As you focus on breathing in and out, imagine that you are sitting next to a stream. In your imagination, you may clearly see and hear the stream, or you may have difficulty visualizing the stream. Follow along with the guided exercise; either way, it will work just as well.

Now begin to notice the thoughts that come into your mind. Some thoughts rush by, while others linger. Just allow yourself to notice your thoughts. As you begin to notice each thought, imagine putting those words onto a leaf as it floats by on the stream. Just let the thoughts come, watching them drift by on the leaves. If your thoughts briefly stop, continue to watch the water flow down the stream. Eventually, your thoughts will come again. Just let them come, and as they do, place them onto a leaf. Your attention may wander. Painful feelings may arise. You may feel uncomfortable or start to think that the exercise is "stupid." You may hook onto a thought-rehashing it repeatedly. That's okay; it's what our minds do. As soon as you notice your mind wandering or getting stuck, just gently bring your focus back to your thoughts, and place them onto the leaves. Now, bring your attention back to your breath for a moment, then open your eyes and become more aware of your environment.
Facilitated Questions:

What was it like for you to observe your thoughts?

Did you get distracted? Stuck?

Were you able to bring yourself back to the exercise after getting distracted?

In what ways was the exercise uncomfortable?

In what ways was the exercise comforting?

For clients and practitioners who want to develop a greater capacity for mindfulness, see Kabat-Zinn's books Wherever You Go, There You Are: Mindfulness Meditation In Everyday Life ( 1994) and Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness ( 1990). For clinical applications of mindfulness, see Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse ( Segal et al., 2002) and Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors ( Marlatt & Donovan, 2005).

Pharmacological Therapy

Pharmacotherapy for people with mental, substance use, and traumatic stress disorders needs to be carefully managed by physicians who are well versed in the treatment of each condition. Medications can help manage and control symptoms; however, they are only a part of a comprehensive treatment plan. There are no specific "antitrauma" drugs; rather, certain drugs target specific trauma symptoms. Clients receiving pharmacotherapy need careful assessment. Some clients with preexisting mental disorders may need further adjustment in medications due to the physiological effects of traumatic stress. In addition, sudden withdrawal from a pattern of self-administered substances can not only lead to dangerous levels of physical distress, but also exacerbate the emergence of more severe PTSD symptoms. Distress after trauma often lessens over time, which can sometimes make the use of medications unnecessary for some individuals. Some trauma survivors do not develop long-term psychological problems from their experiences that require medication; others may simply refuse the initiation of pharmacotherapy or the use of additional medications.

Concluding Note

Behavioral health counselors can best serve clients who have experienced trauma by providing integrated treatment that combines therapeutic models to target presenting symptoms and disorders. Doing so acknowledges that the disorders interact with each other. Some models have integrated curricula; others that address trauma alone can be combined with behavioral health techniques with which the counselor is already familiar.

In part, the choice of a treatment model or general approach will depend on the level of evidence for the model, the counselor's training, identified problems, the potential for prevention, and the client's goals and readiness for treatment. Are improved relationships with family members a goal? Will the client be satisfied if sleep problems decrease, or is the goal resolution of broader issues? Are there substance use or substance-related disorders? Is the goal abstinence? Collaborating with clients to decide on goals, eliciting what they would like from treatment, and determining what they expect to happen can provide some clues as to what treatment models or techniques might be successful in keeping clients engaged in recovery.

# data[].attributes.attachment_link.description
This chapter covers various treatment approaches designed specifically to treat trauma-related symptoms, trauma-related disorders, and specific disorders of traumatic stress. The models presented do not comprise an exhaustive list, but rather, serve as examples. These models require training and supervised experience to be conducted safely and effectively.

# data[].attributes.body
In a short-term study, more patients using SPRAVATO® plus oral antidepressant demonstrated rapid and superior reduction in depressive symptoms at four weeks compared to those who received placebo plus an oral antidepressant

Most of the reduction in depressive symptoms was seen at 24 hours

Between 24 hours and four weeks, both groups continued to improve; the difference in improvement between the groups remained but did not appear to increase through four weeks

SPRAVATO® was also studied in a long-term

maintenance-of-effect trial

The study was designed for patients in remission to see if the effect of treatment was maintained.

The trial compared patients who stayed on SPRAVATO® and oral antidepressant vs placebo and oral antidepressant long-term

Patients who stayed on SPRAVATO® were less likely to experience a return in depressive symptoms (known as relapse)

If two or more oral antidepressants haven’t worked for you, ask your doctor if adding SPRAVATO® may be able to help.

Indications And Limitations Of Use:

SPRAVATO® is a prescription medicine, used along with an antidepressant, taken by mouth to treat:

Adults with treatment-resistant depression (TRD)

Depressive symptoms in adults with major depressive disorder (MDD) with suicidal thoughts or actions

Limitations of Use:

SPRAVATO® is not for use as a medicine to prevent or relieve pain (anesthetic). It is not known if SPRAVATO® is safe or effective as an anesthetic medicine.

It is not known if SPRAVATO® is safe and effective for use in preventing suicide or in reducing suicidal thoughts or actions. SPRAVATO® is not for use in place of hospitalization if your healthcare provider determines that hospitalization is needed, even if improvement is experienced after the first dose of SPRAVATO®.

It is not known if SPRAVATO® is safe and effective in children.

IMPORTANT SAFETY INFORMATION

What is the most important information I should know about SPRAVATO®?

SPRAVATO® can cause serious side effects, including:

Sedation and dissociation. SPRAVATO® may cause sleepiness (sedation), fainting, dizziness, spinning sensation, anxiety, or feeling disconnected from yourself, your thoughts, feelings, space and time (dissociation).

Tell your healthcare provider right away if you feel like you cannot stay awake or if you feel like you are going to pass out.

Your healthcare provider must monitor you for serious side effects for at least 2 hours after taking SPRAVATO®. Your healthcare provider will decide when you are ready to leave the healthcare setting.

Respiratory depression was observed with the use of SPRAVATO®; additionally, there were rare reports of respiratory arrest.

Your healthcare provider must monitor you for serious side effects for at least 2 hours (including pulse oximetry) after taking SPRAVATO®. Your healthcare provider will decide when you are ready to leave the healthcare setting.

Abuse and misuse. There is a risk for abuse and physical and psychological dependence with SPRAVATO® treatment. Your healthcare provider should check you for signs of abuse and dependence before and during treatment with SPRAVATO®.

Tell your healthcare provider if you have ever abused or been dependent on alcohol, prescription medicines, or street drugs.

Your healthcare provider can tell you more about the differences between physical and psychological dependence and drug addiction.

SPRAVATO® Risk Evaluation and Mitigation Strategy (REMS). Because of the risks for sedation, dissociation, respiratory depression, and abuse and misuse, SPRAVATO® is only available through a restricted program called the SPRAVATO® Risk Evaluation and Mitigation Strategy (REMS) Program. SPRAVATO® can only be administered at healthcare settings certified in the SPRAVATO® REMS Program. Patients treated in outpatient healthcare settings (e.g., medical offices and clinics) must be enrolled in the program.

Increased risk of suicidal thoughts and actions. Antidepressant medicines may increase suicidal thoughts and actions in some people 24 years of age and younger, especially within the first few months of treatment or when the dose is changed. SPRAVATO® is not for use in children.

Depression and other serious mental illnesses are the most important causes of suicidal thoughts and actions. Some people may have a higher risk of having suicidal thoughts or actions. These include people who have (or have a family history of) depression or a history of suicidal thoughts or actions.

How can I watch for and try to prevent suicidal thoughts and actions in myself or a family member?

Pay close attention to any changes, especially sudden changes, in mood, behavior, thoughts, or feelings, or if you develop suicidal thoughts or actions.

Tell your healthcare provider right away if you have any new or sudden changes in mood, behavior, thoughts, or feelings.

Keep all follow-up visits with your healthcare provider as scheduled. Call your healthcare provider between visits as needed, especially if you have concerns about symptoms.

Tell your healthcare provider right away if you or your family member have any of the following symptoms, especially if they are new, worse, or worry you:

suicide attempts

thoughts about suicide or dying

worsening depression

other unusual changes in behavior or mood

Do not take SPRAVATO® if you:

have blood vessel (aneurysmal vascular) disease (including in the brain, chest, abdominal aorta, arms and legs)

have an abnormal connection between your veins and arteries (arteriovenous malformation)

have a history of bleeding in the brain

are allergic to esketamine, ketamine, or any of the other ingredients in SPRAVATO®.

If you are not sure if you have any of the above conditions, talk to your healthcare provider before taking SPRAVATO®.

Before you take SPRAVATO®, tell your healthcare provider about all of your medical conditions, including if you:

have heart or brain problems, including:

high blood pressure (hypertension)

slow or fast heartbeats that cause shortness of breath, chest pain, lightheadedness, or fainting

# data[].attributes.attachment_link.provider_name
SPRAVATO® (esketamine) | Official Patient Website

# data[].attributes.attachment_link.title
SPRAVATO® (esketamine) | Official Patient Website

# data[].attributes.attachment_link.description
Learn about SPRAVATO® (esketamine) CIII nasal spray, a prescription medicine for two indications. See full Prescribing & Safety Info, including BOXED WARNINGS.

# data[].attributes.body
The term “ACEs” is an acronym for Adverse Childhood Experiences. It originated in a groundbreaking study conducted in 1995 by the Centers for Disease Control and the Kaiser Permanente health care organization in California. In that study, “ACEs” referred to three specific kinds of adversity children faced in the home environment—various forms of physical and emotional abuse, neglect, and household dysfunction. The key findings of dozens of studies using the original ACEs data are: (1) ACEs are quite common, even among a middle-class population: more than two-thirds of the population report experiencing one ACE, and nearly a quarter have experienced three or more. (2) There is a powerful, persistent correlation between the more ACEs experienced and the greater the chance of poor outcomes later in life, including dramatically increased risk of heart disease, diabetes, obesity, depression, substance abuse, smoking, poor academic achievement, time out of work, and early death.

# data[].attributes.attachment_link.provider_name
Center on the Developing Child at Harvard University

# data[].attributes.attachment_link.readable_text
What are ACEs?

The term "ACEs" is an acronym for Adverse Childhood Experiences. It originated in a groundbreaking study conducted in 1995 by the Centers for Disease Control and the Kaiser Permanente health care organization in California. In that study, "ACEs" referred to three specific kinds of adversity children faced in the home environment-various forms of physical and emotional abuse, neglect, and household dysfunction. The key findings of dozens of studies using the original ACEs data are: (1) ACEs are quite common, even among a middle-class population: more than two-thirds of the population report experiencing one ACE, and nearly a quarter have experienced three or more. (2) There is a powerful, persistent correlation between the more ACEs experienced and the greater the chance of poor outcomes later in life, including dramatically increased risk of heart disease, diabetes, obesity, depression, substance abuse, smoking, poor academic achievement, time out of work, and early death.

How do ACEs relate to toxic stress?

ACEs research shows the correlation between early adversity and poor outcomes later in life. Toxic stress explains how ACEs "get under the skin" and trigger biological reactions that lead to those outcomes. In the early 2000s, the National Scientific Council on the Developing Child coined the term " toxic stress " to describe extensive, scientific knowledge about the effects of excessive activation of stress response systems on a child's developing brain, as well as the immune system, metabolic regulatory systems, and cardiovascular system. Experiencing ACEs triggers all of these interacting stress response systems. When a child experiences multiple ACEs over time-especially without supportive relationships with adults to provide buffering protection-the experiences will trigger an excessive and long-lasting stress response, which can have a wear-and-tear effect on the body, like revving a car engine for days or weeks at a time.

Importantly, the Council also expanded its definition of adversity beyond the categories that were the focus of the initial ACE study to include community and systemic causes-such as violence in the child's community and experiences with racism and chronic poverty-because the body's stress response does not distinguish between overt threats from inside or outside the home environment, it just recognizes when there is a threat, and goes on high alert.

What is trauma, and how does it connect to ACEs and toxic stress?

While trauma has many definitions, typically in psychology it refers to an experience of serious adversity or terror-or the emotional or psychological response to that experience. Trauma-informed care or services are characterized by an understanding that problematic behaviors may need to be treated as a result of the ACEs or other traumatic experiences someone has had, as opposed to addressing them as simply willful and/or punishable actions.

What can we do to help mitigate the effects of ACEs?

People who have experienced significant adversity (or many ACEs) are not irreparably damaged. There is a spectrum of potential responses to ACEs and their possible chain of developmental harm that can help a person recover from trauma caused by toxic stress.

At the most intensive end of the spectrum are therapeutic interventions, ranging from in-patient treatment to regular sessions with a mental health professional, which are designed specifically to deal with serious trauma.

Trauma-informed care or practice is less intensive, but affects how practitioners in a range of fields, such as social work, medicine, and education, work with people who have experienced toxic stress, and reflects an awareness of the harm that has occurred and takes that into account. There are also many less-intensive practices that can help individuals reduce the effects of stress-from meditation and breathing exercises, to physical exercise and social supports.

ACEs-based screening and referral is an increasingly common approach, in which individuals are given an ACE score based on a brief survey of their own personal history of ACEs. This can indicate a general, non-specific sense of increased risk based on population-level probabilities, but it cannot predict accurately how any one individual will fare. In other words, a high ACE score can serve as a rough first screener to identify people who may benefit from services, but it cannot tell you what specifically you are at risk for, nor what to do about it.

The ideal approach to ACEs is one that prevents the need for all levels of services: by reducing the sources of stress in people's lives, whether basic needs like food, housing, and diapers, or more entrenched sources of stress, like substance abuse, mental illness, violent relationships, community crime, discrimination, or poverty. Supporting responsive relationships with a parent or caregiver can also help to buffer a child from the effects of stress, and helping children and adults build their core life skills-such as planning, focus, and self-control-can strengthen the building blocks of resilience. These three principles-reducing stress, building responsive relationships, and strengthening life skills-are the best way to prevent the long-term effects of ACEs.

# data[].attributes.attachment_link.title
What Are ACEs? And How Do They Relate to Toxic Stress?

# data[].attributes.attachment_link.description
What are Adverse Childhood Experiences (ACEs)? In this infographic and FAQ, learn about ACEs and toxic stress, and how to prevent or reduce lasting harm.

# data[].attributes.body
OCD obsessions are lasting and unwanted thoughts that keeping coming back or urges or images that are intrusive and cause distress or anxiety. You might try to ignore them or get rid of them by acting based on ritual. These obsessions usually intrude when you're trying to think of or do other things.

Obsessions often have themes, such as:

Fear of contamination or dirt.

Doubting and having a hard time dealing with uncertainty.

Needing things to be orderly and balanced.

Aggressive or horrific thoughts about losing control and harming yourself or others.

Unwanted thoughts, including aggression, or sexual or religious subjects.

# data[].attributes.attachment_link.readable_text
Overview

Obsessive-compulsive disorder (OCD) features a pattern of unwanted thoughts and fears known as obsessions. These obsessions lead you to do repetitive behaviors, also called compulsions. These obsessions and compulsions get in the way of daily activities and cause a lot of distress.

Ultimately, you feel driven to do compulsive acts to ease your stress. Even if you try to ignore or get rid of bothersome thoughts or urges, they keep coming back. This leads you to act based on ritual. This is the vicious cycle of OCD.

OCD often centers around certain themes, such as being overly fearful of getting contaminated by germs. To ease contamination fears, you may wash your hands over and over again until they're sore and chapped.

If you have OCD, you may be ashamed, embarrassed and frustrated about the condition. But treatment can be effective.

Symptoms

Obsessive-compulsive disorder usually includes both obsessions and compulsions. But it's also possible to have only obsession symptoms or only compulsion symptoms. You may or may not know that your obsessions and compulsions are beyond reason. But they take up a great deal of time, reduce your quality of life, and get in the way of your daily routines and responsibilities.

Obsession symptoms

OCD obsessions are lasting and unwanted thoughts that keeping coming back or urges or images that are intrusive and cause distress or anxiety. You might try to ignore them or get rid of them by acting based on ritual. These obsessions usually intrude when you're trying to think of or do other things.

Obsessions often have themes, such as:

Fear of contamination or dirt.

Doubting and having a hard time dealing with uncertainty.

Needing things to be orderly and balanced.

Aggressive or horrific thoughts about losing control and harming yourself or others.

Unwanted thoughts, including aggression, or sexual or religious subjects.

Examples of obsession symptoms include:

Fear of being contaminated by touching objects others have touched.

Doubts that you've locked the door or turned off the stove.

Intense stress when objects aren't orderly or facing a certain way.

Images of driving your car into a crowd of people.

Thoughts about shouting obscenities or not acting the right way in public.

Unpleasant sexual images.

Staying away from situations that can cause obsessions, such as shaking hands.

Compulsion symptoms

OCD compulsions are repetitive behaviors that you feel driven to do. These repetitive behaviors or mental acts are meant to reduce anxiety related to your obsessions or prevent something bad from happening. But taking part in the compulsions brings no pleasure and may offer only limited relief from anxiety.

You may make up rules or rituals to follow that help control your anxiety when you're having obsessive thoughts. These compulsions are beyond reason and often don't relate to the issue they're intended to fix.

As with obsessions, compulsions usually have themes, such as:

Washing and cleaning.

Checking.

Counting.

Ordering.

Following a strict routine.

Demanding reassurance.

Examples of compulsion symptoms include:

Hand-washing until your skin becomes raw.

Checking doors over and over again to make sure they're locked.

Checking the stove over and over again to make sure it's off.

Counting in certain patterns.

Silently repeating a prayer, word or phrase.

Trying to replace a bad thought with a good thought.

Arranging your canned goods to face the same way.

Severity varies

OCD usually begins in the teen or young adult years, but it can start in childhood. Symptoms usually begin over time and tend to vary in how serious they are throughout life. The types of obsessions and compulsions you have also can change over time. Symptoms generally get worse when you are under greater stress, including times of transition and change. OCD, usually thought to be a lifelong disorder, can have mild to moderate symptoms or be so severe and time-consuming that it becomes disabling.

When to see a doctor

There's a difference between being a perfectionist - someone who needs flawless results or performance - and having OCD. OCD thoughts aren't simply excessive worries about real issues in your life or liking to have things clean or arranged in a specific way.

If your obsessions and compulsions affect your quality of life, see your doctor or mental health professional.

From Mayo Clinic to your inbox

Sign up for free and stay up to date on research advancements, health tips, current health topics, and expertise on managing health. Click here for an email preview.

Email field is required

Include a valid email address

Learn more about Mayo Clinic's use of data.

We use the data you provide to deliver you the content you requested. To provide you with the most relevant and helpful information, we may combine your email and website data with other information we have about you. If you are a Mayo Clinic patient, we will only use your protected health information as outlined in our Notice of Privacy Practices. You may opt out of email communications at any time by clicking on the unsubscribe link in the email.

Thank you for subscribing!

You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox.

Sorry something went wrong with your subscription

Please, try again in a couple of minutes

Causes

The cause of obsessive-compulsive disorder isn't fully understood. Main theories include:

Biology. OCD may be due to changes in your body's natural chemistry or brain functions.

Genetics. OCD may have a genetic component, but specific genes have yet to be found.

Learning. Obsessive fears and compulsive behaviors can be learned from watching family members or learning them over time.

Risk factors

Factors that may raise the risk of causing obsessive-compulsive disorder include:

Family history. Having parents or other family members with the disorder can raise your risk of getting OCD.

Stressful life events. If you've gone through traumatic or stressful events, your risk may increase. This reaction may cause the intrusive thoughts, rituals and emotional distress seen in OCD.

Other mental health disorders. OCD may be related to other mental health disorders, such as anxiety disorders, depression, substance abuse or tic disorders.

Complications

Issues due to obsessive-compulsive disorder include:

Excessive time spent taking part in ritualistic behaviors.

Health issues, such as contact dermatitis from frequent hand-washing.

Having a hard time going to work or school or taking part in social activities.

Troubled relationships.

Poor quality of life.

Thoughts about suicide and behavior related to suicide.

Prevention

There's no sure way to prevent obsessive-compulsive disorder. However, getting treated as soon as possible may help keep OCD from getting worse and disrupting activities and your daily routine.

# data[].attributes.attachment_link.title
Obsessive-compulsive disorder (OCD) - Symptoms and causes

# data[].attributes.attachment_link.description
OCD features unwanted thoughts and fears, or obsessions. These obsessions lead to repetitive behaviors, also known as compulsions, that get in the way of daily activities.

# data[].attributes.body
Autism, or autism spectrum disorder (ASD), refers to a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication. According to the Centers for Disease Control, autism affects an estimated 1 in 36 children and 1 in 45 adults in the United States today.

# data[].attributes.attachment_link.readable_text
Autism, or autism spectrum disorder (ASD), refers to a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication. According to the Centers for Disease Control, autism affects an estimated 1 in 36 children in the United States today.

We know that there is not one autism but many subtypes, most influenced by a combination of genetic and environmental factors. Because autism is a spectrum disorder, each person with autism has a distinct set of strengths and challenges. The ways in which people with autism learn, think and problem-solve can range from highly skilled to severely challenged. Some people with ASD may require significant support in their daily lives, while others may need less support and, in some cases, live entirely independently.

Several factors may influence the development of autism, and it is often accompanied by sensory sensitivities and medical issues such as gastrointestinal (GI) disorders, seizures or sleep disorders, as well as mental health challenges such as anxiety, depression and attention issues.

Signs of autism usually appear by age 2 or 3. Some associated development delays can appear even earlier, and often, it can be diagnosed as early as 18 months. Research shows that early intervention leads to positive outcomes later in life for people with autism.

# data[].attributes.attachment_link.description
What is autism spectrum disorder (asd)? Click here to read the definition, learn about different types of autism and how to help autistic kids.

# data[].attributes.body
The Day the Crayons Came Home

Part of: The Day The Crayons Quit (Picture Books) (2 books)

# data[].attributes.body
own Syndrome (Down's Syndrome), also known as Trisomy 21 is a genetic disorder caused when abnormal cell division results in an extra full or partial copy of chromosome 21. This extra genetic material causes the developmental changes and physical features of Down syndrome.

# data[].attributes.attachment_link.title
What is Down Syndrome (Trisomy 21)? Down syndrome (Trisomy 21) Made Easy

# data[].attributes.body
lthough the exact causes of OCD are unknown, various risk factors increase the chances of developing the disorder.

