Post-Traumatic Stress Disorder

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Post-Traumatic Stress Disorder

Definition

Post-traumatic stress disorder (PTSD) is primarily caused by human reactions to events outside the realm of ordinary life experience. Domestic and criminal violence, natural disasters, and transportation accidents are major categories of incidents associated with PTSD. Once thought to be experienced primarily by war veterans, PTSD is now known to occur in survivors of sexual, physical, or emotional abuse, and in persons who have witnessed a traumatic event.

PTSD may result from long-term experiences of trauma as well as from time-limited violent events. It is now recognized that repeated traumas or such traumas of long duration as child abuse, domestic violence, stalking, cult membership, and hostage situations may also produce the symptoms of PTSD in survivors.

Description

After a traumatic event, the person who suffered the trauma, as well as others who witnessed it or were involved as emergency workers, may experience a range of symptoms. These may include physical pain; change in bowel function, such as diarrhea and/or constipation; change in sleep patterns, such as sleeping more or less than before the trauma; heart palpitations, sweating, being easily startled or becoming hypervigilant; becoming increasingly susceptible to illness.

As the individual struggles to cope with life after the event, ordinary events or situations that resemble the trauma in certain respects often trigger frightening, vivid memories or flashbacks. For example, one survivor of a plane crash would have flashbacks of the crash whenever he smelled something burning. A Vietnam veteran would have flashbacks whenever he heard a car backfire.

Causes and symptoms

Causes

While it is not clear why some people develop PTSD following a trauma and others do not, experts suspect that it may be influenced both by the severity of the event, by the person's personality and genetic make-up, and by whether or not the trauma was expected. In addition, occupational factors play a role; persons who work as fire fighters, police officers, emergency room staff, or in similar high-risk occupations have a higher rate of PTSD than the general population. Lastly, the nature of the trauma itself is a factor; as a rule, traumas resulting from intentional human behavior (rape, torture, genocide, domestic violence, etc.) are experienced as more stressful than traumas resulting from accidents, natural disasters, or animal attacks.

Symptoms

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), specifies six diagnostic criteria for PTSD:

Traumatic stressor: The patient has been exposed to a catastrophic event involving actual or threatened death or injury, or a threat to the physical integrity of the self or others. During exposure to the trauma, the person's emotional response was marked by intense fear, feelings of helplessness, or horror.
Intrusive symptoms: The patient experiences flash-backs, traumatic daydreams, or nightmares, in which he or she relives the trauma as if it were recurring in the present. Intrusive symptoms result from an abnormal process of memory formation.
Avoidant symptoms: The patient attempts to reduce the possibility of exposure to anything that might trigger memories of the trauma, and to minimize his or her reactions to such memories. This cluster of symptoms includes dissociative symptoms (derealization and depersonalization), psychic numbing, and avoidance of places, persons, or things associated with the trauma. Patients with PTSD are at increased risk of substance abuse as a form of self-medication to numb painful memories.
Hyperarousal: Hyperarousal is a condition in which the patient's nervous system is always on "red alert" for the return of danger. This symptom cluster includes hypervigilance, insomnia, difficulty concentrating, general irritability, and an extreme startle response.
Duration of symptoms: The symptoms must persist for at least one month.
Significance: The patient suffers from significant social, interpersonal, or work-related problems as a result of the PTSD symptoms. A common social symptom of PTSD is a feeling of disconnection from other people (including loved ones); from the larger society; and from God or other sources of meaning.

The symptoms of PTSD usually begin within three months of the trauma, although sometimes PTSD does not develop until years after the initial trauma occurred. Once the symptoms begin, they may fade away again within six months. Others suffer with the symptoms for far longer; and in some cases, the problem may become chronic.

PTSD in children

PTSD in children may trigger the onset of learning disabilities, self-mutilation or other destructive behaviors, sleep terrors, and a variety of conduct disorders. Children may also develop abnormally close attachments to their primary caretakers or other dependency behaviors in their attempts to cope with the traumatic experience.

Treatment

A diagnosis of PTSD does not indicate personal weakness or mental illness. It is a perfectly natural and normal reaction to one or more abnormal events. Just like a perfectly healthy bone will break if placed under enough stress, a perfectly healthy person placed under sufficient stress can develop PTSD.

It is important to understand that not every person who experiences a traumatic event will experience PTSD. There is some evidence that an approach known as critical incident stress debriefing, or CISD, may lower the incidence of PTSD in survivors of a large-scale civilian disaster or war zone trauma. CISD should be offered to survivors within 48 hours of the traumatic event. In general, persons who are experiencing some of the symptoms of PTSD should consult a mental health professional. He or she will diagnose the condition if the symptoms of stress last for more than a month after a traumatic event. While a formal diagnosis of PTSD is made only in the wake of a severe trauma, it is possible to have a mild PTSD-like reaction following less severe stress.

