Preventing Anxiety, OCD, PTSD and Somatoform Disorders

1The morning after the accident

A school bus overturns on a hill road; several students are injured and all are badly shaken. The next morning a well-meaning head teacher plans to gather the passengers and have each one describe the accident in full detail, "to get it all out". It sounds caring. But research shows that this kind of single-session psychological debriefing does not prevent PTSD, and in some studies it made later symptoms worse. What should the school do instead? This lesson looks at prevention for anxiety disorders, OCD, PTSD and somatoform disorders, and at the difference between what feels helpful and what the evidence supports. (The accident is an illustrative case.)

21. Preventing anxiety disorders

• Universal school programmes. Programmes that teach every pupil to recognise anxiety, use relaxation and problem-solving, and challenge anxious thoughts (for example the CBT-based FRIENDS programme) show small benefits on average. In a large English trial (Stallard and others, 2014), FRIENDS reduced anxiety when run by trained health facilitators but not when run by school staff, a reminder that a programme is only as good as its delivery.
• Selective prevention through parents. Ronald Rapee and colleagues taught the parents of very shy, inhibited preschool children to reduce overprotection and to encourage gradual "brave" steps. Fewer of these children had anxiety disorders in the following years than children in a control group.
• Indicated prevention. Brief CBT for children and adolescents who already show raised anxiety reduces the chance that it becomes a disorder.
• Everyday principle: approach, not avoidance. Because avoidance maintains fear (Unit 7, Lesson 2), parents and teachers prevent anxiety by helping children face manageable challenges, not by removing every difficulty.

32. OCD

OCD often begins in childhood or adolescence and has a genetic component, so primary prevention is hard. The main gains come from secondary prevention: many people wait years before getting help, often from shame about their thoughts. Teaching that intrusive thoughts are normal, recognising OCD early and starting exposure and response prevention quickly all shorten suffering. Families can help by gradually reducing family accommodation, with professional guidance.

43. PTSD: what to do after trauma

Primary prevention means preventing trauma itself: reducing violence in homes and communities, gender-based violence and child abuse, and preparing for disasters and accidents. When trauma does happen, the evidence points to a stepped approach (Figure 1).

Figure 1. Preventing PTSD after a traumatic event: a stepped approach based on WHO guidance (2011, 2013). Most people recover with support; specialised treatment is kept for those whose symptoms persist.

• Debriefing does not work. A Cochrane review (Rose and others, 2002) found no evidence that single-session debriefing prevents PTSD. In a three-year follow-up of road accident survivors (Mayou, Ehlers and Hobbs, 2000), people who had been debriefed did worse than those who had not. The WHO (2013) recommends that it should not be used.
• Psychological first aid follows five principles drawn from research (Stevan Hobfoll and colleagues, 2007): promote a sense of safety, calm, connectedness, self-efficacy and hope. It does not force anyone to talk.
• No routine benzodiazepines. The WHO (2013) advises against giving them to prevent PTSD in the first month.
• Indicated prevention. For people who still have marked symptoms after some weeks, brief trauma-focused CBT reduces the chance of chronic PTSD, while offering it to everyone shows no benefit.

A Rwandan example. Community-based sociotherapy in Rwanda brings groups together for fifteen weekly sessions to rebuild trust, safety and mutual support after mass violence; it is open to anyone over 15. In a quasi-experimental study, participants' scores on a screening questionnaire for common mental disorders (the SRQ-20) fell by 2.3 points, against 0.8 points in a similar comparison group, eight months later (Scholte and others, 2011). Evaluate: the groups were matched but not randomly assigned, and about a fifth of participants dropped out, so the result is encouraging rather than conclusive.

54. Somatoform disorders

• In the clinic: clear, respectful explanations; checking properly for physical causes, but avoiding repeated unnecessary tests, which can increase worry; treating anxiety and depression early.
• In families: responding calmly to children's minor illnesses and rewarding a return to normal activity, rather than giving extra attention only when a child is ill.
• In the community: health workers who understand local ways of expressing distress through the body, such as ihahamuka (Unit 7), can recognise psychological distress early and offer the right support.