Genetics: Studies have shown that having a first-degree relative (parent or sibling) with OCD is associated with an increased chance of developing the disorder. Scientists have not identified any one gene or set of genes that definitively leads to OCD, but studies exploring the connection between genetics and OCD are ongoing.

# data[].attributes.attachment_link.provider_name
National Institute of Mental Health (NIMH)

# data[].attributes.attachment_link.description
Learn about obsessive-compulsive disorder, including signs and symptoms, risk factors, treatments and therapies, and links to other resources to learn more.

# data[].attributes.body
Screen for PTSD. Target patient care.

PTSD is often underdiagnosed or misdiagnosed.¹⁻⁵ This 5-question screening tool is designed to help identify probable PTSD in a primary care setting.⁶

# data[].attributes.attachment_link.title
Resources for Treatment & Care | Tethered to PTSD

# data[].attributes.attachment_link.description
Educational resources and advocacy organizations for healthcare professionals who treat PTSD patients.

# data[].attributes.body
This identify what is trauma and relationship between trauma and health risk.

# data[].attributes.attachment_link.title
What is Trauma? - Trauma-Informed Care Implementation Resource Center

# data[].attributes.attachment_link.description
Learn about trauma, its causes, and the negative long-term effects of trauma on health and wellbeing.

# data[].attributes.headline
4types of trauma and how impact our relationships.

# data[].attributes.subject
4types of trauma and how impact our relationships.

# data[].attributes.body
In this video, we explore the 4 types of trauma and how they can impact your relationships. Trauma can be caused by a variety of experiences, such as abuse, neglect, or even natural disasters. When left unaddressed, it can lead to negative patterns in our relationships. We discuss the impact of rejection trauma, abandonment trauma, betrayal trauma, and humiliation trauma on our relationships and provide tips on how to overcome the negative effects of emotional trauma or psychological trauma.

# data[].attributes.attachment_link.title
4 Types of Trauma & How It Impacts Your Relationship

# data[].attributes.body
This about PTSD what is it, the symptoms and strategies to help.

# data[].attributes.attachment_link.description
Understand how depression and post traumatic stress disorder (PTSD) are linked and understand your own mental health better.

# data[].attributes.body
Trauma is often the result of an overwhelming amount of stress from a situation that exceeds one's ability to cope, such as the death of a loved one, the end of a meaningful relationship, or the rejection of a loved one. Do you pretend that everything is good when it really isn’t? When you don’t have a positive and healthy way of dealing with your trauma, you end up repressing your negative emotions. It can be hard to recognize unresolved trauma on the surface, especially within ourselves.

# data[].attributes.body
When trapped in a constant trauma response people with PTSD experience four types of difficult PTSD symptoms including: 1. Painful thoughts 2. Intense emotions 3. Bodily changes 4. Behavioral changes These “symptoms” show up because after experiencing trauma, your brain changes on a physical level. This isn’t simply “damage” as people would perhaps think, but it’s your brain adapting to the experience that the world isn’t safe, and in my opinion, taking measures to help you avoid future dangers.

# data[].attributes.body
Bessel van der Kolk has studied trauma for 50 years. Though we once considered trauma exclusive to veterans and people growing up in extreme circumstances, we now know it is an extremely common experience. Van der Kolk discusses the impact of trauma and the pathway to healing.

# data[].attributes.attachment_link.title
How the body keeps the score on trauma | Bessel van der Kolk for Big Think+

# data[].attributes.body
From his years of experience as a physician and addiction recovery expert, Dr. Gabor Maté has identified seven major impacts that trauma has on a person. In this video, Gabor explains these impacts. In the full series Healing Trauma & Addiction, he goes more in-depth about the impacts of trauma and how to heal from them.

# data[].attributes.body
Dr. Gabor Mate shares his personal journey of healing the trauma he experienced as an infant baby when his Jewish family was subject to Nazi occupation in Hungary. Trauma is not what happened to you. Trauma is the wound that you sustained. This is a good thing! Because if trauma was what happened to you, how can you heal? But emotional wounds can be healed at any time if one is willing to recognize their wounds and begin to give them the loving attention they require to heal.

# data[].attributes.attachment_link.title
The Secret To Healing Trauma | Dr. Gabor Mate

# data[].attributes.body
Conventional psychiatric practices tell us that if we feel bad, take this drug and it will go away. But after years of research with some of the top psychiatric practitioners in the world, we’ve found that drugs simply don’t work that well for many, and our conventional ways of healing trauma need to change. In recent years, experts in the study of trauma have been experimenting with ‘new age’ healing mechanisms that are making massive waves for trauma patients. Some of these new healing methods include EDMR, yoga, theater and movement, neural feedback, and even psychedelics. Many of these methods have proven to be more effective than conventional pharmaceuticals.

# data[].attributes.attachment_link.title
6 ways to heal trauma without medication | Bessel van der Kolk | Big Think

# data[].attributes.body
In this insightful video, renowned trauma expert Dr. Gabor Maté delves into the holistic approach to healing emotional wounds, emphasizing compassion for oneself and others. Learn how storytelling and narratives play a vital role in understanding human experiences, emotional dynamics, and the path to recovery. Explore the profound impact of childhood adversity on emotional well-being and why validating emotions, especially in children, is key to fostering resilience. Dr. Maté also reveals how life's challenges—like grief and disappointment—are natural parts of our journey and essential to personal growth. I find this doctor talking about trauma and many subjects that interest me.

# data[].attributes.attachment_link.title
How Your Trauma Actually HEALS (with Dr. Gabor Maté)

# data[].attributes.headline
12 sign you might be suffering from PTSD

# data[].attributes.subject
12 sign you might be suffering from PTSD

# data[].attributes.body
Complex Post Traumatic Stress Disorder (C-PTSD) refers to a state in which we are severely impacted in the present by emotional neglect in our childhoods. The symptoms include high anxiety, low self-esteem, a constant sense of dread - and (often) difficulty being able to sleep. By learning more about our condition, we can (probably through the help of psychotherapy) hope to free ourselves and be more at ease in the world.

# data[].attributes.attachment_link.title
12 signs you might be suffering from PTSD

# data[].attributes.body
How to Heal and Forgive: Dr. Gabor Maté's Powerful Message Dr. Gabor Maté shares powerful insights on healing, forgiveness, and emotional wholeness in this inspiring video. Learn how to heal and forgive through spirituality and mental health practices. In this powerful video, Dr. Gabor Maté shares profound insights on healing, forgiveness, and finding closure. Discover how acknowledging personal pain and suffering is crucial for your healing journey, even if closure doesn’t come from those who caused the pain. Learn about the role of traditions and rituals in finding inner peace.

# data[].attributes.attachment_link.title
How to Heal and Forgive: Dr. Gabor Maté's Powerful Message

# data[].attributes.body
ADHD is typically diagnosed by mental health providers or primary care providers. A psychiatric evaluation will include a description of symptoms from the patient and caregivers, completion of scales and questionnaires by patient, caregivers and teachers, complete psychiatric and medical history, family history, and information regarding education, environment, and upbringing. It may also include a referral for medical evaluation to rule out other medical conditions.

# data[].attributes.body
A child with combined ADHD has symptoms of both inattention and hyperactivity.

Combined is the most common type of ADHD, and hyperactive-impulsive is the least common type.

# data[].attributes.attachment_link.title
Attention Deficit Hyperactivity Disorder (ADHD)

# data[].attributes.attachment_link.description
ADHD is the most commonly diagnosed mental disorder in children. Find out the symptoms in children and adults, types, causes, diagnosis, treatment, and outlook.

# data[].attributes.body
Dr. Robert Wilfahrt, a family medicine physician at Mayo Clinic, discusses ADHD in adults. Dr. Wilfahrt is also a content editor and board member for the Mayo Clinic Health Letter.

# data[].attributes.body
ADHD SIGNS IN YOUNG CHILDREN! Let's talk about the early signs of ADHD in a 4-year-old child. Lex is 4 years old and has been diagnosed with Autism Spectrum Disorder (borderline high functioning) and combined-type ADHD or known as ADHD-C. Comment below the early symptoms you noticed in your kiddo

# data[].attributes.body
Gabor Mate is an expert physician who specialises in neurology. He has ADHD himself and in this clip explains the truth about the condition.

# data[].attributes.attachment_link.title
World Leading Physician View On ADHD: Gabor Mate

# data[].attributes.body
There's a lot of resources out there for ADHD, so where should you start? Here's a list of my 10 favorite online resources for ADHD.

# data[].attributes.attachment_link.title
My 10 Favorite Online Resources for ADHD

# data[].attributes.body
sleep is as important for good health as diet and exercise. Good sleep improves your brain performance, mood, and health.

Not getting enough quality sleep regularly raises the risk of many diseases and disorders. These range from heart disease and stroke to obesity and dementia.

# data[].attributes.attachment_link.readable_text
Get the Rest You Need

Sometimes, the pace of modern life barely gives you time to stop and rest. It can make getting a good night's sleep on a regular basis seem like a dream.

But sleep is as important for good health as diet and exercise. Good sleep improves your brain performance, mood, and health.

Not getting enough quality sleep regularly raises the risk of many diseases and disorders. These range from heart disease and stroke to obesity and dementia.

There's more to good sleep than just the hours spent in bed, says Dr. Marishka Brown, a sleep expert at NIH. "Healthy sleep encompasses three major things," she explains. "One is how much sleep you get. Another is sleep quality-that you get uninterrupted and refreshing sleep. The last is a consistent sleep schedule."

People who work the night shift or irregular schedules may find getting quality sleep extra challenging. And times of great stress-like the current pandemic-can disrupt our normal sleep routines. But there are many things you can do to improve your sleep.

Sleep for Repair

Why do we need to sleep? People often think that sleep is just "down time," when a tired brain gets to rest, says Dr. Maiken Nedergaard, who studies sleep at the University of Rochester.

"But that's wrong," she says. While you sleep, your brain is working. For example, sleep helps prepare your brain to learn, remember, and create.

Nedergaard and her colleagues discovered that the brain has a drainage system that removes toxins during sleep.

"When we sleep, the brain totally changes function," she explains. "It becomes almost like a kidney, removing waste from the system."

Her team found in mice that the drainage system removes some of the proteins linked with Alzheimer's disease. These toxins were removed twice as fast from the brain during sleep.

Everything from blood vessels to the immune system The system that protects your body from invading viruses, bacteria, and other microscopic threats. uses sleep as a time for repair, says Dr. Kenneth Wright, Jr., a sleep researcher at the University of Colorado.

"There are certain repair processes that occur in the body mostly, or most effectively, during sleep," he explains. "If you don't get enough sleep, those processes are going to be disturbed."

Sleep Myths and Truths

How much sleep you need changes with age. Experts recommend school-age children get at least nine hours a night and teens get between eight and 10. Most adults need at least seven hours or more of sleep each night.

There are many misunderstandings about sleep. One is that adults need less sleep as they get older. This isn't true. Older adults still need the same amount. But sleep quality can get worse as you age. Older adults are also more likely to take medications that interfere with sleep.

Another sleep myth is that you can "catch up" on your days off. Researchers are finding that this largely isn't the case.

"If you have one bad night's sleep and take a nap, or sleep longer the next night, that can benefit you," says Wright. "But if you have a week's worth of getting too little sleep, the weekend isn't sufficient for you to catch up. That's not a healthy behavior."

In a recent study, Wright and his team looked at people with consistently deficient sleep. They compared them to sleep-deprived people who got to sleep in on the weekend.

Both groups of people gained weight with lack of sleep. Their bodies' ability to control blood sugar levels also got worse. The weekend catch-up sleep didn't help.

On the flip side, more sleep isn't always better, says Brown. For adults, "if you're sleeping more than nine hours a night and you still don't feel refreshed, there may be some underlying medical issue," she explains.

Sleep Disorders

Some people have conditions that prevent them from getting enough quality sleep, no matter how hard they try. These problems are called sleep disorders.

The most common sleep disorder is insomnia. "Insomnia is when you have repeated difficulty getting to sleep and/or staying asleep," says Brown. This happens despite having the time to sleep and a proper sleep environment. It can make you feel tired or unrested during the day.

Insomnia can be short-term, where people struggle to sleep for a few weeks or months. "Quite a few more people have been experiencing this during the pandemic," Brown says. Long-term insomnia lasts for three months or longer.

Sleep apnea is another common sleep disorder. In sleep apnea, the upper airway becomes blocked during sleep. This reduces or stops airflow, which wakes people up during the night. The condition can be dangerous. If untreated, it may lead to other health problems.

If you regularly have problems sleeping, talk with your health care provider. They may have you keep a sleep diary to track your sleep for several weeks. They can also run tests, including sleep studies. These look for sleep disorders.

Getting Better Sleep

If you're having trouble sleeping, hearing how important it is may be frustrating. But simple things can improve your odds of a good night's sleep. See the Wise Choices box for tips to sleep better every day.

Treatments are available for many common sleep disorders. Cognitive behavioral therapy can help many people with insomnia get better sleep. Medications can also help some people.

Many people with sleep apnea benefit from using a device called a CPAP machine. These machines keep the airway open so that you can breathe. Other treatments can include special mouthguards and lifestyle changes.

For everyone, "as best you can, try to make sleep a priority," Brown says. "Sleep is not a throwaway thing-it's a biological necessity."

# data[].attributes.attachment_link.description
Does getting a good night's sleep seem like a dream? Find tips for getting a better night's sleep.

# data[].attributes.body
When trapped in a constant trauma response people with PTSD experience four types of difficult PTSD symptoms including: 1. Painful thoughts 2. Intense emotions 3. Bodily changes 4. Behavioral changes These “symptoms” show up because after experiencing trauma, your brain changes on a physical level. This isn’t simply “damage” as people would perhaps think, but it’s your brain adapting to the experience that the world isn’t safe, and in my opinion, taking measures to help you avoid future dangers.

# data[].attributes.body
This identify what is trauma and relationship between trauma and health risk.

# data[].attributes.attachment_link.title
What is Trauma? - Trauma-Informed Care Implementation Resource Center

# data[].attributes.attachment_link.description
Learn about trauma, its causes, and the negative long-term effects of trauma on health and wellbeing.

# data[].attributes.body
Experts recommend that adults sleep between 7 and 9 hours a night.

Adults who sleep less than 7 hours a night may have more health issues than those who sleep 7 or more hours a night. Sleeping more than 9 hours a night is not necessarily harmful and may be helpful for young adults, people who are recovering from sleep deprivation, and people who are sick.

How much sleep children should get depends on their age. Sleep experts consider naps to be appropriate for children under age 7.

# data[].attributes.attachment_link.description
Learn about how sleep works, and how many hours of sleep to get each night--no matter what your age.

# data[].attributes.body
Why We Sleep: The New Science of Sleep and Dreams (or simply known as Why We Sleep) is a 2017 popular science book about sleep written by Matthew Walker, an English scientist and the director of the Center for Human Sleep Science at the University of California, Berkeley, who specializes in neuroscience and psychology. In the book, Walker discusses about the importance of sleeping, the side effects of failing to do so, and its impact on society

# data[].attributes.attachment_link.readable_text
Why We Sleep: The New Science of Sleep and Dreams (or simply known as Why We Sleep) is a 2017 popular science book about sleep written by Matthew Walker, an English scientist and the director of the Center for Human Sleep Science at the University of California, Berkeley, who specializes in neuroscience and psychology. In the book, Walker discusses about the importance of sleeping, the side effects of failing to do so and its impact on society.

Walker spent four years writing the book, in which he asserts that sleep deprivation is linked to numerous fatal diseases, including dementia.

Why We Sleep has gone on to become a bestseller under The New York Times and The Sunday Times that questions its namesake from the viewpoint of neuroscience. The book has received generally positive reviews from critics, who praised Walker's research and views on the science of sleep, while criticizing the book for its certain claims regarding sleep.

According to Walker, who had never written a book at the time, he was motivated to write the book after an encounter with a woman who peeked at his work related to sleep and its benefits for health, with the woman stating, "When that comes out, I want to read it". Walker described this encounter as a sincere "independent ratification" that made him write the book. The book took Walker roughly four and a half years to write. Walker and his team spent roughly 20 years studying the rejuvenating ability sleep has, to much avail. Walker's communication style, in which he makes use of "metaphors and analogies effectively," allowed him to explain ideas related to sleep in detail.

At 18 years of age, Walker, who was a medical student at the time, became an "accidental sleep researcher" and moved over to studying neuroscience because of his habit of asking many questions. It was during his PhD at London's Medical Research Council when Walker learned about how little information there was on sleep. A scientific paper helped Walker with his research after his failure to determine the differences of brainwave activity between various dementia found in people, with the paper's contents describing the areas of the brain each variant of dementia attacks. It was then Walker realized that in order to measure his patients' brainwave patterns properly, they need to be asleep. Walker spent six months teaching himself how to set up his sleep laboratory, which allowed him to voice his findings on sleep differences amongst his patients.

Walker noted that many people misinterpret the amount of sleep they actually receive, likely caused by deep thought during the light sleep phases. Following the release of the book, Walker went on to describe his book has having the potential to make readers sleep and jokingly admitted to being concerned to hear if his book kept people awake at night.

The book is written from a neuroscientific view and is mainly devoted to discussing about the impact sleep has on the functions of the human brain. The book is divided into four parts, each section focusing on how sleep works, its benefits, the reason why dreams occur and sleep issues surrounding society. The book is written in a way so that it does not need to be read sequentially. In the book, Walker discusses about the effects of the widespread effect of sleep-loss, in which the goal in mind being that readers will endeavour in achieving eight hours of sleep once they learn about the connection sleep loss has to other health issues, such as Alzheimer's disease. Other details about lack of sleep explained by Walker include adults who sleep for less than 6 hours at the age of 40 and above have a higher chance of suffering a cardiac arrest or a stroke during their lifetime.

"Sleep pressure and circadian rhythms", the driving forces and the framework of sleep, are brought up by Walker in the book. Other sleep behaviors, such as non-rapid eye movement sleep and rapid eye movement sleep, and the impact sleep has on "synaptic pruning" and the creation of memories during a human's lifespan are also covered. NREM and REM are further explained by Walker to be the two sleeping basics, with 5 cycles present in a person's good night sleep. The book mentions about "morning types" and "evening types" of people, with Walker writing about how spending fewer amounts of time sleeping benefited earlier human predecessors who slept in groups of people due to their time period being safer than now.

The book emphasises on the significance of having a good night's sleep without the feeling of uneasiness or guilt of laziness. Walker, in his book, defines insomnia as a disorder that usually related to an overwrought commiserating nervous system that's usually caused by anxiousness. He goes on to addresses the P.T.S.D victims' nightmares, stating that their dreams' ability to heal them by reducing the emotions connected to a distressing memory is affected by an unusual quantity of noradrenaline being created. Walker also believed that dreams carry information regarding fundamental emotions while admitting that they can be quite apparent to people, resulting in no explanations required to describe them.

The values of sleep and the consequences of sleep deprivation are also brought up in the book. One particular research conducted in the past, where people volunteered themselves to sleep for only six hours in a span of 10 nights, is brought up by Walker. This resulted in the volunteers being "cognitively impaired" along with their brains being heavily damaged, regardless of the three week eight-hour sleep schedule they received later. Actions carried out by sleep-deprived people, such as answering emails at every hour of a day, are brought to question in the book. Walker wrote that research proves that sleeping after studying allows for "memory, integration and retention benefits" to occur. He further wrote that sleeping has the ability to retain memories and amend the abilities of human learning. Many organizations, who make creativeness, productiveness and resilient workers valued, give themselves a "sleep bonus", with the amount of extra sleep received being determined through electronic monitoring. Walker further noted that companies are changing their workplaces by allowing more "flexible working" and comfort zones for people to rest.

Walker's research on what impacts sleep is brought up in the book, with temperature influencing sleep being one of them. A five-step guideline is written in the book, with Walker explaining how to prevent "self-euthanasia" from missing sleep. The guideline also brings up "individual-level transformation" and a reformation of society. The book teaches about the basics behind how sleep works neurologically and biologically. The impact of caffeine on sleep is written in the book, with Walker noting its effects on the adenosine that allows people to fall asleep. It is further explained that caffeine will take more time to exit the body as it ages, with younger people having the ability to break caffeine down at a fast pace.

Walker wrote the book in a "reader-friendly" in areas such as discussing about neuroscientific techniques and how they were created. The book ends with Walker's advice for better sleep through 12 tips, with one of the tips written in the book being to have an eight-to-nine-hour period of sleep.

Why We Sleep has garnered a generally positive reception from critics, with Walker admitting to not knowing his book would be a hit amongst readers. The book would go on to make Walker famous in his field of expertise. The book became an international bestseller, including a #1 on the Sunday Times Bestseller in the UK, and a #8 on the New York Times Bestseller. It received numerous other reviews, including the Guardian, BBC, NPR, Financial Times, UC Berkeley and Kirkus Reviews. Critics praised the book for Walker's convincing studies on the importance of sleep and its impact on society.

Seithikurippu R. Pandi-Perumal praised Walker's structuring of the book, calling it informative, organised and intelligibly written while noting its informative yet reader-friendly nature. In a review from Bill Gates, he noted that the book teaches about the importance of sleeping, despite some points in the book not being convincing. He also noted that the book aided him in sleeping better, pointing out that it took a longer time to finish the book as he followed Walker's word on putting the book down to go to sleep. Kylie O'Brien's review described the book as "beautifully written" and filled with scientific facts that clarifies the question its title asks.

A review by Christopher Torrens in The Physiological Society described the book as informative and helpful, noting the book's evidence related to the consequences of having little to no sleep. He praised the book's style and formatting of being able to be read "from cover to cover or by cherry-picking chapters in whatever order you choose". A review by Joy Richards described the book as "tremendously terrifying" and unforgettable. Ruth Armstrong wrote that the book was loaded with recent research towards sleep, noting the change in his sleeping patterns.

Criticism surrounding the book involved the book telling stories about sleep instead of explaining facts about it. A review from Alexey Guzey, an independent researcher, criticized the book in an essay entitled Matthew Walker's "Why We Sleep" Is Riddled with Scientific and Factual Errors. The criticism was discussed on the BBC series More and Less. Guzey's criticism was also discussed by Andrew Gelman, a statistician at Columbia University. In a later post on Columbia's statistics blog, Gelman indicated that Walker's purported removal of a bar from a graph could be a "smoking gun," commenting that it entered "research misconduct" territory.