Medication

The most helpful treatment of PTSD appears to be a combination of medication along with supportive and cognitive-behavioral therapies. Effective medications include anxiety-reducing medications and anti-depressants, especially the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac). Sleep problems can be lessened with brief treatment with an anti-anxiety drug, such as a benzodiazepine like alprazolam (Xanax), but long-term usage can lead to disturbing side effects, such as increased anger.

Psychotherapy

Therapy can help reduce negative thought patterns and self-talk, in that many PTSD patients blame themselves for the traumatic event, their reactions to it, or both. Cognitive-behavioral therapy focuses on changing specific actions and thoughts with the help of relaxation training and breathing techniques. Group therapy with other PTSD sufferers and family therapy can also be helpful.

Alternative and complementary approaches

Patients diagnosed with PTSD may benefit from such complementary approaches as meditation and mindfulness training, which appear to be useful in reducing the number of flashbacks. Yoga, bodywork, and massage therapy help to reduce the muscle soreness and tension associated with PTSD. Lastly, some patients find martial arts training useful in restoring a sense of personal competence and safety.

Prognosis

The severity of PTSD depends in part on the predictability of the trauma; its severity; its duration and chronicity; the role of human intention in inflicting the trauma; and the patient's personality style, overall state of health, and genetic predisposition.

With appropriate medication, emotional support, and counseling, most people show significant improvement. On the other hand, prolonged exposure to severe trauma—such as experienced by victims of prolonged physical or sexual abuse and survivors of the Holocaust—may cause permanent psychological scars.

Health care team roles

It is essential for all treatment team members to know their roles and execute them properly throughout the treatment and recovery phases of this disorder. Depending on whether outpatient or inpatient treatment is being provided, the team leaders may include psychiatrists, psychologists, nursing staff, behavior specialists and other medical/behavioral staff. In some cases it may be appropriate to include the patient's religious or spiritual advisor as a member of the team, in that increasing numbers of clergy have taken advanced training in trauma therapy.

Regular meetings are important so that all persons involved can provide input. Family members involved in patient care should be reaffirmed as to their need to provide consistency and adherence to the plan of care. Psychological evaluations will provide a base for the rest of the team to compose and/or update the treatment plan.

During treatment planning phases, needs and strengths are assessed, as well as progress from prior plans. The treatment team leader, normally a behavior specialist, a psychologist or a psychiatrist, will then compose a plan of care that will describe goals for the next phase of care, interventions and other information needed to initiate or continue care.

KEY TERMS

Benzodiazepines— A class of drugs that have a hypnotic and sedative action, used mainly as tranquilizers to control symptoms of anxiety.

Cognitive-behavioral therapy— A type of psychotherapy used to treat anxiety disorders (including PTSD) that emphasizes behavioral change as well as alteration of negative thought patterns.

Dissociation— The splitting off of certain mental processes from conscious awareness. Many PTSD patients have dissociative symptoms.

Flashback— An abnormally vivid, often recurrent, recollection of a traumatic event.

Hyperarousal— A condition of abnormally intense nervous excitement. Some symptoms of PTSD are classified as symptoms of hyperarousal.

Hypervigilance— A condition of abnormally intense watchfulness or wariness. Hypervigilance is one of the most common symptoms of PTSD.

Selective serotonin reuptake inhibitors (SSRIs)— A class of antidepressants that work by blocking the reabsorption of serotonin in the brain, raising the levels of serotonin. SSRIs include Prozac, Zoloft, and Paxil.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: American Psychiatric Association, 1994.

Eisendrath, Stuart J., MD, and Jonathan E. Lichtmacher, MD. "Psychiatric Disorders." Current Medical Diagnosis & Treatment 2001, 40th ed. Edited by L. M. Tierney, Jr., MD, et al. New York: Lange Medical Books/McGraw-Hill, 2001.

Greist, J., and James Jefferson. Anxiety and Its Treatment. New York: Warner Books, 1986.

Herman, Judith, MD. Trauma and Recovery, 2nd ed., rev. New York: Basic Books, 1997.

Kulka, Richard A. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel, 1990.

"Posttraumatic Stress Disorder." The Merck Manual of Diagnosis and Therapy, ed. Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Bullman, Tim A., and Han K. Kang. "A Study of Suicide Among Vietnam Veterans." Federal Practitioner 12, no. 3 (March 1995): 9-13.

Ford, Julian. "Managing Stress and Recovering from Trauma: Facts and Resources for Veterans and Families." National Center for PTSD. ?http://www.dartmouth.edu/dms/ptsd?. (March 19, 1997).