The book's failure to answer its own title 'Why We Sleep' has been criticised, with renowned sleep researcher William Dement commenting that people only need sleep due to the sleepiness accumulated. Anu Valtonen found fault in the book naming neuroscience as "the science that provides the knowledge of sleep and dreams" and its overlooking of other disciplinary areas related to sleep. She also criticised the book for lacking certain information on sleep, such as the "social aspects" of sleep or "socio-historical" route of sleep hygiene. Rosa Breed criticised Walker's lack of references when writing the book, noting that there was no proof in certain statements made by him, such as Walker's suggestion of sleeping for eight hours as a necessity. Jonathan Hawken felt that some of the book's contents were rather selective, criticising the book's lack of in-depth analysis towards the effect of sleep apnea.

The book has spawned controversy related to Walker's belief that the amount of sleep received worldwide has decreased. A researcher on sleep, Jim Horne, disagreed with the idea regarding how people are weighed down by a lack of sleep and that everybody was required to sleep for at least eight hours. Bill Gates wrote that he disagreed with Walker's claim that sleep and Alzheimer's disease have a strong connection to each other. Anu Valtonen voiced her concern regarding the speculation the book makes when taking a neuroscientific stance on the main insights into how sleep and dreams function.

Some critics felt that Walker's way of writing made the book feel similar to a horror story. Rosa Breed felt that some ideas brought up by Walker in the book were thought to be disturbing, noting Walker's suggestion for having people's sleeping behaviours be measured by "health insurance companies" to be prying. Some of Walker's claims were based on laboratory studies without supporting real-world evidence, making them questionable to critics.

# data[].attributes.attachment_link.description
Why We Sleep: The New Science of Sleep and Dreams (or simply known as Why We Sleep) is a 2017 popular science book about sleep written by Matthew Walker, an English scientist and the director of the Center for Human Sleep Science at the University of California, Berkeley, who specializes in neuroscience and psychology.

# data[].attributes.body
Sleep is a period of rest during which your body gets a break from daytime stress and activity. Although the body is relaxed during sleep, the mind is hard at work! In fact, what happens during sleep affects almost every bodily system. Sleep is just as important to your health as food and water. What happens during sleep affects how you think, feel, and function during the day. Good sleep leaves you feeling your best and comes with a range of benefits — from a better mood to enhanced learning and memory.

# data[].attributes.body
Matthew Walker: My name is Matthew Walker, I am a professor of neuroscience and psychology at the University of California, Berkeley, and I am the author of the book "Why We Sleep." We certainly know that a lack of sleep will actually prevent your brain from being able to initially make new memories, so it's almost as though without sleep the memory inbox of the brain shuts down and you can't commit new experiences to memory. So those new incoming informational emails are just bounced, and you end up feeling as though you're amnesiac. You can't essentially make and create those new memories

# data[].attributes.attachment_link.title
What Happens To Your Body And Brain If You Don't Get Sleep | The Human Body

# data[].attributes.body
If you are one of the millions of people who always feels tired, you can blame it on your alarm clock, the industrial revolution and a general lack of understanding about the bodily behavior. Or, maybe it is because you sleep too long. It turns out the human body has an internal clock that is so precise, there are many factors that can cause you to wake up tired. One thing that is known for sure - if you are not hitting every sleep cycle, you are not getting a good night's rest.

# data[].attributes.attachment_link.title
How sleep works: The reasons why we can't live without it

# data[].attributes.body
Meditation is a practice that involves focusing the mind to achieve a state of calm and clarity. When we explore the meaning of meditation, we understand it as a method to cultivate mindfulness and awareness. To define meditation more precisely, it is a technique that trains the mind to concentrate and redirect thoughts, often towards the breath, which serves as an anchor.

# data[].attributes.attachment_link.description
We will walk you through how to meditate properly, the benefits of regular meditation practice, and the various styles of meditation. Free guided audio meditations and resources.

# data[].attributes.body
This identify what is trauma and relationship between trauma and health risk.

# data[].attributes.attachment_link.title
What is Trauma? - Trauma-Informed Care Implementation Resource Center

# data[].attributes.attachment_link.description
Learn about trauma, its causes, and the negative long-term effects of trauma on health and wellbeing.

# data[].attributes.body
This identify what is trauma and relationship between trauma and health risk.

# data[].attributes.attachment_link.title
What is Trauma? - Trauma-Informed Care Implementation Resource Center

# data[].attributes.attachment_link.description
Learn about trauma, its causes, and the negative long-term effects of trauma on health and wellbeing.

# data[].attributes.body
Meditation is simpler (and harder) than most people think. Read these steps, make sure you’re somewhere where you can relax into this process, set a timer, and give it a shot:

1) Take a seat

Find place to sit that feels calm and quiet to you.

2) Set a time limit

If you’re just beginning, it can help to choose a short time, such as five or 10 minutes.

# data[].attributes.attachment_link.description
We will walk you through how to meditate properly, the benefits of regular meditation practice, and the various styles of meditation. Free guided audio meditations and resources.

# data[].attributes.body
The first thing to clarify: What we’re doing here is aiming for mindfulness, not some process that magically wipes your mind clear of the countless and endless thoughts that erupt and ping constantly in our brains. We’re just practicing bringing our attention to our breath, and then back to the breath when we notice our attention has wandered.

# data[].attributes.attachment_link.readable_text
The first thing to clarify: What we're doing here is aiming for mindfulness, not some process that magically wipes your mind clear of the countless and endless thoughts that erupt and ping constantly in our brains. We're just practicing bringing our attention to our breath, and then back to the breath when we notice our attention has wandered.

1. Get comfortable and prepare to sit still for a few minutes. After you stop reading this, you're going to simply focus on your own natural inhaling and exhaling of breath.

2. Focus on your breath. Where do you feel your breath most? In your belly? In your nose? Try to keep your attention on your inhale and exhale.

3. Follow your breath for two minutes. Take a deep inhale, expanding your belly, and then exhale slowly, elongating the out-breath as your belly contracts.

Here are five reasons to meditate:

1. Understand your pain

2. Lower your stress

3. Connect better

4. Improve focus

5. Reduce brain chatter

How to Meditate

Meditation is simpler (and harder) than most people think. Read these steps, make sure you're somewhere where you can relax into this process, set a timer, and give it a shot:

1. Take a seat

Find a place to sit that feels calm and quiet to you.

2. Set a time limit

If you're just beginning, it can help to choose a short time, such as five or 10 minutes.

3. Notice your body

You can sit in a chair with your feet on the floor, you can sit loosely cross-legged, you can kneel-all are fine. Just make sure you are stable and in a position you can stay in for a while.

4. Feel your breath

Follow the sensation of your breath as it goes in and as it goes out.

5. Notice when your mind has wandered

Inevitably, your attention will leave the breath and wander to other places. When you get around to noticing that your mind has wandered-in a few seconds, a minute, five minutes-simply return your attention to the breath.

6. Be kind to your wandering mind

Don't judge yourself or obsess over the content of the thoughts you find yourself lost in. Just come back.

7. Close with kindness

When you're ready, gently lift your gaze (if your eyes are closed, open them). Take a moment and notice any sounds in the environment. Notice how your body feels right now. Notice your thoughts and emotions.

That's it! That's the practice. You go away, you come back, and you try to do it as kindly as possible.

# data[].attributes.attachment_link.description
The first thing to clarify: What we’re doing here is aiming for mindfulness, not some process that magically wipes your mind clear of the countless and endless thoughts that erupt and ping constantly in our brains. We’re just practicing bringing our attention to our breath, and then back to the breath when we notice our attention has wandered.

# data[].attributes.body
This 10 minute mindful meditation will give you the mental clarity and space necessary to ground yourself with beautiful focus and set your day on the perfect track for success and fulfillment.

# data[].attributes.attachment_link.title
10 MIN Guided Meditation To Clear Your Mind & Start New Positive Habits

# data[].attributes.body
In just 5 minutes you can reset your day in a positive way.

# data[].attributes.body
Take a little moment to restore calm and confidence. and I put 10 min then 5 then two to show that we can find a less time to start with if we don't stay for long time .

# data[].attributes.body
Obsessive-compulsive disorder (OCD) features a pattern of unwanted thoughts and fears known as obsessions. These obsessions lead you to do repetitive behaviors, also called compulsions. These obsessions and compulsions get in the way of daily activities and cause a lot of distress.

# data[].attributes.attachment_link.readable_text
Overview

Obsessive-compulsive disorder (OCD) features a pattern of unwanted thoughts and fears known as obsessions. These obsessions lead you to do repetitive behaviors, also called compulsions. These obsessions and compulsions get in the way of daily activities and cause a lot of distress.

Ultimately, you feel driven to do compulsive acts to ease your stress. Even if you try to ignore or get rid of bothersome thoughts or urges, they keep coming back. This leads you to act based on ritual. This is the vicious cycle of OCD.

OCD often centers around certain themes, such as being overly fearful of getting contaminated by germs. To ease contamination fears, you may wash your hands over and over again until they're sore and chapped.

If you have OCD, you may be ashamed, embarrassed and frustrated about the condition. But treatment can be effective.

Symptoms

Obsessive-compulsive disorder usually includes both obsessions and compulsions. But it's also possible to have only obsession symptoms or only compulsion symptoms. You may or may not know that your obsessions and compulsions are beyond reason. But they take up a great deal of time, reduce your quality of life, and get in the way of your daily routines and responsibilities.

Obsession symptoms

OCD obsessions are lasting and unwanted thoughts that keeping coming back or urges or images that are intrusive and cause distress or anxiety. You might try to ignore them or get rid of them by acting based on ritual. These obsessions usually intrude when you're trying to think of or do other things.

Obsessions often have themes, such as:

Fear of contamination or dirt.

Doubting and having a hard time dealing with uncertainty.

Needing things to be orderly and balanced.

Aggressive or horrific thoughts about losing control and harming yourself or others.

Unwanted thoughts, including aggression, or sexual or religious subjects.

Examples of obsession symptoms include:

Fear of being contaminated by touching objects others have touched.

Doubts that you've locked the door or turned off the stove.

Intense stress when objects aren't orderly or facing a certain way.

Images of driving your car into a crowd of people.

Thoughts about shouting obscenities or not acting the right way in public.

Unpleasant sexual images.

Staying away from situations that can cause obsessions, such as shaking hands.

Compulsion symptoms

OCD compulsions are repetitive behaviors that you feel driven to do. These repetitive behaviors or mental acts are meant to reduce anxiety related to your obsessions or prevent something bad from happening. But taking part in the compulsions brings no pleasure and may offer only limited relief from anxiety.

You may make up rules or rituals to follow that help control your anxiety when you're having obsessive thoughts. These compulsions are beyond reason and often don't relate to the issue they're intended to fix.

As with obsessions, compulsions usually have themes, such as:

Washing and cleaning.

Checking.

Counting.

Ordering.

Following a strict routine.

Demanding reassurance.

Examples of compulsion symptoms include:

Hand-washing until your skin becomes raw.

Checking doors over and over again to make sure they're locked.

Checking the stove over and over again to make sure it's off.

Counting in certain patterns.

Silently repeating a prayer, word or phrase.

Trying to replace a bad thought with a good thought.

Arranging your canned goods to face the same way.

Severity varies

OCD usually begins in the teen or young adult years, but it can start in childhood. Symptoms usually begin over time and tend to vary in how serious they are throughout life. The types of obsessions and compulsions you have also can change over time. Symptoms generally get worse when you are under greater stress, including times of transition and change. OCD, usually thought to be a lifelong disorder, can have mild to moderate symptoms or be so severe and time-consuming that it becomes disabling.

When to see a doctor

There's a difference between being a perfectionist - someone who needs flawless results or performance - and having OCD. OCD thoughts aren't simply excessive worries about real issues in your life or liking to have things clean or arranged in a specific way.

If your obsessions and compulsions affect your quality of life, see your doctor or mental health professional.

From Mayo Clinic to your inbox

Sign up for free and stay up to date on research advancements, health tips, current health topics, and expertise on managing health. Click here for an email preview.

Email field is required

Include a valid email address

Learn more about Mayo Clinic's use of data.

We use the data you provide to deliver you the content you requested. To provide you with the most relevant and helpful information, we may combine your email and website data with other information we have about you. If you are a Mayo Clinic patient, we will only use your protected health information as outlined in our Notice of Privacy Practices. You may opt out of email communications at any time by clicking on the unsubscribe link in the email.

Thank you for subscribing!

You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox.

Sorry something went wrong with your subscription

Please, try again in a couple of minutes

Causes

The cause of obsessive-compulsive disorder isn't fully understood. Main theories include:

Biology. OCD may be due to changes in your body's natural chemistry or brain functions.

Genetics. OCD may have a genetic component, but specific genes have yet to be found.

Learning. Obsessive fears and compulsive behaviors can be learned from watching family members or learning them over time.

Risk factors

Factors that may raise the risk of causing obsessive-compulsive disorder include:

Family history. Having parents or other family members with the disorder can raise your risk of getting OCD.

Stressful life events. If you've gone through traumatic or stressful events, your risk may increase. This reaction may cause the intrusive thoughts, rituals and emotional distress seen in OCD.

Other mental health disorders. OCD may be related to other mental health disorders, such as anxiety disorders, depression, substance abuse or tic disorders.

Complications

Issues due to obsessive-compulsive disorder include:

Excessive time spent taking part in ritualistic behaviors.

Health issues, such as contact dermatitis from frequent hand-washing.

Having a hard time going to work or school or taking part in social activities.

Troubled relationships.

Poor quality of life.

Thoughts about suicide and behavior related to suicide.

Prevention

There's no sure way to prevent obsessive-compulsive disorder. However, getting treated as soon as possible may help keep OCD from getting worse and disrupting activities and your daily routine.

# data[].attributes.attachment_link.title
Obsessive-compulsive disorder (OCD) - Symptoms and causes

# data[].attributes.attachment_link.description
OCD features unwanted thoughts and fears, or obsessions. These obsessions lead to repetitive behaviors, also known as compulsions, that get in the way of daily activities.

# data[].attributes.body
If you notice several of these signs in your child, it's important to seek a professional evaluation. Start by consulting your child's pediatrician or a developmental pediatrician who specializes in diagnosing and treating developmental disorders. They should provide a referral to a qualified diagnostic professional who can conduct a comprehensive assessment, which may involve observations, interviews, and standardized tests to determine if your child has autism

# data[].attributes.attachment_link.title
What Are the Most Common Signs of Autism? | Arizona Autism United (AZA United)

# data[].attributes.attachment_link.description
Here are some common signs and symptoms of autism, as well as guidance on seeking support and resources for your child and family.

# data[].attributes.body
Autism spectrum disorder is a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication. The disorder also includes limited and repetitive patterns of behavior. The term "spectrum" in autism spectrum disorder refers to the wide range of symptoms and severity.

Autism spectrum disorder includes conditions that were previously considered separate — autism, Asperger's syndrome, childhood disintegrative disorder and an unspecified form of pervasive developmental disorder. Some people still use the term "Asperger's syndrome," which is generally thought to be at the mild end of autism spectrum disorder.

# data[].attributes.attachment_link.readable_text
Overview

Autism spectrum disorder is a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication. The disorder also includes limited and repetitive patterns of behavior. The term "spectrum" in autism spectrum disorder refers to the wide range of symptoms and severity.

Autism spectrum disorder includes conditions that were previously considered separate - autism, Asperger's syndrome, childhood disintegrative disorder and an unspecified form of pervasive developmental disorder. Some people still use the term "Asperger's syndrome," which is generally thought to be at the mild end of autism spectrum disorder.

Autism spectrum disorder begins in early childhood and eventually causes problems functioning in society - socially, in school and at work, for example. Often children show symptoms of autism within the first year. A small number of children appear to develop normally in the first year, and then go through a period of regression between 18 and 24 months of age when they develop autism symptoms.

While there is no cure for autism spectrum disorder, intensive, early treatment can make a big difference in the lives of many children.

Symptoms

Some children show signs of autism spectrum disorder in early infancy, such as reduced eye contact, lack of response to their name or indifference to caregivers. Other children may develop normally for the first few months or years of life, but then suddenly become withdrawn or aggressive or lose language skills they've already acquired. Signs usually are seen by age 2 years.

Each child with autism spectrum disorder is likely to have a unique pattern of behavior and level of severity - from low functioning to high functioning.

Some children with autism spectrum disorder have difficulty learning, and some have signs of lower than normal intelligence. Other children with the disorder have normal to high intelligence - they learn quickly, yet have trouble communicating and applying what they know in everyday life and adjusting to social situations.

Because of the unique mixture of symptoms in each child, severity can sometimes be difficult to determine. It's generally based on the level of impairments and how they impact the ability to function.

Below are some common signs shown by people who have autism spectrum disorder.

Social communication and interaction

A child or adult with autism spectrum disorder may have problems with social interaction and communication skills, including any of these signs:

Fails to respond to his or her name or appears not to hear you at times

Resists cuddling and holding, and seems to prefer playing alone, retreating into his or her own world

Has poor eye contact and lacks facial expression

Doesn't speak or has delayed speech, or loses previous ability to say words or sentences

Can't start a conversation or keep one going, or only starts one to make requests or label items

Speaks with an abnormal tone or rhythm and may use a singsong voice or robot-like speech

Repeats words or phrases verbatim, but doesn't understand how to use them

Doesn't appear to understand simple questions or directions

Doesn't express emotions or feelings and appears unaware of others' feelings

Doesn't point at or bring objects to share interest

Inappropriately approaches a social interaction by being passive, aggressive or disruptive

Has difficulty recognizing nonverbal cues, such as interpreting other people's facial expressions, body postures or tone of voice

Patterns of behavior

A child or adult with autism spectrum disorder may have limited, repetitive patterns of behavior, interests or activities, including any of these signs:

Performs repetitive movements, such as rocking, spinning or hand flapping

Performs activities that could cause self-harm, such as biting or head-banging

Develops specific routines or rituals and becomes disturbed at the slightest change

Has problems with coordination or has odd movement patterns, such as clumsiness or walking on toes, and has odd, stiff or exaggerated body language

Is fascinated by details of an object, such as the spinning wheels of a toy car, but doesn't understand the overall purpose or function of the object

Is unusually sensitive to light, sound or touch, yet may be indifferent to pain or temperature

Doesn't engage in imitative or make-believe play

Fixates on an object or activity with abnormal intensity or focus

Has specific food preferences, such as eating only a few foods, or refusing foods with a certain texture

As they mature, some children with autism spectrum disorder become more engaged with others and show fewer disturbances in behavior. Some, usually those with the least severe problems, eventually may lead normal or near-normal lives. Others, however, continue to have difficulty with language or social skills, and the teen years can bring worse behavioral and emotional problems.

When to see a doctor

Babies develop at their own pace, and many don't follow exact timelines found in some parenting books. But children with autism spectrum disorder usually show some signs of delayed development before age 2 years.

If you're concerned about your child's development or you suspect that your child may have autism spectrum disorder, discuss your concerns with your doctor. The symptoms associated with the disorder can also be linked with other developmental disorders.

Signs of autism spectrum disorder often appear early in development when there are obvious delays in language skills and social interactions. Your doctor may recommend developmental tests to identify if your child has delays in cognitive, language and social skills, if your child:

Doesn't respond with a smile or happy expression by 6 months

Doesn't mimic sounds or facial expressions by 9 months

Doesn't babble or coo by 12 months

Doesn't gesture - such as point or wave - by 14 months

Doesn't say single words by 16 months

Doesn't play "make-believe" or pretend by 18 months

Doesn't say two-word phrases by 24 months

Loses language skills or social skills at any age

Causes

Autism spectrum disorder has no single known cause. Given the complexity of the disorder, and the fact that symptoms and severity vary, there are probably many causes. Both genetics and environment may play a role.

Genetics. Several different genes appear to be involved in autism spectrum disorder. For some children, autism spectrum disorder can be associated with a genetic disorder, such as Rett syndrome or fragile X syndrome. For other children, genetic changes (mutations) may increase the risk of autism spectrum disorder. Still other genes may affect brain development or the way that brain cells communicate, or they may determine the severity of symptoms. Some genetic mutations seem to be inherited, while others occur spontaneously.

Environmental factors. Researchers are currently exploring whether factors such as viral infections, medications or complications during pregnancy, or air pollutants play a role in triggering autism spectrum disorder.

No link between vaccines and autism spectrum disorder

One of the greatest controversies in autism spectrum disorder centers on whether a link exists between the disorder and childhood vaccines. Despite extensive research, no reliable study has shown a link between autism spectrum disorder and any vaccines. In fact, the original study that ignited the debate years ago has been retracted due to poor design and questionable research methods.

Avoiding childhood vaccinations can place your child and others in danger of catching and spreading serious diseases, including whooping cough (pertussis), measles or mumps.

Risk factors

The number of children diagnosed with autism spectrum disorder is rising. It's not clear whether this is due to better detection and reporting or a real increase in the number of cases, or both.

Autism spectrum disorder affects children of all races and nationalities, but certain factors increase a child's risk. These may include:

Your child's sex. Boys are about four times more likely to develop autism spectrum disorder than girls are.

Family history. Families who have one child with autism spectrum disorder have an increased risk of having another child with the disorder. It's also not uncommon for parents or relatives of a child with autism spectrum disorder to have minor problems with social or communication skills themselves or to engage in certain behaviors typical of the disorder.

Other disorders. Children with certain medical conditions have a higher than normal risk of autism spectrum disorder or autism-like symptoms. Examples include fragile X syndrome, an inherited disorder that causes intellectual problems; tuberous sclerosis, a condition in which benign tumors develop in the brain; and Rett syndrome, a genetic condition occurring almost exclusively in girls, which causes slowing of head growth, intellectual disability and loss of purposeful hand use.

Extremely preterm babies. Babies born before 26 weeks of gestation may have a greater risk of autism spectrum disorder.

Parents' ages. There may be a connection between children born to older parents and autism spectrum disorder, but more research is necessary to establish this link.

Complications

Problems with social interactions, communication and behavior can lead to:

Problems in school and with successful learning

Employment problems

Inability to live independently

Social isolation

Stress within the family

Victimization and being bullied

Prevention

There's no way to prevent autism spectrum disorder, but there are treatment options. Early diagnosis and intervention is most helpful and can improve behavior, skills and language development. However, intervention is helpful at any age. Though children usually don't outgrow autism spectrum disorder symptoms, they may learn to function well.

# data[].attributes.attachment_link.title
Autism spectrum disorder - Symptoms and causes

# data[].attributes.attachment_link.description
Autism spectrum disorder is a serious condition related to brain development that impairs the ability to communicate and interact with others.

# data[].attributes.body
Professor Andrew Whitehouse leads the Autism Research Team at Telethon Kids Institute, working with children with autism and their families to reduce the disability associated with the disorder. In this short video he shares his top ten things that everyone should know about autism spectrum disorder.

# data[].attributes.attachment_link.title
Autism Spectrum Disorder: 10 things you should know

# data[].attributes.body
What's an autistic person supposed to look like anyway? 8 people with autism set the record straight so everyone else can stop asking such cringeworthy questions.

# data[].attributes.headline
4types of trauma and how impact our relationships.

# data[].attributes.subject
4types of trauma and how impact our relationships.

# data[].attributes.body
In this video, we explore the 4 types of trauma and how they can impact your relationships. Trauma can be caused by a variety of experiences, such as abuse, neglect, or even natural disasters. When left unaddressed, it can lead to negative patterns in our relationships. We discuss the impact of rejection trauma, abandonment trauma, betrayal trauma, and humiliation trauma on our relationships and provide tips on how to overcome the negative effects of emotional trauma or psychological trauma.

# data[].attributes.attachment_link.title
4 Types of Trauma & How It Impacts Your Relationship

# data[].attributes.body
There is a topic in autism that is not discussed at all. It is almost even more taboo than healing autism — life expectancy. If you are a parent of an autistic child, I want you to know - there is hope. You and your child can smile again. There can be laughter and connection. So many fun times can be part of your future. You probably feel that possibility in your gut but you're not sure how to get here. Let me help guide you.

# data[].attributes.attachment_link.authors[].name
Navigating AWEtism with Theresa Lyons, PhD

# data[].attributes.body
The term “ACEs” is an acronym for Adverse Childhood Experiences. It originated in a groundbreaking study conducted in 1995 by the Centers for Disease Control and the Kaiser Permanente health care organization in California. In that study, “ACEs” referred to three specific kinds of adversity children faced in the home environment—various forms of physical and emotional abuse, neglect, and household dysfunction. The key findings of dozens of studies using the original ACEs data are: (1) ACEs are quite common, even among a middle-class population: more than two-thirds of the population report experiencing one ACE, and nearly a quarter have experienced three or more. (2) There is a powerful, persistent correlation between the more ACEs experienced and the greater the chance of poor outcomes later in life, including dramatically increased risk of heart disease, diabetes, obesity, depression, substance abuse, smoking, poor academic achievement, time out of work, and early death.

# data[].attributes.attachment_link.provider_name
Center on the Developing Child at Harvard University

# data[].attributes.attachment_link.readable_text
What are ACEs?

The term "ACEs" is an acronym for Adverse Childhood Experiences. It originated in a groundbreaking study conducted in 1995 by the Centers for Disease Control and the Kaiser Permanente health care organization in California. In that study, "ACEs" referred to three specific kinds of adversity children faced in the home environment-various forms of physical and emotional abuse, neglect, and household dysfunction. The key findings of dozens of studies using the original ACEs data are: (1) ACEs are quite common, even among a middle-class population: more than two-thirds of the population report experiencing one ACE, and nearly a quarter have experienced three or more. (2) There is a powerful, persistent correlation between the more ACEs experienced and the greater the chance of poor outcomes later in life, including dramatically increased risk of heart disease, diabetes, obesity, depression, substance abuse, smoking, poor academic achievement, time out of work, and early death.

How do ACEs relate to toxic stress?

ACEs research shows the correlation between early adversity and poor outcomes later in life. Toxic stress explains how ACEs "get under the skin" and trigger biological reactions that lead to those outcomes. In the early 2000s, the National Scientific Council on the Developing Child coined the term " toxic stress " to describe extensive, scientific knowledge about the effects of excessive activation of stress response systems on a child's developing brain, as well as the immune system, metabolic regulatory systems, and cardiovascular system. Experiencing ACEs triggers all of these interacting stress response systems. When a child experiences multiple ACEs over time-especially without supportive relationships with adults to provide buffering protection-the experiences will trigger an excessive and long-lasting stress response, which can have a wear-and-tear effect on the body, like revving a car engine for days or weeks at a time.

Importantly, the Council also expanded its definition of adversity beyond the categories that were the focus of the initial ACE study to include community and systemic causes-such as violence in the child's community and experiences with racism and chronic poverty-because the body's stress response does not distinguish between overt threats from inside or outside the home environment, it just recognizes when there is a threat, and goes on high alert.

What is trauma, and how does it connect to ACEs and toxic stress?

While trauma has many definitions, typically in psychology it refers to an experience of serious adversity or terror-or the emotional or psychological response to that experience. Trauma-informed care or services are characterized by an understanding that problematic behaviors may need to be treated as a result of the ACEs or other traumatic experiences someone has had, as opposed to addressing them as simply willful and/or punishable actions.

What can we do to help mitigate the effects of ACEs?

People who have experienced significant adversity (or many ACEs) are not irreparably damaged. There is a spectrum of potential responses to ACEs and their possible chain of developmental harm that can help a person recover from trauma caused by toxic stress.

At the most intensive end of the spectrum are therapeutic interventions, ranging from in-patient treatment to regular sessions with a mental health professional, which are designed specifically to deal with serious trauma.

Trauma-informed care or practice is less intensive, but affects how practitioners in a range of fields, such as social work, medicine, and education, work with people who have experienced toxic stress, and reflects an awareness of the harm that has occurred and takes that into account. There are also many less-intensive practices that can help individuals reduce the effects of stress-from meditation and breathing exercises, to physical exercise and social supports.

ACEs-based screening and referral is an increasingly common approach, in which individuals are given an ACE score based on a brief survey of their own personal history of ACEs. This can indicate a general, non-specific sense of increased risk based on population-level probabilities, but it cannot predict accurately how any one individual will fare. In other words, a high ACE score can serve as a rough first screener to identify people who may benefit from services, but it cannot tell you what specifically you are at risk for, nor what to do about it.

The ideal approach to ACEs is one that prevents the need for all levels of services: by reducing the sources of stress in people's lives, whether basic needs like food, housing, and diapers, or more entrenched sources of stress, like substance abuse, mental illness, violent relationships, community crime, discrimination, or poverty. Supporting responsive relationships with a parent or caregiver can also help to buffer a child from the effects of stress, and helping children and adults build their core life skills-such as planning, focus, and self-control-can strengthen the building blocks of resilience. These three principles-reducing stress, building responsive relationships, and strengthening life skills-are the best way to prevent the long-term effects of ACEs.

# data[].attributes.attachment_link.title
What Are ACEs? And How Do They Relate to Toxic Stress?

# data[].attributes.attachment_link.description
What are Adverse Childhood Experiences (ACEs)? In this infographic and FAQ, learn about ACEs and toxic stress, and how to prevent or reduce lasting harm.

# data[].attributes.body
Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood. ACEs can include violence, abuse, and growing up in a family with mental health or substance use problems. Toxic stress from ACEs can change brain development and affect how the body responds to stress. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. However, ACEs can be prevented

# data[].attributes.attachment_link.provider_name
Centers for Disease Control and Prevention

# data[].attributes.attachment_link.readable_text
Adverse Childhood Experiences (ACEs)

Preventing early trauma to improve adult health

At least 5 of the top 10 leading causes of death are associated with ACEs.

Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood. ACEs can include violence, abuse, and growing up in a family with mental health or substance use problems. Toxic stress from ACEs can change brain development and affect how the body responds to stress. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. However, ACEs can be prevented.
Preventing ACEs can help children and adults thrive and potentially:

Lower risk for conditions like depression, asthma, cancer, and diabetes in adulthood.

Reduce risky behaviors like smoking and heavy drinking.

Improve education and employment potential.

Stop ACEs from being passed from one generation to the next.

Preventing ACEs could reduce a large number of health conditions.

Potential reduction of negative outcomes in adulthood

Adverse Childhood Experiences impact lifelong health and opportunities.

ACEs are common and the effects can add up over time.

61% of adults had at least one ACE and 16% had 4 or more types of ACEs.

Females and several racial/ethnic minority groups were at greater risk for experiencing 4 or more ACEs.

Many people do not realize that exposure to ACEs is associated with increased risk for health problems across the lifespan.

Healthcare Providers Can:

Anticipate and recognize current risk for ACEs in children and history of ACEs in adults. Refer patients to effective services and support.

Link adults to family-centered treatment approaches that include substance abuse treatment and parenting interventions.

Employers Can:

Adopt and support family-friendly policies, such as paid family leave and flexible work schedules.

States and Communities Can:

Improve access to high-quality childcare by expanding eligibility, activities offered, and family involvement.

Use effective social and economic supports that address financial hardship and other conditions that put families at risk for ACEs.

Enhance connections to caring adults and increase parents' and youth skills to manage emotions and conflicts using approaches in schools and other settings.

Everyone Can:

Change how people think about the causes of ACEs and who could help prevent them.

Shift the focus from individual responsibility to community solutions.

Reduce stigma around seeking help with parenting challenges or for substance misuse, depression, or suicidal thoughts.

Promote safe, stable, nurturing relationships and environments where children live, learn, and play.

Related Pages and Resources
Resources:

For More Information
1-800-CDC-INFO (232-4636)
TTY: 1-888-232-6348
Web: www.cdc.gov

Centers for Disease Control and Prevention
1600 Clifton Road NE
Atlanta, GA 30333
Publication date: November 5, 2019

# data[].attributes.attachment_link.description
Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood.

# data[].attributes.body
This questionnaire asks about 10 categories of childhood experiences that may affect your health and well-being. You can check the categories you experienced and get your ACE score

# data[].attributes.body
Effect of ACES on our childhood experience and what might lead and affect our life.

# data[].attributes.body
parents plays an important role of our ACES the video example of real life and how ACES affect our life and how we can prevent it.

# data[].attributes.attachment_link.authors[].name
Centers for Disease Control and Prevention (CDC)

# data[].attributes.body
Adverse Childhood Experiences (ACEs) can have a significant impact on the brain ¹ ² ³:

ACEs include potentially traumatic events such as violence, abuse, and growing up in a family with mental health or substance use problems.

Toxic stress from ACEs can change brain development and affect how the body responds to stress.

ACEs can negatively affect children’s brain development, immune systems, and stress-response systems.

Psychological trauma from ACEs can lead to difficulty in regulating behavior, impulse control, and fear responses, which is managed by the prefrontal cortex.

MRI studies have shown that people who have experienced ACEs have less gray matter in the prefrontal cortex, explaining the difficulty in regulation.

# data[].attributes.attachment_link.title
Adverse Childhood Experiences (ACEs): Impact on brain, body and behaviour

# data[].attributes.body
Down syndrome is a genetic disorder caused when abnormal cell division results in an extra full or partial copy of chromosome 21. This extra genetic material causes the developmental changes and physical features of Down syndrome.

Down syndrome varies in severity among individuals, causing lifelong intellectual disability and developmental delays. It's the most common genetic chromosomal disorder and cause of learning disabilities in children. It also commonly causes other medical abnormalities, including heart and gastrointestinal disorders.

# data[].attributes.attachment_link.readable_text
Overview

Down syndrome is a genetic disorder caused when abnormal cell division results in an extra full or partial copy of chromosome 21. This extra genetic material causes the developmental changes and physical features of Down syndrome.

Down syndrome varies in severity among individuals, causing lifelong intellectual disability and developmental delays. It's the most common genetic chromosomal disorder and cause of learning disabilities in children. It also commonly causes other medical abnormalities, including heart and gastrointestinal disorders.

Better understanding of Down syndrome and early interventions can greatly increase the quality of life for children and adults with this disorder and help them live fulfilling lives.

Symptoms

Each person with Down syndrome is an individual - intellectual and developmental problems may be mild, moderate or severe. Some people are healthy while others have significant health problems such as serious heart defects.

Children and adults with Down syndrome have distinct facial features. Though not all people with Down syndrome have the same features, some of the more common features include:

Flattened face

Small head

Short neck

Protruding tongue

Upward slanting eye lids (palpebral fissures)

Unusually shaped or small ears

Poor muscle tone

Broad, short hands with a single crease in the palm

Relatively short fingers and small hands and feet

Excessive flexibility

Tiny white spots on the colored part (iris) of the eye called Brushfield's spots

Short height

Infants with Down syndrome may be average size, but typically they grow slowly and remain shorter than other children the same age.

Intellectual disabilities

Most children with Down syndrome have mild to moderate cognitive impairment. Language is delayed, and both short and long-term memory is affected.

When to see a doctor

Children with Down syndrome usually are diagnosed before or at birth. However, if you have any questions regarding your pregnancy or your child's growth and development, talk with your doctor.

Causes

Human cells normally contain 23 pairs of chromosomes. One chromosome in each pair comes from your father, the other from your mother.

Down syndrome results when abnormal cell division involving chromosome 21 occurs. These cell division abnormalities result in an extra partial or full chromosome 21. This extra genetic material is responsible for the characteristic features and developmental problems of Down syndrome. Any one of three genetic variations can cause Down syndrome:

Trisomy 21. About 95 percent of the time, Down syndrome is caused by trisomy 21 - the person has three copies of chromosome 21, instead of the usual two copies, in all cells. This is caused by abnormal cell division during the development of the sperm cell or the egg cell.

Mosaic Down syndrome. In this rare form of Down syndrome, a person has only some cells with an extra copy of chromosome 21. This mosaic of normal and abnormal cells is caused by abnormal cell division after fertilization.

Translocation Down syndrome. Down syndrome can also occur when a portion of chromosome 21 becomes attached (translocated) onto another chromosome, before or at conception. These children have the usual two copies of chromosome 21, but they also have additional genetic material from chromosome 21 attached to another chromosome.

There are no known behavioral or environmental factors that cause Down syndrome.

Is it inherited?

Most of the time, Down syndrome isn't inherited. It's caused by a mistake in cell division during early development of the fetus.

Translocation Down syndrome can be passed from parent to child. However, only about 3 to 4 percent of children with Down syndrome have translocation and only some of them inherited it from one of their parents.

When balanced translocations are inherited, the mother or father has some rearranged genetic material from chromosome 21 on another chromosome, but no extra genetic material. This means he or she has no signs or symptoms of Down syndrome, but can pass an unbalanced translocation on to children, causing Down syndrome in the children.

Risk factors

Some parents have a greater risk of having a baby with Down syndrome. Risk factors include:

Advancing maternal age. A woman's chances of giving birth to a child with Down syndrome increase with age because older eggs have a greater risk of improper chromosome division. A woman's risk of conceiving a child with Down syndrome increases after 35 years of age. However, most children with Down syndrome are born to women under age 35 because younger women have far more babies.

Being carriers of the genetic translocation for Down syndrome. Both men and women can pass the genetic translocation for Down syndrome on to their children.

Having had one child with Down syndrome. Parents who have one child with Down syndrome and parents who have a translocation themselves are at an increased risk of having another child with Down syndrome. A genetic counselor can help parents assess the risk of having a second child with Down syndrome.

Complications

People with Down syndrome can have a variety of complications, some of which become more prominent as they get older. These complications can include:

Heart defects. About half the children with Down syndrome are born with some type of congenital heart defect. These heart problems can be life-threatening and may require surgery in early infancy.

Gastrointestinal (GI) defects. GI abnormalities occur in some children with Down syndrome and may include abnormalities of the intestines, esophagus, trachea and anus. The risk of developing digestive problems, such as GI blockage, heartburn (gastroesophageal reflux) or celiac disease, may be increased.

Immune disorders. Because of abnormalities in their immune systems, people with Down syndrome are at increased risk of developing autoimmune disorders, some forms of cancer, and infectious diseases, such as pneumonia.

Sleep apnea. Because of soft tissue and skeletal changes that lead to the obstruction of their airways, children and adults with Down syndrome are at greater risk of obstructive sleep apnea.

Obesity. People with Down syndrome have a greater tendency to be obese compared with the general population.

Spinal problems. Some people with Down syndrome may have a misalignment of the top two vertebrae in the neck (atlantoaxial instability). This condition puts them at risk of serious injury to the spinal cord from overextension of the neck.

Leukemia. Young children with Down syndrome have an increased risk of leukemia.

Dementia. People with Down syndrome have a greatly increased risk of dementia - signs and symptoms may begin around age 50. Having Down syndrome also increases the risk of developing Alzheimer's disease.

Other problems. Down syndrome may also be associated with other health conditions, including endocrine problems, dental problems, seizures, ear infections, and hearing and vision problems.

For people with Down syndrome, getting routine medical care and treating issues when needed can help with maintaining a healthy lifestyle.

Life expectancy

Life spans have increased dramatically for people with Down syndrome. Today, someone with Down syndrome can expect to live more than 60 years, depending on the severity of health problems.

Prevention

There's no way to prevent Down syndrome. If you're at high risk of having a child with Down syndrome or you already have one child with Down syndrome, you may want to consult a genetic counselor before becoming pregnant.

A genetic counselor can help you understand your chances of having a child with Down syndrome. He or she can also explain the prenatal tests that are available and help explain the pros and cons of testing.

# data[].attributes.attachment_link.description
Down syndrome is a genetic disorder caused when abnormal cell division results in extra genetic material from chromosome 21.

# data[].attributes.body
ach person with Down syndrome is an individual — intellectual and developmental problems may be mild, moderate or severe. Some people are healthy while others have significant health problems such as serious heart defects.

Children and adults with Down syndrome have distinct facial features. Though not all people with Down syndrome have the same features, some of the more common features include:

Flattened face

Small head

Short neck

Protruding tongue

Upward slanting eye lids (palpebral fissures)

Unusually shaped or small ears

Poor muscle tone

Broad, short hands with a single crease in the palm

Relatively short fingers and small hands and feet

Excessive flexibility

Tiny white spots on the colored part (iris) of the eye called Brushfield's spots

Short height

# data[].attributes.attachment_link.readable_text
Down syndrome is a genetic condition that causes mild to serious physical and developmental problems.

People with Down syndrome are born with an extra chromosome. Chromosomes are bundles of genes, and your body relies on having just the right number of them. With Down syndrome, this extra chromosome leads to a range of issues that affect you both mentally and physically.

Down syndrome is a lifelong condition. Although it can't be cured, doctors know more about it now than ever. If your child has it, getting the right care early on can make a big difference in helping them live a full and meaningful life.

While Down syndrome affects people both physically and mentally, it's very different for each person. And there's no telling early on what its impacts will be. No matter what symptoms a person with Down syndrome has, early treatment is key. (Photo credit: Eleonoraos/Dreamstime)

There are three types of Down syndrome, including:

Trisomy 21. This is the most common type of Down syndrome, with 95% of people with Down syndrome having this type. It happens when your body's cells have three copies of chromosome 21 instead of two.

Translocation Down syndrome. About 3% of people with Down syndrome have this type, where there's an extra part or whole chromosome 21 but it's attached to another chromosome instead of being a separate chromosome 21.

Mosaic Down syndrome. This type of Down syndrome, which affects about 2% of people with the condition, happens when only some cells have an extra chromosome 21.

You can't tell what type of Down syndrome someone has by how they look. The effects of all three types are very similar, but someone with mosaic Down syndrome may not have as many symptoms because fewer cells have the extra chromosome.

Down syndrome can have many effects, and it's different for each person. Some will grow up to live almost entirely on their own, while others will need more help taking care of themselves.

Mental abilities vary, but most people with Down syndrome have mild to moderate issues with thinking, reasoning, and understanding. They'll learn and pick up new skills their whole lives, but they may take longer to reach important goals like walking, talking, and developing social skills.

People with Down syndrome tend to have certain physical features in common. These may include:

Eyes that slant up at the outer corner

Small ears

Flat noses

Tongue that sticks out

Tiny white spots in the colored part of the eyes

Short neck and overall height

Small hands and feet

Short stature

Loose joints

Weak muscle tone and joints

Small pinky fingers that curve in

One crease across the palm of the hand

Many people with Down syndrome don't have any other health issues, but some do. Some conditions include eye disease, hearing loss and ear infections, sleep apnea, and heart problems.

People with Down syndrome may also have trouble with behavior - they may not pay attention well, or can be obsessive about some things. That's because it's harder for them to control their impulses, relate to others, and manage their feelings when they get frustrated.

As adults, people with Down syndrome may learn to decide many things on their own but will likely need help with more complex issues like birth control or managing money. Some may go to a college that can provide accommodations and modifications tailored to developmental and intellectual delays and may go on to live independently, while others will need more day-to-day care.

For most people, each cell in your body has 23 pairs of chromosomes. One chromosome in each pair comes from your mother and the other comes from your father.

But with Down syndrome, you get an extra copy of chromosome 21. That means you have three copies instead of two, which leads to the symptoms of Down syndrome. Doctors aren't sure why this happens. There's no link to anything in the environment or anything the parents did or didn't do.

While doctors don't know what causes it, they do know that women 35 and older have a higher chance of having a baby with Down syndrome. If you've already had a child with Down syndrome, you're more likely to have another one who also has it.

It's not common, but it's possible to pass Down syndrome from parent to child. Sometimes, a parent has what experts call "translocated" genes. That means some of their genes aren't in their normal place, perhaps on a different chromosome from where they'd usually be found.

The parent doesn't have Down syndrome because they have the right number of genes, but their child may have translocation Down syndrome, where they have an extra chromosome 21. Not everyone with translocation Down syndrome gets it from their parents -- it may also happen by chance.

Routine tests done during pregnancy can check if it's likely your baby has Down syndrome. If those results are positive, or if you're at high risk, you may choose to have additional, more invasive tests to be sure.

Screening tests are usually done first and are considered safe to you and your growing baby. These normally include a combination of blood tests, which look at the amount of certain levels in your blood, and ultrasounds, which show images of your baby.

In the first trimester, you may have:

Blood tests. Your doctor measures the levels of a protein called PAPP-A and a hormone called hCG in your blood. Anything out of the normal range could mean a problem with the baby. If you're at high risk for Down syndrome, they may also look for DNA from the baby in your blood, which they can examine for abnormal chromosomes.

Ultrasound. Your doctor looks at a picture of your baby and measures the folds of tissue at the back of their neck. Babies with Down syndrome tend to have extra fluid there.

In the second trimester, you may have:

Blood tests. Either a triple or quad-screen test measures other substances in your blood, including the protein AFP and the hormone estriol. Those levels, combined with the results from the first trimester tests, give your doctor a good estimate of the chances your baby has Down syndrome.

Ultrasound. When your baby is more developed, an ultrasound can show some of the physical features of Down syndrome.

Other kinds of tests can diagnose Down syndrome before your baby is born by checking a sample of their DNA for an extra chromosome 21. These diagnostic tests usually happen after screening test results are positive, to confirm a Down syndrome diagnosis. They include:

Chorionic villus sampling (CVS). This can be done during the first trimester, using cells taken from the placenta.

Amniocentesis. Fluid is taken from the amniotic sac surrounding the baby, usually during the second trimester.

Percutaneous umbilical blood sampling (PUBS). This is also done in the second trimester using blood removed from the umbilical cord.

After a baby is born, a doctor may suspect Down syndrome in a newborn based on the baby's appearance. But some babies without Down syndrome may have similar physical features to a baby with Down syndrome.

A diagnosis can be confirmed by a blood test called a karyotype test that lines up the chromosomes and will show if there's an extra chromosome 21.

Babies with Down syndrome may be born with other physical problems, and they're at higher risk for certain health issues later in life.

Possible complications of Down syndrome include:

They're also more likely to have:

Blood conditions like anemia, where you have low iron. It's not as common, but they also have a higher chance of getting leukemia, a type of blood cancer.

Infections. People with Down syndrome may get sick more often because they tend to have weaker immune systems.

As they age, adults with Down syndrome are at a higher risk of depression and Alzheimer's dementia, which are conditions that will also affect their behavior.

People with Down syndrome have a shorter life span.

There's no specific treatment for Down syndrome. But there is a wide range of physical and developmental therapies designed to help people with Down syndrome reach their full potential. The earlier you start treatment, the better.

Each child will have different needs. Yours may benefit from:

Physical, occupational, and speech therapy

Specialized education services

Social and recreation activities

Programs that offer job training and teach self-care skills

You'll also work closely with your child's doctor to watch for and manage any health problems associated with the condition.

When your child has Down syndrome, one of the most useful things you can do is learn as much about it as you can. You might search online for programs and resources to help your child.

Along the way, maybe you talk with other parents whose children have Down syndrome so you can learn tips and find out what to expect. And as your child grows, you can work with doctors, therapists, teachers, and other specialists.

Beyond these big-picture tasks, it can also help to know what you can do day to day not only to support your child, but to take care of yourself, too.

Down syndrome support

Every family has their joys, stresses, and challenges, but when you have a child with Down syndrome, things look a little different. Besides juggling school, music lessons, sports, and jobs, you typically have a lot of extra visits with doctors and therapists.

Your needs and the needs of your child make it even more important to accept help when it's offered. Here are a few ideas:

Build a support system. Invite your friends and family to take part in caregiving. They can let you have a little time to yourself to walk, read a book, or just zone out for a while. A break, even a small one, can help you be a better parent and partner.

Talk about your challenges. People want to help, but don't always know how. A simple, "It's hard to get a healthy dinner on the table with all these appointments," opens a door and gives them ideas of what they can do.

Keep a list of things you need. And don't be afraid to use it. Next time someone says, "Just let me know how I can help," you'll be ready.

Find time for friends. Even if it's just a small moment after the kids go to bed, friends can help you laugh and recharge.

Consider therapy. You might think about seeing a therapist. They can help you work through your feelings and give you tools to handle everyday stresses.

Take care of your health. Exercise and eat well, even when you feel burnt out. Try to make a plan and stick to it as best you can.

Everyday tips

Like most children, kids with Down syndrome tend to do well with routine. They also respond better to positive support than discipline. Keep both of those things in mind as you try the following daily tips:

Give your child chores around the house, but break them up into small steps and be patient.

Have your child play with other kids who do and don't have Down syndrome.

Keep your expectations high as your child tries and learns new things.

Make time to play, read, have fun, and go out together.

Support your child in doing day-to-day tasks on their own.

For everyday tasks, you can try to:

Create a daily schedule and stick to it as best you can. For example, the morning might be getting up, eating breakfast, brushing teeth, and getting dressed.

Help your child change from one activity to the next with very clear signals. For younger kids, seeing a picture or singing a song can help.

Use pictures to make a daily plan your child can see.

Use simple terms when talking to your child, with fewer steps.

Encourage your child to repeat directions back to you. This helps to make sure they understand.

Name and talk about things your child seems excited about.

To help your child with school, you might:

Avoid saying "That's wrong" to correct mistakes. Instead, say, "Try it again." Offer help if it's needed.

As you work with doctors, therapists, and teachers, focus on your child's needs rather than on the condition.

Look at what your child is learning at school and see if you can work those lessons into your home life.

It's also important for all kids to feel like they have some control over their lives. It's even more important for kids with Down syndrome, and it's one way to help them live a fulfilling life. To do this, you can:

Let your child make choices when it makes sense to. This can be as simple as letting them choose what clothes to wear.

Allow them to take reasonable risks. This is a challenge every parent faces. You need to protect your children, but also let them see what they can handle.

Support them in solving problems, like how to deal with an issue with friends or approach a problem at school. You don't have to fix it for them, but help them do it themselves.

# data[].attributes.attachment_link.description
People with Down syndrome have an extra chromosome that impacts how a person looks and their ability to think, learn, and reason. Find out the type, causes, and kinds of effects it can have.

# data[].attributes.body
The extra genetic material from the third copy of chromosome 21 causes the body to develop differently. This occurs whether a person has full trisomy 21, mosaic Down syndrome, or translocation.

This produces changes in the developing fetus's physical features. Many of the changes are present at birth, and some can develop as the child grows into adolescence and adulthood.

# data[].attributes.attachment_link.description
Down syndrome is a genetic condition that impacts the brain and body’s development. Learn about the causes, symptoms, and diagnosis of this condition.

# data[].attributes.body
In every cell in the human body there is a nucleus, where genetic material is stored in genes. Genes carry the codes responsible for all of our inherited traits and are grouped along rod-like structures called chromosomes. Typically, the nucleus of each cell contains 23 pairs of chromosomes, half of which are inherited from each parent. Down syndrome occurs when an individual has a full or partial extra copy of chromosome 21.

# data[].attributes.attachment_link.readable_text
In every cell in the human body there is a nucleus, where genetic material is stored in genes. Genes carry the codes responsible for all of our inherited traits and are grouped along rod-like structures called chromosomes. Typically, the nucleus of each cell contains 23 pairs of chromosomes, half of which are inherited from each parent. Down syndrome occurs when an individual has a full or partial extra copy of chromosome 21.

This additional genetic material alters the course of development and causes the characteristics associated with Down syndrome. A few of the common physical traits of Down syndrome are low muscle tone, small stature, an upward slant to the eyes, and a single deep crease across the center of the palm - although each person with Down syndrome is a unique individual and may possess these characteristics to different degrees, or not at all.

Donate

How common is Down syndrome?

According to the Centers for Disease Control and Prevention, approximately one in every 772 babies in the United States is born with Down syndrome, making Down syndrome the most common chromosomal condition. About 5,100 babies with Down syndrome are born in the United States each year. (De Graaf et al., 2022).

When was Down syndrome discovered?

Are there different types of Down syndrome?

What is the likelihood of having a child with Down syndrome?

Down syndrome occurs in people of all races and economic levels, though older women have an increased chance of having a child with Down syndrome. A 35-year-old woman has about a one in 350 chance of conceiving a child with Down syndrome, and this chance increases gradually to 1 in 100 by age 40. At age 45 the incidence becomes approximately 1 in 30. The age of the mother, or birthing parent, does not seem to be linked to the risk of translocation.

Since many couples are postponing parenting until later in life, the incidence of Down syndrome conceptions is expected to increase. Therefore, genetic counseling for parents is becoming increasingly important. Still, many physicians are not fully informed about advising their patients about the incidences of Down syndrome, advancements in diagnosis, and the protocols for care and treatment of babies born with Down syndrome.

What impact does Down syndrome have on society?

Individuals with Down syndrome are becoming increasingly integrated into society and community organizations, such as schools, health care systems, work forces, and social and recreational activities. Individuals with Down syndrome possess varying degrees of cognitive delays, from very mild to severe. Most people with Down syndrome have cognitive delays that are mild to moderate.

Due to advances in medical technology, individuals with Down syndrome are living longer than ever before. In 1910, children with Down syndrome were expected to survive to age nine. With the discovery of antibiotics, the average survival age increased to 19 or 20. Now, with recent advancements in clinical treatment, most particularly corrective heart surgeries, as many as 80% of adults with Down syndrome reach age 60, and many live even longer (Down syndrome, 2018). More and more Americans are interacting with individuals with Down syndrome, increasing the need for widespread public education and acceptance.

# data[].attributes.attachment_link.description
In every cell in the human body there is a nucleus, where genetic material is stored in genes. Genes carry the codes responsible for all of our inherited traits and are grouped along rod-like structures called chromosomes. Typically, the nucleus of each cell contains 23 pairs of chromosomes, half of which are inherited from each parent.

# data[].attributes.body
What is Down syndrome (trisomy 21)? Down syndrome is a set of symptoms that arise from a genetic abnormality, in which an individual's cells have an extra copy of chromosome 21. Find our full video library only on Osmosis: http://osms.it/more. Join millions of current and future clinicians who learn by Osmosis, along with hundreds of universities around the world who partner with Osmosis from Elseiver to make medical and health education more engaging and efficient. We have unparalleled tools and materials to prepare you for success in school, on your board exams, and as a future clinician

# data[].attributes.attachment_link.title
Down syndrome (trisomy 21) - causes, symptoms, diagnosis, & pathology

# data[].attributes.body
A new study highlights the potential of psilocybin, a psychedelic compound, in treating obsessive-compulsive disorder (OCD) and Tourette's Syndrome. Research conducted on mice showed that psilocybin and psychedelic mushroom extract significantly reduced OCD-like behaviors and tic-like head-body twitches. These promising results pave the way for clinical trials and offer hope for new, effective treatments for OCD and Tourette's Syndrome.

# data[].attributes.attachment_link.readable_text
A new study highlights the potential of psilocybin, a psychedelic compound, in treating obsessive-compulsive disorder (OCD) and Tourette's Syndrome. Research conducted on mice showed that psilocybin and psychedelic mushroom extract significantly reduced OCD-like behaviors and tic-like head-body twitches. These promising results pave the way for clinical trials and offer hope for new, effective treatments for OCD and Tourette's Syndrome.

A new study, published in Molecular Psychiatry, led by Prof. Bernard Lerer from the Department of Psychiatry at the Hadassah - Hebrew University Medical Center shows promising results for using psilocybin, a psychedelic compound, as a potential treatment for obsessive-compulsive disorder (OCD) and Tourette's Syndrome. The research provides significant insights into the benefits of psilocybin for managing symptoms similar to those experienced by people with OCD and Tourette's Syndrome.

The study included 50 genetically modified mice that displayed excessive grooming and anxiety, similar to human OCD behaviors and head-body twitches similar to tics suffered by patients with Tourette's Syndrome. These mice were randomly given either a single injection of psilocybin, a psychedelic mushroom extract, or a placebo. Raters, unaware of which treatment each mouse received, evaluated the effects at several points over a three-week period.

Key outcomes of the study include:

Mice treated with psilocybin showed a 14.60% decrease in excessive grooming, while those receiving the mushroom extract saw a 19.20% reduction, compared to a significant increase of 118.71 in grooming in the placebo group.

The study also observed reductions in other symptoms like tic-like movements and anxiety, with the mushroom extract showing greater benefit in its effect on anxiety.

The positive effects from a single treatment lasted up to seven weeks in some mice.

Understanding that over 40% of OCD patients don't find relief with current treatments, our findings are crucial as they suggest a new way to help these individuals. We look forward to advancing to human trials and further exploring how these treatments can provide long-term benefits. The effects observed on tic-like head body twitches raise the previously unreported possibility that psilocybin may be effect in patients with Tourette's Syndrome."

Prof. Bernard Lerer, Department of Psychiatry, Hadassah - Hebrew University Medical Center

This research highlights the potential of psilocybin and similar substances in treating psychiatric conditions and supports ongoing efforts to discover new, effective mental health therapies.

# data[].attributes.attachment_link.title
Study highlights the potential of psilocybin in treating obsessive-compulsive disorder

# data[].attributes.attachment_link.description
A new study highlights the potential of psilocybin, a psychedelic compound, in treating obsessive-compulsive disorder (OCD) and Tourette's Syndrome.

# data[].attributes.body
Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker, or other licensed mental health professional. OCD, like other mental and behavioral health disorders, cannot be diagnosed by a medical exam,[7] nor are there any medical exams that can predict if one will fall victim to such illnesses. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM notes that there are multiple characteristics that can turn obsessions and compulsions from normalized behavior to "clinically significant". There has to be recurring and strong thoughts or impulsive that intrude on the day-to-day lives of the patients and cause noticeable levels of anxiousness.[2]

# data[].attributes.attachment_link.description
Obsessive–compulsive disorder (OCD) is a mental and behavioral disorder in which an individual has intrusive thoughts (an obsession) and feels the need to perform certain routines (compulsions) repeatedly to relieve the distress caused by the obsession, to the extent where it impairs general function.[1][2][7]

# data[].attributes.body
Obsessive-compulsive disorder treatment may not result in a cure. But it can help bring symptoms under control so that they don't rule your daily life. Depending on how serious your OCD is, you may need long-term, ongoing or more-intensive treatment.

The two main treatments for OCD are psychotherapy and medicines. Psychotherapy also is known as talk therapy. Often, a mix of both treatments is most effective.

# data[].attributes.attachment_link.description
Intelligent search from Bing makes it easier to quickly find what you’re looking for and rewards you.

# data[].attributes.body
Stress is not a new phenomenon; we are all very familiar with it. We simply call it by a different name – Life!

Consider this for a moment: is it really possible to fully separate life from stress? Isn’t the very process of living, in some ways, a stressful experience? Stress is a natural part of our lives. However, what we need to manage is the excess build-up of stress over time, which can affect our normal daily functioning

# data[].attributes.attachment_link.title
10 Effective Stress Relief Methods • Go Beyond Stress • Nirvana

# data[].attributes.attachment_link.description
What is Stress and how to go beyond it? Learn 10 quick & effective ways of managing daily stress. Find long-term stress relief.

# data[].attributes.body
stress can be defined as a state of worry or mental tension caused by a difficult situation. Stress is a natural human response that prompts us to address challenges and threats in our lives. Everyone experiences stress to some degree. The way we respond to stress, however, makes a big difference to our overall well-being.

# data[].attributes.attachment_link.readable_text
Stress can be defined as a state of worry or mental tension caused by a difficult situation. Stress is a natural human response that prompts us to address challenges and threats in our lives. Everyone experiences stress to some degree. The way we respond to stress, however, makes a big difference to our overall well-being.

Stress affects both the mind and the body. A little bit of stress is good and can help us perform daily activities. Too much stress can cause physical and mental health problems. Learning how to cope with stress can help us feel less overwhelmed and support our mental and physical well-being.

Stress makes it hard for us to relax and can come with a range of emotions, including anxiety and irritability. When stressed, we may find it difficult to concentrate. We may experience headaches or other body pains, an upset stomach or trouble sleeping. We may find we lose our appetite or eat more than usual. Chronic stress can worsen pre-existing health problems and may increase our use of alcohol, tobacco and other substances.

Stressful situations can also cause or exacerbate mental health conditions, most commonly anxiety and depression, which require access to health care. When we suffer from a mental health condition, it may be because our symptoms of stress have become persistent and have started affecting our daily functioning, including at work or school.

No, everyone reacts differently to stressful situations. Coping styles and symptoms of stress vary from person to person. ​​

Yes, it is natural to feel stressed in challenging situations such as job interviews, school exams, unrealistic workloads, an insecure job, or conflict with family, friends or colleagues. For many people stress reduces over time as the situation improves or as they learn to cope emotionally with the situation. Stress tends to be widespread during events such as major economic crises, disease outbreaks, natural disasters, war, and community violence.

Most of us manage stress well and continue to function. If we have difficulties coping with stress, we should seek help from a trusted health-care provider or from another trusted person in our community.

Learn stress management Keep a daily routine
WHO's stress management guide - Doing what matters in times of stress - aims to equip people with practical skills to cope with stress. A few minutes each day are enough to practise the guide's self-help techniques. The guide can be used alone or with its accompanying audio exercises.
Get plenty of sleep
Having a daily schedule can help us use our time efficiently and feel more in control. Set time for regular meals, time with family members, exercise, daily chores and other recreational activities.

Getting enough sleep is important for both body and mind. Sleep repairs, relaxes and rejuvenates our body and can help reverse the effect of stress.

Good sleep habits (also known as sleep hygiene) include:

Be consistent. Go to bed at the same time each night and get up at the same time each morning, including on the weekends.

If possible, make your sleeping area quiet, dark, relaxing and at a comfortable temperature.

Limit your use of electronic devices, such as TVs, computers and smart phones, before sleeping.

Avoid large meals, caffeine and alcohol before bedtime.

Get some exercise. Being physically active during the day can help you fall asleep more easily at night.

Connect with others ​
Eat healthy​
Keep in touch with family and friends and share your concerns and feelings with people you trust. Connecting with others can lift our mood and help us feel less stressed.

Exercise regularly ​
What we eat and drink can affect our health. Try to eat a balanced diet and to eat at regular intervals. Drink enough fluids. Eat lots of fresh fruits and vegetables if you can.
Limit time following news ​
Regular daily exercise can help to reduce stress. This can include walking, as well as more intensive exercise.

Spending too much time following news on television and social media can increase stress. Limit the time you spend following the news if it increases your stress.

# data[].attributes.attachment_link.description
What is stress? How can we manage it? Find out in these Q and As.

# data[].attributes.body
stress symptoms may be affecting your health, even though you might not know it. You may blame sickness for that annoying headache, your sleeping troubles, feeling unwell or your lack of focus at work. But stress may really be the cause.

Common effects of stress

Stress symptoms can affect your body, your thoughts and feelings, and your behavior. Knowing common stress symptoms can help you manage them. Stress that's not dealt with can lead to many health problems, such as high blood pressure, heart disease, stroke, obesity and diabetes.

# data[].attributes.attachment_link.readable_text
From Mayo Clinic to your inbox

Sign up for free and stay up to date on research advancements, health tips, current health topics, and expertise on managing health. Click here for an email preview.

Email field is required

Include a valid email address

Learn more about Mayo Clinic's use of data.

To provide you with the most relevant and helpful information, and understand which information is beneficial, we may combine your email and website usage information with other information we have about you. If you are a Mayo Clinic patient, this could include protected health information. If we combine this information with your protected health information, we will treat all of that information as protected health information and will only use or disclose that information as set forth in our notice of privacy practices. You may opt-out of email communications at any time by clicking on the unsubscribe link in the e-mail.

Thank you for subscribing!

You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox.

Sorry something went wrong with your subscription

Please, try again in a couple of minutes

# data[].attributes.attachment_link.title
How stress affects your body and behavior

# data[].attributes.attachment_link.description
Learn how stress symptoms can affect your health so that you can take action.

# data[].attributes.body
There are three main kinds of stress: acute, episodic acute and chronic.

Acute stress: Acute stress is short-term stress that comes and goes quickly. It can be positive or negative. It’s the feeling you get when you’re riding on a rollercoaster or having a fight with your boyfriend. Everyone experiences acute stress from time to time.

Episodic acute stress: Episodic acute stress is when you experience acute stress on a regular basis. With this kind of stress, you don’t ever get the time you need to return to a calm, relaxed state. Episodic stress frequently affects people working in certain professions, like healthcare providers.

Chronic stress: Chronic stress is long-term stress that goes on for weeks or months. You may experience chronic stress due to marriage troubles, issues at work or financial problems. It’s important to find ways to manage chronic stress because it can lead to health issues.

# data[].attributes.attachment_link.readable_text
Stress can cause physical, psychological or behavioral symptoms.

How does stress affect the body?

Your body's autonomic nervous system controls your heart rate, breathing, vision changes and more. Its built-in stress response - the " fight-or-flight response " - helps your body face stressful situations.

When you have long-term (chronic) stress, continued activation of the stress response causes wear and tear on your body. You may develop stress symptoms that are physical, psychological or behavioral.

Physical symptoms

Physical symptoms of stress may include:

Aches and pains.

Chest pain or a feeling like your heart is racing.

Exhaustion or trouble sleeping.

Headaches, dizziness or shaking.

High blood pressure (hypertension).

Muscle tension or jaw clenching.

Stomach or digestive problems.

Trouble having sex.

Weakened immune system.

Psychological symptoms

Stress can lead to emotional and mental (psychological) symptoms, like:

Behavioral symptoms

Often, people with chronic stress try different things to cope. And some of those things are habit-forming and can have an impact on your health. These may include:

Stress rash

Stress rashes often appear as pink or discolored, raised bumps called hives. Hives are welts that can develop and swell on the surface of your skin. They can itch, burn and even hurt. Hives are usually an allergic reaction to something, like certain kinds of foods, fabrics or chemicals. But sometimes, stress can trigger an outbreak.

Stress rashes are more common in women and people assigned female at birth (AFAB) than men and people assigned male at birth (AMAB), and they affect people in their 20s, 30s and 40s most often. But they can also affect anyone. Like other kinds of hives, you can try treating them with an antihistamine. But it's also important to manage your stress.

What causes stress?

Stress is how your body reacts to a change or challenge, and many different things can lead to it. Stressors can also be positive or negative. For instance, getting a new job or losing a job can both cause stress. Other causes of stress include:

An illness or death of a loved one.

Marriage, separation or divorce.

Financial issues.

Moving to a new house.

Going on vacation.

Having a baby.

Retiring.

Stress can also be acute, meaning short term. Causes of acute stress may include everyday stressors, like:

Studying for a big test.

Getting ready for a work presentation.

Having an argument with a friend or loved one.

Needing to get a lot completed in a short amount of time.

Experiencing many small problems all at once, like getting in a traffic jam, spilling coffee all over yourself and running late.

What are the complications of stress?

Chronic stress can lead to many long-term health issues affecting your:

Immune system (like arthritis, fibromyalgia and psoriasis).

Digestive system (like weight gain or loss, ulcers and irritable bowel syndrome).

Cardiovascular system (like high blood pressure, increased heart rate and heart palpitations).

Reproductive system (like infections, polycystic ovarian syndrome and infertility).

Stress can also put you at a higher risk of developing a mental health condition, like depression or anxiety. If you're feeling severely stressed and/or thinking about hurting yourself, call or text 988 to reach the 988 Suicide & Crisis Lifeline.

How is stress diagnosed?

Stress is subjective - not measurable with tests. Only the person experiencing it can determine whether it's present and how severe it feels. A healthcare provider may use questionnaires to understand your stress and how it affects your life.

If you have chronic stress, your healthcare provider can evaluate symptoms that result from stress. For example, they can diagnose and treat high blood pressure.

# data[].attributes.attachment_link.description
Stress is a natural human reaction. When you experience changes or challenges (stressors), your body produces physical and mental responses. That's stress.

# data[].attributes.body
family, or a painful life event can be a natural part of life. You may feel down or anxious, and that’s normal too for a while.

Talk to your doctor if you feel down or anxious for more than several weeks or if it starts to interfere with your home or work life. Therapy, medication, and other strategies can help.

In the meantime, there are things you can learn to help you manage stress before it gets to be too much. These tips may help you keep stress

# data[].attributes.attachment_link.readable_text
Stress is part of being human, and it can help motivate you to get things done. Even high stress from serious illness, job loss, a death in the family, or a painful life event can be a natural part of life. You may feel down or anxious, and that's normal too for a while.

Talk to your doctor if you feel down or anxious for more than several weeks or if it starts to interfere with your home or work life. Therapy, medication, and other strategies can help.

In the meantime, there are things you can learn to help you manage stress before it gets to be too much. These tips may help you keep stress at bay:

Keep a positive attitude.

Accept that there are events that you cannot control.

Be assertive instead of aggressive. Assert your feelings, opinions, or beliefs instead of becoming angry, defensive, or passive.

Learn to manage your time more effectively.

Set limits appropriately and say no to requests that would create excessive stress in your life.

Make time for hobbies and interests.

Don't rely on alcohol, drugs, or compulsive behaviors to reduce stress. Drugs and alcohol can stress your body even more.

Seek out social support. Spend enough time with those you love.

Seek treatment with a psychologist or other mental health professional trained in stress management or biofeedback techniques to learn more healthy ways of dealing with the stress in your life.

There's a lot more you can do to help manage stress. Consider these lifestyle changes:

To start with, physical activity can help improve your sleep. And better sleep means better stress management. Doctors don't yet know exactly why, but people who exercise more tend to get better deep "slow wave" sleep that helps renew the brain and body. Just take care not to exercise too close to bedtime, which disrupts sleep for some people.

Exercise also seems to help mood. Part of the reason may be that it stimulates your body to release a number of hormones like endorphins and endocannabinoids that help block pain, improve sleep, and sedate you. Some of them (endocannabinoids) may be responsible for the euphoric feeling, or "runner's high," that some people report after long runs.

People who exercise also tend to feel less anxious and more positive about themselves. When your body feels good, your mind often follows. Get a dose of stress relief with these exercises:

If you don't have the time for a formal exercise program, you can still find ways to move throughout your day. Try these tips:

Bike instead of driving to the store.

Use the stairs instead of the elevator.

Park as far as you can from the door.

Hand-wash your car.

Clean your house.

Walk on your lunch break.

The benefits of eating health foods extend beyond your waistline to your mental health. A healthy diet can lessen the effects of stress, build up your immune system, level your mood, and lower your blood pressure. Lots of added sugar and fat can have the opposite effect. And junk food can seem even more appealing when you're under a lot of stress.

To stay healthy and on an even keel, look for complex carbohydrates, lean proteins, and fatty acids found in fish, meat, eggs, and nuts.

Antioxidants help too. They protect your cells against damage that chronic stress can cause. You can find them in a huge variety of foods like beans, fruits, berries, vegetables, and spices such as ginger.

Stick to a healthy diet with a few simple tips. Make a shopping list. Carry healthy snacks with you when you leave the house. Stay away from processed foods, and try not to eat mindlessly.

Scientists have pinpointed some nutrients that seem to help lessen the effects of stress on the body and mind. Be sure to get enough these as part of a balanced diet:

A common side effect of stress is that you may struggle to fall asleep. If this happens three times a week for at least 3 months, you may have insomnia, an inability to fall and stay asleep. Lack of sleep can also add to your stress level and cause a cycle of stress and sleeplessness.

Better sleep habits can help. This includes both your daily routine and the way you set up your bedroom. Habits that may help include:

Exercise regularly.

Get out in the sunlight.

Drink less alcohol and caffeine close to bedtime.

Set a sleep schedule.

Don't look at your electronics 30-60 minutes before bed.

Try meditation or other forms of relaxation at bedtime.

The role of your bedroom in good sleep hygiene also is important. In general, your room should be dark, quiet, and cool. Your bed also plays an important role. Your mattress should provide support, space and most of all, comfort.

Yoga. This is a form of exercise, but it can also be a meditation. There are many types of yoga. The ones that focus on slow movement, stretching, and deep breathing are best for lowering your anxiety and stress.

Meditation. It has been around for over 5,000 years for a reason. Meditation works well for many people and has many benefits. It can lower stress, anxiety, and chronic pain as well as improve sleep, energy levels, and mood. To meditate, you will need to:

1. Find a quiet place.

2. Get comfortable (sitting or lying down).

3. Focus your attention on a word, phrase, object, or even your breath.

4. Let your thoughts come and go and do not judge them.

Deep breathing. When you practice deep breathing, you turn on your body's natural ability to relax. This creates a state of deep rest that can change how your body responds to stress. It sends more oxygen to your brain and calms the part of your nervous system that handles your ability to relax.

Try belly breathing. Get comfortable, close your eyes, and place one hand on your stomach and the other on your chest. Take a deep breath in through your nose. You should feel your belly rise more than your chest. Now, exhale through your nose and pay close attention to how your body relaxes. Repeat.

Biofeedback. Learn how to manage your heart rate, muscle tension, and blood pressure when stress hits. Biofeedback gives you information about how your body reacts when you try to relax. Sensors are placed on your body that call out changes in everything from your brain-wave pattern to your muscle tone. Working with a biofeedback therapist, you can start to take control of the signals by changing how your body reacts to the sensor.

Connect with people. Spend time with a friend or family member who will listen to you. It is a natural way to calm you and lower your stress. When you connect with people in person, your body releases a hormone that stops your fight-or-flight response. You relax.

Behavior. How you respond to people directly impacts your stress levels. Manage your response with these tips:

Try not to overcommit yourself

Share the responsibility

Count to 10 before you respond

Walk away from a heated situation

Distract yourself with music or podcasts

Inner voice. Nothing affects your stress levels like the voice inside your head. The good news is you are in control. You can exchange negative thoughts for positive ones. There are more benefits to positive self-talk than reducing stress. These include a longer life, lower levels of depression, greater resistance to the common cold and cardiovascular disease, and better coping skills for when hard times hit.

Laugh therapy. When you laugh, you take in more oxygen. Your heart, lungs, and muscles get a boost and your body releases those feel-good hormones. Laughter also improves your immune system, lessens pain, and improves your mood for long periods of time.

Talk therapy. Long-term talk therapy helps some people deal with stress. One approach, cognitive behavioral therapy, helps you change negative thought patterns. Your therapist can guide you toward other approaches that might be helpful.

# data[].attributes.attachment_link.description
Before stress takes a toll on your health, learn how you can keep it under control and manage it.

# data[].attributes.body
Developing a personalized approach to reducing stress can help you manage your mental health condition and improve your quality of life. Once you’ve learned what your triggers are, experiment with coping strategies. Some common ones include:

Accept your needs. Recognize what your triggers are. What situations make you feel physically and mentally agitated? Once you know this, you can avoid them when it’s reasonable to, and to cope when you can’t.

Manage your time. Prioritizing your activities can help you use your time well. Making a day-to-day schedule helps ensure you don’t feel overwhelmed by everyday tasks and deadlines.

Practice relaxation. Deep breathing, meditation and progressive muscle relaxation are good ways to calm yourself. Taking a break to refocus can have benefits beyond the immediate moment.

# data[].attributes.attachment_link.description
Everyone experiences stress. Sometimes it can help you focus and get the task at hand done. But when stress is frequent and intense, it can strain your body and make it impossible to function. Finding effective ways to deal is crucial to living well. How Stress Affects You Stress affects your entire body, mentally as […]

# data[].attributes.body
Social and emotional learning is a strengths-based, developmental process that begins at birth and evolves across the lifespan (Weissberg et al., 2015). It is the process through which children, adolescents, and adults learn skills to support healthy development and relationships.

Adult and student social and emotional learning competencies include self awareness, self management, social awareness, relationship skills, and responsible decision-making (Weissberg et al., 2015).

# data[].attributes.attachment_link.title
Defining Social and Emotional Learning | NC DPI

# data[].attributes.attachment_link.description
Social and emotional learning is the process through which all young people and adults acquire and apply the knowledge, skills, and attitudes to support healthy development, manage emotions and achieve personal and collective goals, feel and show empathy for others, establish and maintain supportive relationships, and make responsible and caring decisions.

# data[].attributes.body
1. Social-emotional skills improve academic achievement.

A meta-analysis revealed that learners who participated in SEL programs made an 11 percentile increase in academic achievement. This makes sense: when kids feel better about themselves, they’re more available to learn.

# data[].attributes.attachment_link.readable_text
Social emotional learning has gained a lot of attention lately. Some questions I've seen recently include: What is SEL? Why does it matter? Why are teachers teaching these skills in school? While most are on board with the idea of social-emotional supports in the classroom, there are some who are raising concerns. Some even claim that SEL should not be taught in schools at all. My belief is that the majority of those who make these statements fundamentally misunderstand what SEL is and why it matters for our kids.

What is Social Emotional Learning?

So, let's start with what SEL is. Social-emotional learning is the process for helping learners acquire skills necessary for success in life. That is for sure a huge umbrella. The 5 core competencies of SEL include:

Self-awareness - understanding who we are as unique individuals.

Self-management - managing our behaviors to help us reach goals.

Social awareness - understanding the social world around us to make good choices.

Relationships - developing meaningful relationships with others.

Decision-making - learning to make healthy choices for now and the future.

The truth is that the idea of teaching and supporting social and emotional skills in the classroom is not anything new. For years teachers have been helping kids learn how to work with others, develop meaningful friendships, work towards goals, and make good choices.

Why SEL Belongs in School

Social emotional learning belongs in school. It always has and it still does today. In case you need more convincing, here's why:

1. Social-emotional skills improve academic achievement.

A meta-analysis revealed that learners who participated in SEL programs made an 11 percentile increase in academic achievement. This makes sense: when kids feel better about themselves, they're more available to learn.

2. Social-emotional skills are life skills.

Social-emotional skills are literally in everything we do. That's true whether we are 6 or 60. SEL skills do help in school, but they're not just school skills; they're life skills. Working towards goals, understanding emotions, managing tough emotions, building and maintaining friendships, conflict resolution, and staying organized. These are just a few of the SEL skills we are all working on and building now and as we get older. Kids and teens deserve to have a strong foundation.

3. SEL is a process, not a curriculum or program.

Social emotional learning is a process for helping kids acquire important life skills. It's not one curriculum or program. I'm saying this as a creator of SEL curriculum sets and resources. While there are curriculum sets and activities can make teaching these skills easier for busy educators, SEL is the bigger picture.

Teachers already use social-emotional practices in the classroom, and have for years. Just a few common SEL practices include:

Morning circle (or morning meeting) when students start their day.

Classroom greetings at the door.

Using literature to talk about empathy and other skills.

Finding ways to connect and build relationships with every child.

Holding class meetings to work through problems.

4. Strong social-emotional skills means better classroom performance.

In order to perform well in the classroom, students need to acquire certain skills: how to work well in a group, how to work through a tough test independently, and how to manage emotions when something doesn't go your way. These skills might seem trivial, but many students walk into our classrooms without these skills in tact. It only makes sense to help students learn these skills so they can perform their best in the classroom (and beyond).

5. SEL skills teach academic and study skills too.

SEL skills include many skills that actually help students become better at learning, studying, test-taking, and working on goals. When we teach many SEL skills, we're teaching kids how to become better learners at the very same time.

6. SEL helps build confident learners.

If we want kids and teens to do their best, they have to feel good about themselves. Just a few confidence-building skills kids learn with SEL include understanding their strengths, working on their challenges, and learning to self-advocate when they need something. Research has highlighted that mentally healthy individuals have optimistic views of themselves. We want students to believe that if they work hard at these skills and believe in themselves, they can change anything. Again, these skills not only translate into kids personal lives, but to their lives as learners in the classroom too.

7. Social-emotional skills build strong decision-makers.

One of the five core competencies that social emotional learning focuses on is responsible decision-making. Emphasizing these skills from every direction is critical for growing kids and teens. There is science behind that idea, too. Kids and teens' brains are still developing. The thinking part of their brains (frontal lobes) lags behind the emotional part of their brains (limbic system). It's the reason why children and teens are known to sometimes make impulsive decisions; their brains are still under construction.

This is where social-emotional learning comes in to help. Growing learners need strategies to help them manage their emotions and activate the thinking parts of their brains so they can make good choices now and in the future.

8. SEL improves behavior in the classroom.

Behavior challenges can take up a substantial amount of time in the classroom. This means time away from learning for the whole classroom at times. One of the most obvious solutions to this challenge is integrating social-emotional supports in the classroom. A meta-analysis found that students who participated in SEL programs significantly improved behaviors in the classroom. Again, this makes sense: if we teach the skills and help students be successful, they can be.

Of course, this helps ALL students do better. When the classroom can run smoothly, that's a win for everyone.

9. SEL builds a strong classroom and school community.

We want kids and teens to wake up and be excited to attend school every day. We want kids motivated to learn. This doesn't happen magically overnight, but it can happen with intentional supports built into the school day. Morning meeting, for example, can become a safe space for kids to share what is on their minds before moving into academics. Even simple greetings at the door are a research-backed way to improve student attitudes in school.

Research tells us that kids and teens need to feel physically and emotionally safe before they are available to learn at an optimal level; SEL supports are one way we get there.

10. SEL skills can be integrated in current content.

It's important to remember that SEL itself is process, not a curriculum or class. With that, teaching social emotional skills doesn't require a separate block of time or special curriculum. While these things certainly make it easier to teach SEL skills, there are many ways teachers can integrate these skills into the current school day. Just a few examples include reading literature, journal writing, and class discussions. Teaching SEL skills doesn't always mean extra time during the school day.

11. SEL helps partners with families.

Social emotional learning can help partner with families to teach these skills from all directions. In today's world, kids need strong social skills now more than ever: how to make good decisions, combating peer pressure, managing stress, and working through challenges. These are just a few skills both schools and families work on together.

One of the most common reasons to not teach SEL in school is that families should be teaching these skills at home. And while it's true that many of these skills are taught at home, the truth is that you can't over-teach decision-making or self-management skills. Growing minds need LOTS of instruction, practice, and support to learn these along the way. It's about working together.

Getting Started with SEL

If you are interested in getting started with SEL, feel free to visit some of the links below:

# data[].attributes.attachment_link.title
Social Emotional Learning: 10+ Reasons Why SEL Belongs in Schools

# data[].attributes.attachment_link.description
Social emotional learning has gained a lot of attention lately. Some questions I've seen recently include: What is SEL? Why does it matter? Why are teachers teaching these skills in school?

# data[].attributes.body
This is the ability to recognise and understand your own emotions, thoughts and values, and understand how they affect your behaviour. It’s about understanding and assessing your personal strengths, and understanding that abilities and intelligence can be developed and improved. The main skills include:

identifying emotions

self-perception

understanding strengths

self-confidence

self-efficacy.

# data[].attributes.attachment_link.readable_text
Be You's approach to SEL is based on the model developed by the Collaborative for Academic, Social and Emotional Learning (CASEL), an internationally recognised organisation in this area of research.

The model defines ﬁve social and emotional skill areas essential for the development of good mental health. Each of these skill areas includes a number of specific elements. Intentional teaching of the competencies is also crucial to implementing effective SEL, as are opportunities for children and young people to practise and generalise them.

Teaching SEL works best when the focus is on helping children and young people learn skills from each domain so that they gradually and progressively build their skills and knowledge throughout early learning and school. It's an ongoing process across all year levels.

Self-awareness

This is the ability to recognise and understand your own emotions, thoughts and values, and understand how they affect your behaviour. It's about understanding and assessing your personal strengths, and understanding that abilities and intelligence can be developed and improved. The main skills include:

identifying emotions

self-perception

understanding strengths

self-confidence

self-efficacy.

Self-management

This is the ability to manage and regulate your emotions and behaviour, including managing stress, controlling impulses and keeping yourself motivated. The main skills include:

impulse control

stress management

self-discipline

self-motivation

goal-setting

organisational skills.

Social awareness

This is the ability to understand and empathise with people from a range of diverse backgrounds, and to understand social and ethical norms of behaviour. The main skills include:

perspective-taking

empathy

appreciating diversity

respect for others.

Relationship skills

These involve the ability to develop and maintain healthy and positive relationships with others. They include the ability to communicate clearly, listen, cooperate, resist peer pressure and negotiate conflict. The main skills include:

Responsible decision-making

This is the ability to make informed and responsible decisions about personal behaviour and social interactions with others, based on adherence to ethical standards, safety concerns and social norms. The main skills include:

identifying problems

analysing situations

solving problems

self-evaluation

self-reflection

ethical responsibility.

# data[].attributes.attachment_link.title
Five areas of social and emotional learning - Be You

# data[].attributes.attachment_link.description
Social and emotional learning (SEL) involves developing the ability to understand and manage our emotions, establish positive relationships, develop empathy for others, set and achieve goals and feel good about ourselves.

# data[].attributes.body
Social Emotional Learning (SEL) is a crucial aspect of personal development and overall well-being. It encompasses the skills and competencies needed to understand and manage emotions, set and achieve goals, show empathy, establish positive relationships, and make responsible decisions. While the concept of SEL may seem abstract, understanding it in real-life situations can make it more relatable and applicable. In this blog post, I will provide you with some real-life examples to help you grasp the essence of SEL and its significance in everyday life.

# data[].attributes.attachment_link.readable_text
Real-life examples to understand Social Emotional Learning

Social Emotional Learning (SEL) is a crucial aspect of personal development and overall well-being. It encompasses the skills and competencies needed to understand and manage emotions, set and achieve goals, show empathy, establish positive relationships, and make responsible decisions. While the concept of SEL may seem abstract, understanding it in real-life situations can make it more relatable and applicable. In this blog post, I will provide you with some real-life examples to help you grasp the essence of SEL and its significance in everyday life.

Example 1: Empathy

Empathy is the ability to understand and share the feelings of others. It plays a vital role in SEL as it promotes positive relationships and fosters a sense of community. Let me illustrate this with a real-life example:

Imagine a student in your child's class who recently lost a family member. This student is visibly upset and withdrawn. One of their classmates, who possesses a high level of empathy, notices their distress and approaches them. Instead of ignoring or avoiding the situation, this empathetic classmate takes the time to listen and offer support. They express their condolences and offer a shoulder to lean on. This act of empathy not only provides comfort to the grieving student but also strengthens the bond between them and their classmate.

Example 2: Self-Awareness

Self-awareness is the ability to recognize and understand one's own emotions, strengths, and weaknesses. It is a fundamental aspect of SEL as it enables individuals to regulate their emotions and make informed decisions. Let's explore a real-life example that showcases self-awareness:

Imagine a professional setting where a team is working on a challenging project. One team member, who is highly self-aware, realizes that they have a tendency to become easily frustrated when faced with obstacles. Instead of allowing their frustration to negatively impact their performance and relationships with colleagues, they take a step back and reflect on their emotions. They acknowledge their frustration and consciously choose to approach the situation with a calm and composed demeanor. This self-awareness not only helps them navigate the challenges more effectively but also contributes to a positive team dynamic.

Example 3: Responsible Decision-Making

Responsible decision-making involves considering ethical standards, safety concerns, and the well-being of oneself and others when making choices. It is a critical component of SEL as it empowers individuals to make informed and thoughtful decisions. Let's delve into a real-life example that highlights responsible decision-making:

Imagine a group of friends planning a weekend getaway. One of the friends, who values responsible decision-making, suggests researching and choosing a destination that aligns with their shared interests and budget. They take into account factors such as accessibility, accommodation options, and activities available. By making a responsible decision, they ensure that everyone's needs and preferences are considered, leading to a memorable and enjoyable trip for all.

Example 4: Relationship Skills

Relationship skills encompass the ability to establish and maintain healthy and positive connections with others. They are integral to SEL as they contribute to effective communication, collaboration, and conflict resolution. Let's explore a real-life example that demonstrates effective relationship skills:

Imagine a workplace scenario where two colleagues have differing opinions on a project approach. Instead of engaging in a heated argument or dismissing each other's perspectives, they utilize their relationship skills to engage in a respectful and constructive dialogue. They actively listen to each other, express their viewpoints without aggression, and work together to find a compromise that benefits both parties. This demonstration of relationship skills not only resolves the conflict but also strengthens their professional relationship.

Example 5: Self-Management

Self-management involves regulating one's emotions, thoughts, and behaviors in order to achieve personal and academic goals. It is a key aspect of SEL as it enables individuals to cope with stress, adapt to change, and maintain a positive mindset. Let's examine a real-life example that exemplifies self-management:

Imagine a student preparing for a challenging exam. They are feeling overwhelmed and anxious about the amount of material they need to study. However, instead of succumbing to their negative emotions, they practice self-management techniques. They break down their study material into manageable chunks, create a study schedule, and engage in self-care activities to alleviate stress. By practicing self-management, they are able to approach the exam with a clear and focused mind, leading to better performance.

Conclusion

Understanding Social Emotional Learning (SEL) in real-life situations is essential for its effective application. By exploring these real-life examples of empathy, self-awareness, responsible decision-making, relationship skills, and self-management, you can gain a deeper understanding of SEL and its impact on personal and interpersonal well-being. I encourage you to apply these principles in your everyday life and witness the positive outcomes they can bring.

To explore more SEL examples and resources, I invite you to start your EverydaySpeech free trial. EverydaySpeech provides a comprehensive platform for Social Emotional Learning, offering a wide range of interactive activities and lessons to support SEL development. Start your free trial today and embark on a journey of personal growth and enhanced social-emotional well-being.

# data[].attributes.attachment_link.title
Real-life examples to understand Social Emotional Learning | Everyday Speech

# data[].attributes.attachment_link.description
Real-life examples to understand Social Emotional Learning Real-life examples to understand Social Emotional Learning Social Emotional Learning (SEL) is a crucial aspect of personal development and overall well-being. It encompasses the skills and competencies needed to understand and manage emotions, set and achieve goals, show empathy, establish positive relationships, and make responsible decisions.

# data[].attributes.body
Social Emotional Learning, also known as S.E.L., is described through this whiteboard animation style video. The video begins with quick definition of social emotional learning. Next, several reasons why SEL should be incorporated into schools are given. One reason being that emotions affect both learning an behavior. Going forward, the video offers several different ways that teachers can actually use it in their classroom. Then the video goes into the social emotional learning core competencies. The competencies include self-awareness, self-management, social awareness, relationship skills, and decision making. Each of these components are explored through basic examples. This video is part of a learning for education framework playlist. Other videos in the playlist include classroom management styles, lesson planning the key components, bloom's taxonomy, instructional practices and teaching strategies, marzano's high yield instruction, webb's depth of knowledge, and many many more.

# data[].attributes.body
Researchers and healthcare professionals are still trying to figure out the cause of social anxiety disorder. Social anxiety disorder can sometimes run in families, but researchers aren’t sure why some family members get it and others don’t. Many parts of your brain are involved with fear and anxiety, so social anxiety disorder is a complex condition to study. Researchers are also looking into how stress and environmental factors could contribute to social anxiety.

# data[].attributes.attachment_link.readable_text
What is social anxiety disorder (social phobia)?

Social anxiety disorder (formerly known as social phobia) is a mental health condition where you experience intense and ongoing fear of being judged negatively and/or watched by others.

Social anxiety disorder is a common anxiety disorder.

If you have social anxiety disorder, you have anxiety or fear in specific or all social situations, including:

Meeting new people.

Performing in front of people.

Taking or making phone calls.

Using public restrooms.

Asking for help in a restaurant, store or other public place.

Dating.

Answering a question in front of people.

Eating in front of people.

Participating in an interview.

A core feature of social anxiety disorder is that you're afraid of being judged, rejected and/or humiliated.

Who does social anxiety affect?

Social anxiety disorder is a common mental health condition that can affect anyone. Most people who have social anxiety disorder experience symptoms before they're 20 years old. People assigned female at birth (AFAB) experience higher rates of social anxiety than people assigned male at birth (AMAB).

How common is social anxiety disorder?

Social anxiety disorder isn't uncommon. Approximately 5% to 10% of people across the world have social anxiety disorder. It's the third most common mental health condition behind substance use disorder and depression.

Are there different types of social anxiety?

A person with social anxiety disorder can have a mild, moderate or extreme form of it. Some people with social anxiety only experience symptoms with one type of situation, like eating in front of others or performing in front of others, while other people with social anxiety experience symptoms in several or all forms of social interaction. In general, the different levels of social anxiety include:

Mild social anxiety: A person with mild social anxiety may experience the physical and psychological symptoms of social anxiety but still participate in, or endure, social situations. They may also only experience symptoms in certain social situations.

Moderate social anxiety: A person with mild social anxiety may experience physical and psychological symptoms of social anxiety but still participate in some social situations while avoiding other types of social situations.

Extreme social anxiety: A person with extreme social anxiety may experience more intense symptoms of social anxiety, such as a panic attack, in social situations. Because of this, people with extreme social anxiety usually avoid social situations at all costs. A person with extreme social anxiety likely has symptoms in all or many types of social situations.

It's very common to have anticipatory anxiety when facing these situations. It's possible to fluctuate between different levels of social anxiety throughout your life. No matter which type of social anxiety you have, it's important to seek treatment because this type of anxiety affects your quality of life.

What is the difference between having social anxiety disorder and being shy?

Anyone can experience shyness from time to time. Having social anxiety disorder consistently interferes with or prevents you from doing everyday activities such as going to the grocery store or talking to other people. Because of this, social anxiety disorder can negatively affect your education, career and personal relationships. Being shy from time to time doesn't affect these things.

In general, the three main factors that distinguish social anxiety from shyness are:

How much it interferes with your day-to-day life.

How intense your fear and anxiety are.

How much you avoid certain situations.

Many people with social anxiety disorder don't try to get help or seek treatment because they think social anxiety is just part of their personality. It's important to reach out to your healthcare professional if you're experiencing ongoing and intense symptoms when in social situations.

# data[].attributes.attachment_link.title
Social Anxiety Disorder: Symptoms, Tests, Causes & Treatments

# data[].attributes.attachment_link.description
Social anxiety disorder is a mental health condition where you have an intense fear of being judged or watched by people in social situations. This condition can be treated.

# data[].attributes.body
Despite the availability of effective treatments, fewer than 5% of people of with social anxiety disorder seek treatment in the year following initial onset and more than a third of people report symptoms for 10 or more years before seeking help.

To learn more in-depth about Social Anxiety Disorder and treatments, check out ADAA's Patient Guide to Mood and Anxiety Disorders.

# data[].attributes.attachment_link.readable_text
The defining feature of social anxiety disorder, also called social phobia, is intense anxiety or fear of being judged, negatively evaluated, or rejected in a social or performance situation. People with social anxiety disorder may worry about acting or appearing visibly anxious (e.g., blushing, stumbling over words), or being viewed as stupid, awkward, or boring. As a result, they often avoid social or performance situations, and when a situation cannot be avoided, they experience significant anxiety and distress. Many people with social anxiety disorder also experience strong physical symptoms, such as a rapid heart rate, nausea, and sweating, and may experience full-blown attacks when confronting a feared situation. Although they recognize that their fear is excessive and unreasonable, people with social anxiety disorder often feel powerless against their anxiety.

Social anxiety disorder affects approximately 15 million American adults and is the second most commonly diagnosed anxiety disorder following specific phobia. The average age of onset for social anxiety disorder is during the teenage years. Although individuals diagnosed with social anxiety disorder commonly report extreme shyness in childhood, it is important to note that this disorder is not simply shyness. Read about the difference.

Social anxiety disorder can wreak havoc on the lives of those who suffer from it. For example, individuals may decline a job opportunity that requires frequent interaction with new people or avoid going out to eat with friends due to a fear that their hands will shake when eating or drinking. Symptoms may be so extreme that they disrupt daily life and can interfere significantly with daily routines, occupational performance, or social life, making it difficult to complete school, interview and get a job, and have friendships and romantic relationships. People with social anxiety disorder are also at an increased risk for developing major depressive disorder and alcohol use disorders.

Despite the availability of effective treatments, fewer than 5% of people of with social anxiety disorder seek treatment in the year following initial onset and more than a third of people report symptoms for 10 or more years before seeking help.

Triumph Over Shyness: Conquering Social Anxiety Disorder,
Second Edition

This ADAA publication is full of practical tips, helpful techniques, and more to help manage anxious thoughts and physical symptoms of social anxiety disorder.

Look inside: Read an excerpt of Triumph Over Shyness: Conquering Social Anxiety Disorder. Using humor, warmth, and language that is easy to understand, authors Murray Stein, MD, MPH, and John Walker, PhD, explain what causes social anxiety disorder, how it impacts social and romantic relationships, and what treatments work. Order your copy today.

Additional Resources
Tips to help stop paranoia and cope with anxiety at BetterHelp.com.

# data[].attributes.attachment_link.description
The defining feature of social anxiety disorder, also called social phobia, is intense anxiety or fear of being judged, negatively evaluated, or rejected in a social or performance situation. People with social anxiety disorder may worry about acting or appearing visibly anxious (e.g., blushing, stumbling over words), or being viewed as stupid, awkward, or boring.

# data[].attributes.body
Mental wellbeing is the ability to handle life and its various stresses and challenges. The MHQ is therefore a snapshot of your self-perception along various dimensions of mental function that determine your mental wellbeing. It is not a measure of happiness or life satisfaction. You could, for example, be experiencing very difficult or sad circumstances in your life but nonetheless have all the capabilities to cope as best as one could, and therefore have a high level of mental wellbeing.

# data[].attributes.attachment_link.provider_name
Sapien Labs | Shaping the Future of Mind Health

# data[].attributes.attachment_link.readable_text
You must be 18 years or older to take this assessment. We do not collect any explicitly identifying information. You can read our privacy policy here. Your response will form part of the Global Mind Project (previously the Mental Health Million Project), providing insight into the mental wellbeing of the global population.

What is Mental Wellbeing and What Does the MHQ Tell You?

Mental wellbeing is the ability to handle life and its various stresses and challenges. The MHQ is therefore a snapshot of your self-perception along various dimensions of mental function that determine your mental wellbeing. It is not a measure of happiness or life satisfaction. You could, for example, be experiencing very difficult or sad circumstances in your life but nonetheless have all the capabilities to cope as best as one could, and therefore have a high level of mental wellbeing.

Your MHQ Score and Report

The MHQ will automatically provide you with a composite mental wellbeing score when you have answered all the questions. You can also request an optional report with sub scores along six dimensions of mental health along with explanations and recommendations by providing your email.

Scores across 6 dimensions of mental health

The six dimensions of mental health in the MHQ

# data[].attributes.attachment_link.title
The #MHQ | Mental Health Quotient | Sapien Labs

# data[].attributes.attachment_link.description
What is your Mental Wellbeing Score? Take the MHQ to find out.

# data[].attributes.body
Anxiety has a way of grabbing your attention and turning it inward upon yourself, making you not only self-critical but suddenly noticing how your heartbeat has rapidly increased without your permission, meanwhile, you then suddenly feel yourself getting hotter, red in the face… sweaty… it feels like a domino effect that cannot be interrupted.

But instead, try and focus your attention on what it is you may be doing, so if you are speaking to someone try and pay close attention to what they are saying rather than worrying about what the right thing is to say next.

# data[].attributes.attachment_link.title
7 Tips for Overcoming Social Anxiety - Ditch the Label

# data[].attributes.attachment_link.description
Social anxiety is the most common anxiety in the UK. Here are 7 tips from our mental health experts on overcoming social anxiety.

# data[].attributes.body
Lenore Skenazy, co-founder of a nonprofit focused on childhood independence, believes there is an answer to the alarming rise in childhood mental health problems: Parents must let go to let them grow.

Skenazy has reason to be concerned.

Because of the rising numbers of mental health issues in children, last October the U.S. Preventive Service Task Force amended their screening recommendations for children ages 8 and older to include a screening for anxiety. According to the CDC, 9.4% of children and adolescents had an anxiety disorder in 2019. That's approximately 5.8 million young people.

# data[].attributes.attachment_link.title
A Solution To The Student Mental Health Crisis: Independence

# data[].attributes.attachment_link.description
A loss of childhood independence could be to blame for increasing mental health problems. Children who have more opportunities for independent activities are happier in the long run.

# data[].attributes.body
Separation anxiety is a typical phase for many infants and toddlers. Young children often have a period where they get anxious or distressed when they have to separate from their parent or main caregivers. Examples of this can be tears at daycare drop-off or getting fussy when a new person holds them. This usually starts to improve by about 2 to 3 years of age.

In some children, intense and ongoing separation anxiety is a sign of a more serious condition known as separation anxiety disorder. Separation anxiety disorder can be identified as early as preschool age.

Your child may have separation anxiety disorder if separation anxiety seems more intense than other kids of the same age or lasts a longer time, interferes with school or other daily activities, or includes panic attacks or other problem behaviors. Most often, separation anxiety relates to the child's anxiety about being away from parents or guardians, but it could relate to another close caregiver.

# data[].attributes.attachment_link.readable_text
Overview

Separation anxiety is a normal stage of development for infants and toddlers. Young children often experience a period of separation anxiety, but most children outgrow separation anxiety by about 3 years of age.

In some children, separation anxiety is a sign of a more serious condition known as separation anxiety disorder, starting as early as preschool age.

If your child's separation anxiety seems intense or prolonged - especially if it interferes with school or other daily activities or includes panic attacks or other problems - he or she may have separation anxiety disorder. Most frequently this relates to the child's anxiety about his or her parents, but it could relate to another close caregiver.

Less often, separation anxiety disorder can also occur in teenagers and adults, causing significant problems leaving home or going to work. But treatment can help.

Symptoms

Separation anxiety disorder is diagnosed when symptoms are excessive for the developmental age and cause significant distress in daily functioning. Symptoms may include:

Recurrent and excessive distress about anticipating or being away from home or loved ones

Constant, excessive worry about losing a parent or other loved one to an illness or a disaster

Constant worry that something bad will happen, such as being lost or kidnapped, causing separation from parents or other loved ones

Refusing to be away from home because of fear of separation

Not wanting to be home alone and without a parent or other loved one in the house

Reluctance or refusing to sleep away from home without a parent or other loved one nearby

Repeated nightmares about separation

Frequent complaints of headaches, stomachaches or other symptoms when separation from a parent or other loved one is anticipated

Separation anxiety disorder may be associated with panic disorder and panic attacks ― repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes.

When to see a doctor

Separation anxiety disorder usually won't go away without treatment and can lead to panic disorder and other anxiety disorders into adulthood.

If you have concerns about your child's separation anxiety, talk to your child's pediatrician or other health care provider.

Causes

Sometimes, separation anxiety disorder can be triggered by life stress that results in separation from a loved one. Genetics may also play a role in developing the disorder.

Risk factors

Separation anxiety disorder most often begins in childhood, but may continue into the teenage years and sometimes into adulthood.

Risk factors may include:

Life stresses or loss that result in separation, such as the illness or death of a loved one, loss of a beloved pet, divorce of parents, or moving or going away to school

Certain temperaments, which are more prone to anxiety disorders than others are

Family history, including blood relatives who have problems with anxiety or an anxiety disorder, indicating that those traits could be inherited

Environmental issues, such as experiencing some type of disaster that involves separation

Complications

Separation anxiety disorder causes major distress and problems functioning in social situations or at work or school.

Disorders that can accompany separation anxiety disorder include:

Other anxiety disorders, such as generalized anxiety disorder, panic attacks, phobias, social anxiety disorder or agoraphobia

Obsessive-compulsive disorder

Depression

Prevention

There's no sure way to prevent separation anxiety disorder in your child, but these recommendations may help.

Seek professional advice as soon as possible if you're concerned that your child's anxiety is much worse than a normal developmental stage. Early diagnosis and treatment can help reduce symptoms and prevent the disorder from getting worse.

Stick with the treatment plan to help prevent relapses or worsening of symptoms.

Seek professional treatment if you have anxiety, depression or other mental health concerns, so that you can model healthy coping skills for your child.

# data[].attributes.attachment_link.title
Separation anxiety disorder - Symptoms and causes

# data[].attributes.attachment_link.description
Separation anxiety is a normal stage of development for infants and toddlers. Young children often experience a period of separation anxiety, but most children outgrow separation anxiety by about 3 years of age. In some children, separation anxiety is a sign of a more serious condition known as separation anxiety disorder, starting as early as preschool age.

# data[].attributes.body
person with separation anxiety disorder will have three or more of the following symptoms:

Feel distress when apart from an attachment figure or anticipating separation.

Worry something bad (like injury or death) will happen to an attachment figure.

Worry something bad will happen to one’s own self (like getting lost or being kidnapped) that would cause separation from an attachment figure.

Refuse to leave home or go places like school or work due to fear of separation.

Fear being alone (including in one part of the home) without an attachment figure nearby.

Refuse to go to sleep without an attachment figure nearby.

Have recurring nightmares about being separated from an attachment figure (these might include disasters like fire or murder).

# data[].attributes.attachment_link.readable_text
What are separation anxiety disorder symptoms?

A person with separation anxiety disorder will have three or more of the following symptoms:

Feel distress when apart from an attachment figure or anticipating separation.

Worry something bad (like injury or death) will happen to an attachment figure.

Worry something bad will happen to one's own self (like getting lost or being kidnapped) that would cause separation from an attachment figure.

Refuse to leave home or go places like school or work due to fear of separation.

Fear being alone (including in one part of the home) without an attachment figure nearby.

Refuse to go to sleep without an attachment figure nearby.

Have recurring nightmares about being separated from an attachment figure (these might include disasters like fire or murder).

Have physical symptoms like stomachaches, headaches, vomiting or nausea when apart from an attachment figure or anticipating separation. Adolescents and adults may have heart palpitations or dizziness (these are rare in younger kids).

Recognizing separation anxiety disorder in children

Separation anxiety disorder symptoms can look a little different depending on your child's age. For example, a preschooler might not know how to put their feelings into words. They may simply get upset. An older child might tell you about their nightmares or describe their fears in detail.

If you force a separation despite your child's protests, then your child may appear sad or uninterested in whatever setting they're in (like school). They may have difficulty concentrating on schoolwork and not seem to care about engaging with peers. These are behaviors their teacher might observe.

If away from home for several days (for example, at camp), a child with separation anxiety disorder might get extremely homesick and feel miserable until they're allowed to leave. It's also possible for a child with this disorder to show anger or even aggression toward anyone they perceive as keeping them from you.

Recognizing separation anxiety disorder in adults

When you love someone, it's hard not to worry about them. It's simply a part of life. But the distress with separation anxiety disorder is out of proportion to the situation. It may also start to interfere with your work or relationships. For example, you might call off work to stay with your loved one or text them often to make sure they're OK (and worry until they reply).

When you're living with this disorder, you might not always feel your worries are out of proportion to the situation. Maybe it's only when your child or partner gets frustrated with your checking on them that you realize your anxiety is more than typical.

What causes separation anxiety disorder?

Researchers don't know exactly what causes separation anxiety disorder, but they believe it's likely a combination of genetics and environment. For example, a person might be born with a genetic change ( mutation) that affects how certain chemicals in their brain work.

But genetics alone might not be enough to cause a disorder. It's likely that an environmental factor - like a big life change or an adverse childhood experience - also plays a role. Such factors may cause epigenetic changes, or changes to chemicals attached to your genes that affect how those genes work. For example, certain epigenetic changes might affect how cells in your body "read" genes that control stress response.

Risk factors

A child may have an increased risk of developing separation anxiety disorder if they:

Experience the loss of someone close to them.

Go through a stressful situation like their parents getting divorced.

Switch schools or move to a new place.

Have a history of anxiety disorders in their biological family.

Risk factors for developing separation anxiety disorder as an adult include:

Loss of a loved one.

Illness in a loved one.

Big life changes, like a move, entering a romantic relationship and becoming a parent.

Diagnosis of an anxiety disorder as a child.

Diagnosis of other anxiety or mental health disorders as an adult.

What are the complications of separation anxiety disorder?

Separation anxiety disorder disrupts your life and makes it hard to do necessary and desired things.

Children might:

Have trouble focusing on schoolwork, causing them to fall behind in classes.

Have a hard time engaging with peers or joining in social activities.

Miss opportunities to learn, gain social skills and become more independent.

Adults might:

Have trouble focusing on work or other responsibilities.

Encounter conflicts in their relationships, especially with attachment figures.

Miss opportunities to travel or do other meaningful activities.

# data[].attributes.attachment_link.description
Separation anxiety disorder causes excessive fear or anxiety when you're away from a loved one, like a partner or child. Learn about the symptoms and treatment.

# data[].attributes.body
Easing transitions for your child and you

The trick for surviving separation anxiety demands preparation, brisk transitions, and the evolution of time. I would suggest we parents suffer as much as our children do when we leave. Even though we are often reminded that our children stop crying within minutes of our leave-taking, how many of you have felt like you’re "doing it all wrong" when your child clings to your legs, sobs for you to stay and mourns the parting?

As a working parent, separation anxiety has created questions for me. Although it is an entirely normal behavior and a beautiful sign of a meaningful attachment, separation anxiety can be unsettling for us all.

Here are facts about separation anxiety and tips to improve the transitions I’ve learned the hard way (I’ve made about every mistake):

Facts about separation anxiety

Infants: Separation anxiety develops after a child gains an understanding of object permanence. Once your infant realizes you’re really gone (when you are), it may leave them unsettled. Although some babies display object permanence and separation anxiety as early as 4 to 5 months of age, most develop more robust separation anxiety at around 9 months. The leave- taking can be worse if your infant is hungry, tired, or not feeling well. Keep transitions short and routine if it’s a tough day.

Toddlers: Many toddlers skip separation anxiety in infancy and start demonstrating challenges at 15 or 18 months of age. Separations are more difficult when children are hungry, tired, or sick—which is most of toddlerhood! As children develop independence during toddlerhood, they may become even more aware of separations. Their behaviors at separations will be loud, tearful, and difficult to stop.

Preschoolers: By the time children are 3 years of age, most clearly understand the effect their anxiety or pleas at separation have on us. It doesn’t mean they aren’t stressed, but they certainly are vying for a change. Be consistent; don’t return to the room based on a child’s plea, and certainly don’t cancel plans based on separation anxiety. Your ongoing consistency, explanations, and diligence to return when you say you will are key.

Surviving separation anxiety: 6 tips to try

Create quick good-bye rituals. Even if you have to do major-league- baseball–style hand movements, give triple kisses at the cubby, or provide a special blanket or toy as you leave, keep the good-bye short and sweet. If you linger, the transition time does too. So will the anxiety.

Be consistent. Try to do the same drop-off with the same ritual at the same time each day you separate to avoid unexpected factors whenever you can. A routine can diminish the heartache and will allow your child to simultaneously build trust in her independence and in you.

Attention: When separating, give your child full attention, be loving, and provide affection. Then say good-bye quickly despite their antics or cries for you to stay.

Keep your promise. You’ll build trust and independence as your child becomes confident in her ability to be without you when you stick to your promise of return. The biggest mistake I ever made in this regard was returning to class to "visit" my son about an hour after a terrible transition. I was missing him, and although the return was well intended, I not only extended the separation anxiety, we started all over again in the process. When I left the second time (and subsequent days) it was near nuclear.

Be specific, child style. When you discuss your return, provide specifics that your child understands. If you know you’ll be back by 3:00 pm, tell it to your child on their terms; for example, say, "I’ll be back after nap time and before afternoon snack." Define time they can understand. Talk about your return from a business trip in terms of "sleeps." Instead of saying, "I’ll be home in 3 days," say, "I’ll be home after 3 sleeps."

Practice being apart. Ship the children off to grandma’s home, schedule playdates, allow friends and family to provide child care for you (even for an hour) on the weekend. Before starting child care or preschool, practice going to school and your good-bye ritual before you even have to part ways. Give your child a chance to prepare, experience, and thrive in your absence!

It’s rare that separation anxiety persists on a daily basis after the preschool years. If you’re concerned that your child isn’t adapting to being without you, chat with the pediatrician. Your pediatrician has certainly helped support families in the same situation and can help calm your unease and determine a plan to support both of you!

More information

Top Tips for Surviving Tantrums

Preparing Your Child for the First Day of School

Self-Soothing: Help Your Baby Learn This Life Skill

Tips to Support Emotional Development & Relational Health

About Dr. Swanson

Wendy Sue Swanson, MD, MBE, FAAP, who serves on the American Academy of Pediatrics Council on Communications and Media, is author of Mama Doc Medicine: Finding Calm and Confidence in Child Health, Parenting, and World-Life Balance.

Mama Doc Medicine: Finding Calm and Confidence in Parenting, Child Health, and Work-Life Balance (Copyright © 2014 Wendy Sue Swanson)

The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

# data[].attributes.attachment_link.readable_text
Separation anxiety varies WIDELY between children. Some babies become hysterical when mom is out of sight for a very short time, while other children seem to demonstrate ongoing anxiety at separations during infancy, toddlerhood, and preschool.

To all you working parents

The trick for surviving separation anxiety demands preparation, brisk transitions, and the evolution of time. I would suggest we parents suffer as much as our children do when we leave. Even though we are often reminded that our children stop crying within minutes of our leave-taking, how many of you have felt like you're "doing it all wrong" when your child clings to your legs, sobs for you to stay, and mourns the parting?

As a working parent, separation anxiety creates questions for me. Although it is an entirely normal behavior and a beautiful sign of a meaningful attachment, separation anxiety can be exquisitely unsettling for us all.

Here are facts about separation anxiety and tips to improve the transitions I've learned the hard way (I've made about every mistake):

Facts about separation anxiety

Infants: Separation anxiety develops after a child gains an understanding of object permanence. Once your infant realizes you're really gone (when you are), it may leave them unsettled. Although some babies display object permanence and separation anxiety as early as 4 to 5 months of age, most develop more robust separation anxiety at around 9 months. The leave- taking can be worse if your infant is hungry, tired, or not feeling well. Keep transitions short and routine if it's a tough day.

Toddlers: Many toddlers skip separation anxiety in infancy and start demonstrating challenges at 15 or 18 months of age. Separations are more difficult when children are hungry, tired, or sick-which is most of toddlerhood! As children develop independence during toddlerhood, they may become even more aware of separations. Their behaviors at separations will be loud, tearful, and difficult to stop.

Preschoolers: By the time children are 3 years of age, most clearly understand the effect their anxiety or pleas at separation have on us. It doesn't mean they aren't stressed, but they certainly are vying for a change. Be consistent; don't return to the room based on a child's plea, and certainly don't cancel plans based on separation anxiety. Your ongoing consistency, explanations, and diligence to return when you say you will are key.

How to survive separation anxiety

Create quick good-bye rituals. Even if you have to do major-league- baseball-style hand movements, give triple kisses at the cubby, or provide a special blanket or toy as you leave, keep the good-bye short and sweet. If you linger, the transition time does too. So will the anxiety.

Be consistent. Try to do the same drop-off with the same ritual at the same time each day you separate to avoid unexpected factors whenever you can. A routine can diminish the heartache and will allow your child to simultaneously build trust in her independence and in you.

Attention: When separating, give your child full attention, be loving, and provide affection. Then say good-bye quickly despite their antics or cries for you to stay.

Keep your promise. You'll build trust and independence as your child becomes confident in her ability to be without you when you stick to your promise of return. The biggest mistake I ever made in this regard was returning to class to "visit" my son about an hour after a terrible transition. I was missing him, and although the return was well intended, I not only extended the separation anxiety, we started all over again in the process. When I left the second time (and subsequent days) it was near nuclear.

Be specific, child style. When you discuss your return, provide specifics that your child understands. If you know you'll be back by 3:00 pm, tell it to your child on their terms; for example, say,"I'll be back after nap time and before afternoon snack." Define time they can understand. Talk about your return from a business trip in terms of " sleeps." Instead of saying, " I'll be home in 3 days," say, " I'll be home after 3 sleeps."

Practice being apart. Ship the children off to grandma's home, schedule playdates, allow friends and family to provide child care for you (even for an hour) on the weekend. Before starting child care or preschool, practice going to school and your good-bye ritual before you even have to part ways. Give your child a chance to prepare, experience, and thrive in your absence!

It's rare that separation anxiety persists on a daily basis after the preschool years. If you're concerned that your child isn't adapting to being without you, chat with the pediatrician. Your pediatrician has certainly helped support families in the same situation and can help calm your unease and determine a plan to support both of you!

More information

About Dr. Swanson

Wendy Sue Swanson, MD, MBE, FAAP, who serves on the American Academy of Pediatrics Council on Communications and Media, is author of Mama Doc Medicine: Finding Calm and Confidence in Child Health, Parenting, and World-Life Balance.

Mama Doc Medicine: Finding Calm and Confidence in Parenting, Child Health, and Work-Life Balance (Copyright © 2014 Wendy Sue Swanson)

# data[].attributes.attachment_link.title
How to Ease Your Child's Separation Anxiety

# data[].attributes.attachment_link.description
Separation anxiety varies WIDELY between children. Some babies become hysterical when mom is out of sight for a very short time, while other children seem to demonstrate ongoing anxiety at separations during infancy, toddlerhood, and preschool.

# data[].attributes.body
Separation anxiety disorder (SAD) is an anxiety disorder in which an individual experiences excessive anxiety regarding separation from home and/or from people to whom the individual has a strong emotional attachment (e.g., a parent, caregiver, significant other, or siblings). Separation anxiety is a natural part of the developmental process. It is most common in infants and little children, typically between the ages of six to seven months to three years, although it may pathologically manifest itself in older children, adolescents and adults. Unlike SAD (indicated by excessive anxiety), normal separation anxiety indicates healthy advancements in a child's cognitive maturation and should not be considered a developing behavioral problem

# data[].attributes.attachment_link.title
Separation Anxiety Disorder: Causes, Symptoms And Treatment.

# data[].attributes.body
Separation anxiety is a normal phase of development in which infants and toddlers experience emotional distress or anxiety when separated from their primary caregiver. Separation anxiety can vary in its duration and severity. In most children, separation anxiety will develop around 10 - 12 months of age, but could start earlier. It often disappears around 2-3 years of age. Separation anxiety is often classified into three possible stages: -protest -despair -detachmen

# data[].attributes.attachment_link.title
Separation Anxiety in Children: Stages, Pediatric Nursing NCLEX Review

# data[].attributes.body
BILIFY ASIMTUFII or ABILIFY MAINTENA may cause serious side effects, including:

Increased risk of stroke and ministroke has been reported in clinical studies with oral aripiprazole of elderly people with dementia-related psychosis and can lead to death.

Neuroleptic malignant syndrome (NMS), a serious condition that can lead to death. Call your healthcare provider or go to the nearest emergency room right away if you have some or all of the following signs and symptoms of NMS: high fever, confusion, changes in pulse, heart rate, and blood pressure, stiff muscles, and increased sweating.

Uncontrolled body movements (tardive dyskinesia). ABILIFY ASIMTUFII and ABILIFY MAINTENA may cause movements that you cannot control in your face, tongue, or other body parts. Tardive dyskinesia may not go away, even if you stop receiving ABILIFY ASIMTUFII or ABILIFY MAINTENA. Tardive dyskinesia may also start after you stop receiving ABILIFY ASIMTUFII or ABILIFY MAINTENA.

Problems with your metabolism such as:

High blood sugar (hyperglycemia) and diabetes: Increases in blood sugar can happen in some people who are treated with ABILIFY ASIMTUFII or ABILIFY MAINTENA. Extremely high blood sugar can lead to coma or death. If you have diabetes or risk factors for diabetes such as being overweight or a family history of diabetes, your healthcare provider should check your blood sugar before you start treatment with ABILIFY ASIMTUFII or ABILIFY MAINTENA, and during treatment.

# data[].attributes.attachment_link.title
How ABILIFY ASIMTUFII® (aripiprazole) Bipolar I Maintenance Treatment May Help

# data[].attributes.attachment_link.description
How ABILIFY ASIMTUFII® bipolar I maintenance treatment for adults may help. Please see IMPORTANT SAFETY INFO & Full Prescribing Info, including BOXED WARNING.

# data[].attributes.body
Diagnosis and Evaluation: Our team of mental health professionals uses a variety of evaluation tools, such as medical history, psychiatric assessments, and psychological testing, to gain a better understanding of your mental health condition.

Personalized Treatment Plan: Once we have identified your specific needs, we create a customized treatment plan tailored to your unique circumstances. Our treatment plans may include medication management, psychotherapy, group therapy, family therapy, and other evidence-based treatment modalities.

Support and Aftercare: We understand that the journey to recovery doesn't end when you leave our treatment center. That's why we provide ongoing support and aftercare to ensure that you continue to make progress after you leave our facility. Our support services include aftercare planning, follow-up appointments, support groups, and access to community resources.

# data[].attributes.attachment_link.title
Genesis House - Mental Health and Addiction Treatment Center.

# data[].attributes.attachment_link.description
Luxury Mental Health Treatment Facility. Luxury Drug & Alcohol Recovery Programs. Drug / Alcohol Detox Center

# data[].attributes.body
Talking with your healthcare provider is an important part of working toward your treatment goals. But it’s not always easy to know what to ask. As you consider your treatment options, use the tool below to create a personalized discussion guide that can help you have a more productive discussion

# data[].attributes.attachment_link.title
Talk to Your Doctor | ABILIFY ASIMTUFII® (aripiprazole)

# data[].attributes.attachment_link.description
Start the conversation with your healthcare provider about ABILIFY ASIMTUFII®. Please read IMPORTANT SAFETY INFO & Full Prescribing Info, including BOXED WARNING.

# data[].attributes.body
Major depressive disorder is a serious medical illness affecting an estimated 21 million American adults. MDD can look different from person to person, and not everyone responds to medication the same way. For many, their antidepressant may not be working well enough. A large study showed that 2 out of 3 people taking an antidepressant still experienced symptoms of depression

# data[].attributes.attachment_link.title
About Depression & Partial Response | REXULTI® (brexpiprazole)

# data[].attributes.attachment_link.description
Learn about depression and partial response on antidepressants. See Important Safety Info & Full Prescribing Info, including Boxed WARNING.

# data[].attributes.body
BJECTIVE: This study tested the validity in the adult general population of the Mood Disorder Questionnaire, a screening instrument for bipolar I and II disorders. The Mood Disorder Questionnaire has been validated in a psychiatric outpatient study group. METHOD: A total of 711 subjects (stratified by Mood Disorder Questionnaire score) were randomly selected from a group of 85,358 adult respondents in a nationwide epidemiological general population sample that was balanced for key demographic variables. Of these, 695 subjects received a telephone interview involving an abbreviated version of the Structured Clinical Interview for DSM-IV. RESULTS: A sensitivity of 0.281 and a specificity of 0.972 were obtained for the Mood Disorder Questionnaire. CONCLUSIONS: The Mood Disorder Questionnaire is a useful screening instrument for bipolar I and II disorders in the community. The operating characteristics of the Mood Disorder Questionnaire in the general population differ substantially from its characteristics in outpatient psychiatric settings.

# data[].attributes.attachment_link.title
Validity of the Mood Disorder Questionnaire: A General Population Study | American Journal of Psychiatry

# data[].attributes.attachment_link.description
OBJECTIVE: This study tested the validity in the adult general population of the Mood Disorder Questionnaire, a screening instrument for bipolar I and II disorders. The Mood Disorder Questionnaire has been validated in a psychiatric outpatient study group. METHOD: A total of 711 subjects (stratified by Mood Disorder Questionnaire score) were randomly selected from a group of 85,358 adult respondents in a nationwide epidemiological general population sample that was balanced for key demographic variables. Of these, 695 subjects received a telephone interview involving an abbreviated version of the Structured Clinical Interview for DSM-IV. RESULTS: A sensitivity of 0.281 and a specificity of 0.972 were obtained for the Mood Disorder Questionnaire. CONCLUSIONS: The Mood Disorder Questionnaire is a useful screening instrument for bipolar I and II disorders in the community. The operating characteristics of the Mood Disorder Questionnaire in the general population differ substantially from its characteristics in outpatient psychiatric settings.

# data[].attributes.body
In this insightful video, renowned trauma expert Dr. Gabor Maté delves into the holistic approach to healing emotional wounds, emphasizing compassion for oneself and others. Learn how storytelling and narratives play a vital role in understanding human experiences, emotional dynamics, and the path to recovery. Explore the profound impact of childhood adversity on emotional well-being and why validating emotions, especially in children, is key to fostering resilience. Dr. Maté also reveals how life's challenges—like grief and disappointment—are natural parts of our journey and essential to personal growth. I find this doctor talking about trauma and many subjects that interest me.

# data[].attributes.attachment_link.title
How Your Trauma Actually HEALS (with Dr. Gabor Maté)

# data[].attributes.attachment_caption
What is Trauma? - Trauma-Informed Care ImplementatioAlthough trauma can occur at any age, it has particularly debilitating long-term effects on children’s developing brains. Often referred to as adverse childhood experiences (ACEs), exposure to these experiences is common across all sectors of society:n Resource Center

# data[].attributes.attachment_link.title
What is Trauma? - Trauma-Informed Care Implementation Resource Center

# data[].attributes.attachment_link.description
Learn about trauma, its causes, and the negative long-term effects of trauma on health and wellbeing.

# data[].attributes.body
The overall risk of developing PTSD after a traumatic exposure is 4.0%. This risk varies dramatically by trauma type, with the highest risk of 29.5% being associated with sexual relationship violence, and an 11.7% risk being associated with physical abuse by a partner.6-8†

# data[].attributes.attachment_link.readable_text
Considering the magnitude of patients experiencing PTSD, a broad lens may be needed.

Recognizing when a patient may be living with PTSD

According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PTSD is the development of characteristic symptoms after exposure to one or more traumatic events. ⁴ All of the diagnostic criteria outlined by the DSM-5 must be met to be diagnosed with PTSD.

PTSD is characterized by the 4 symptom clusters: Intrusion (re-experiencing), persistent avoidance of stimuli, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity. 4,5

Download this PTSD symptom sheet to learn about some of the symptoms patients with PTSD may experience.

An Expert's Insights

Dr. Arash Javanbakht sheds light on common PTSD epidemiology
misconceptions

Watch video

Many different types of traumatic events can lead to PTSD

The most common trauma types associated with PTSD6†

†Based on a 2017 analysis of prevalence and distribution of trauma exposure of 51,196 traumatic events by the World Health Organization (WHO) World Mental Health Surveys (2001-2012).

Life-threatening automobile accidents Witnessing or discovering death or serious injury Muggings Unexpected death of a loved one Life-threatening illnesses 1 1.8% 14.0% 14.5% 23.7% 31.4%

Life-threatening illnesses 11.8% Life-threatening automobile accidents 14.0% Muggings 14.5% Witnessing or discovering death or serious injury 23.7% Unexpected death of a loved one 31.4%

Other sources of trauma that can cause PTSD and may be less recognized include major health conditions, health pandemics, and acting as a first responder in an emergency.⁹⁻¹²

PTSD can develop at any age and across genders and identities

The median age of onset is 23 among US adults13‡

‡Based on a US face-to-face household survey conducted between February 2001 and April 2003 using the WHO World Mental Health Survey version of the Composite International Diagnostic Interview (n=9282). ¹³

Adult women account for 66.4% of the overall PTSD population in the US14,15§

§Based on US PTSD prevalence estimates from a secondary analysis of the 2012-2013 National Epidemiologic Survey of Alcohol and Related Conditions assessing PTSD in veterans (n=31,119) and civilians (n=32,982), ³ and 2018 population estimates from the Census Bureau, VA, and DOD, 2,607,131 male and 7,558,833 female adults were estimated to have PTSD in the US civilian population and 1,368,925 male and 293,256 female adults in the US military population. ¹⁴

PTSD can affect all ethnic groups, with prevalence ranging from 8.7% of Blacks, to 7.4% and 7.0% of whites and Hispanics, respectively, to 4.0% of Asian Americans16,17||

||Based on data analyzed from 34,653 adult respondents to the 2004-2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

The majority of patients with PTSD (>80%) are in the civilian population rather than the military population14¶

¶Based on US PTSD prevalence estimates from a secondary analysis of the 2012-2013 National Epidemiologic Survey of Alcohol and Related Conditions assessing PTSD in veterans (n=31,119) and civilians (n=32,982), ³ and 2018 population estimates from the Census Bureau, VA, and DOD, 2,607,131 male and 7,558,833 female adults were estimated to have PTSD in the US civilian population, and 1,368,925 male and 293,256 female adults in the US military population. ¹⁴

The presence of certain risk factors may influence the likelihood of developing PTSD

Increased risk of PTSD has been associated with a higher odds ratio (OR) in adults in the US with exposure to at least 1 traumatic event¹⁸⁻²⁰

#Based on a systematic literature review of published (2015-2019) observational studies of PTSD prevalence in the US compared to those factors not being present.

**Based on data aggregated from studies with varying study designs, and underlying populations and statistical methods reported in 13 publications (2015-2019); compared to males; compared to single people.

††Based on data from 34,653 noninstitutionalized adult US residents from the 2004 to 2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions; compared to heterosexuals.

1.0 Alcohol use disorder 18# 1.2 LGBTQ+20†† 2.0-2.1 Diagnosed mental illness 18# 1.5-3.0

#Based on a systematic literature review of published (2015-2019) observational studies of PTSD prevalence in the US compared to those factors not being present.

**Based on data aggregated from studies with varying study designs, and underlying populations and statistical methods reported in 13 publications (2015-2019); compared to males; compared to single people.

††Based on data from 34,653 noninstitutionalized adult US residents from the 2004 to 2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions; compared to heterosexuals.

1.0 Diagnosed mental illness 18# 1.5-3.0 Younger (<65 years)18# 1.4-4.0

Screen for PTSD. Target patient care.

Increase PTSD screening. Use this 5-question screening tool designed to help identify probable PTSD in a primary care setting.

Download screener

PTSD patients may experience a wide range of impact

If a patient mentions struggling with multiple aspects of marital, parental, occupational, and social activities, with ongoing struggles and disruptive symptoms, PTSD may be a factor. ⁴
Each person's experience with PTSD may be different, and symptoms may vary.

Sign up now

Stay informed with the latest PTSD information and resources

Receive email updates with the latest insights and news in PTSD. Plus, you can access and download complimentary resources.

REFERENCES

1.
US Census Bureau, Population Division. Estimates of the Total Resident Population and Resident Population Age 18 Years and Older for the United States, Regions, States, District of Columbia, and Puerto Rico: July 1, 2022 (SCPRC-EST2022-18+POP). Release date: December 2022.

2.
US Department of Veterans Affairs. PTSD: National Center for PTSD. How common is PTSD in adults? Accessed December 4, 2023. https://www.ptsd.va.gov/understand/common/common_adults.asp

3.
Lehavot K, et al. Post-traumatic stress disorder by gender and veteran status [published correction appears in Am J Prev Med. 2019 Oct;57(4):573]. Am J Prev Med. 2018; 54(1):e1-e9.

4.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. DSM-5™. American Psychiatric Publishing; 2013.

5.
Lancaster CL, et al. Posttraumatic stress disorder: overview of evidence-based assessment and treatment. J Clin Med. 2016;5:E105.

13.
Kessler RC, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62:593-602.

19.
Data on file.

# data[].attributes.attachment_link.title
Recognizing PTSD in Patients | Tethered to PTSD

# data[].attributes.attachment_link.description
PTSD information for medical professionals on recognizing symptoms, risk factors, implications, and more.

# data[].attributes.body
The EMDR Workbook for Trauma and PTSD: Skills to Manage Triggers, Move Beyond Traumatic Memories, and Take Back Your Life

# data[].attributes.attachment_caption
Top 10 PTSD Post-Traumatic Stress Disorder (PTSD) is a mental health condition triggered by experiencing or witnessing a traumatic event. Symptoms may include flashbacks, severe anxiety, and uncontrollable thoughts about the event, which can significantly impact daily functioning and quality of life.

# data[].attributes.attachment_link.readable_text
Post-Traumatic Stress Disorder (PTSD) is a mental health condition triggered by experiencing or witnessing a traumatic event. Symptoms may include flashbacks, severe anxiety, and uncontrollable thoughts about the event, which can significantly impact daily functioning and quality of life.

PTSD can affect individuals of any age and is commonly associated with military veterans, but it can also result from a variety of traumatic experiences, such as natural disasters, accidents, sexual assault, or sudden loss of a loved one. The symptoms typically emerge within three months of the traumatic event but can sometimes take years to manifest. People with PTSD may experience intrusive memories, nightmares, emotional numbness, and avoidance of reminders related to the trauma. Treatment options include psychotherapy, such as cognitive-behavioral therapy (CBT) and exposure therapy, as well as medications like antidepressants to help manage symptoms. Early intervention and support from friends and family are crucial in recovery, promoting resilience and helping individuals regain a sense of safety and normalcy in their lives.

# data[].attributes.attachment_link.description
Post-Traumatic Stress Disorder (PTSD) is a mental health condition triggered by experiencing or witnessing a traumatic event. Symptoms may include flashbacks, severe anxiety, and uncontrollable thoughts about the event, which can significantly impact daily functioning and quality of life.