Post-Traumatic Stress

BIBLIOGRAPHY

The term post-traumatic stress is used to describe an individual’s reaction to an experience of serious, life-threatening trauma. The trauma can come from a single event—such as a physical assault, a car accident, a natural disaster, or witnessing the death of another—or it can come through a series of events, such as chronic abuse or combat experiences. Symptoms include flashbacks, nightmares, intrusive thoughts about the event, decreased ability to concentrate, panic, memory loss, and mood changes (e.g., depression, irritability). Individuals may experience these symptoms immediately following the event, or it may be months to years before symptoms first appear. Symptoms occur in a range of intensity and longevity; for some the symptoms become debilitating.

For many individuals, post-traumatic symptoms diminish over time or with appropriate mental health services, support from friends and family, and other therapeutic or supportive interventions. Although individuals continue to feel the effects of the trauma in some form, most report that the symptoms subside or are minimal, and the effects can be managed so that the individual does not feel burdened. However, as reported by the National Center for Post-Traumatic Stress Disorder (NCPTSD), for 8 percent of men and 20 percent of women, the symptoms do not diminish and develop into post-traumatic stress disorder (PTSD). Furthermore for 30 percent of these individuals, PTSD becomes a chronic condition that persists throughout their lifetimes. PTSD is distinguished from post-traumatic stress by the intensity and duration of the symptoms and by three characteristics of symptoms: they are reexperienced, there is hyperarousal or sensitivity to stimuli, and there is avoidance of triggering stimuli.

The American Psychiatric Association (APA) outlines the PTSD diagnostic criteria in the Diagnostic and Statistical Manual-IV-TR (DSM ):

A. The person has been exposed to a traumatic event in which both of the following were present:(1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; (2) The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganizing or agitated behavior.

B. The traumatic event is persistently re-experienced in one (or more) of the following ways: (1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed; (2) Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content; (3) Acting or feeling as if the traumatic event were recurring (including a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur; (4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: (1) Efforts to avoid thoughts, feelings, or conversation associated with the trauma; (2) Efforts to avoid activities, places, or people that arouse recollections of the trauma; (3) Inability to recall an important aspect of the trauma; (4) Markedly diminished interest or participation in significant activities;

(5) Feeling of detachment or estrangement from others; (6) Restricted range of affect (e.g., unable to have loving feelings); (7) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) Difficulty fallingasleep or staying asleep; (2) Irritability or outbursts of anger; (3) Difficulty concentrating; (4) Hypervigilance; (5) Exaggerated startle response; (6) Duration of the disturbance (symptoms inCriteria B, C, and D) is more than 1 month; (7) The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if: Acute : if duration of symptoms is less than 3 months; Chronic : if duration of symptoms is 3 months or more.

Specify if: With Delayed Onset : if onset of symptoms is at least 6 months after the stressor. (APA 2000, pp. 218–220)

Although these criteria are well-defined, diagnosis of PTSD is a complicated process in part because PTSD symptoms are similar to those of many other psychiatric disorders (e.g., depression), anxiety disorders, and psychotic disorders. In addition many individuals feel shamed or embarrassed by the event or their reactions and may not report the full extent of their symptoms. A multimodal approach is considered to be the most effective for accurately diagnosing PTSD. The NCPTSD suggests an approach including a clinical interview, completion of standardized assessment tools, and a physical assessment.

Statistics from the National Mental Health Association indicate that at least 5.2 million Americans (3.6 percent of U.S. adults) experience PTSD during the course of a year, and nearly 8 percent of Americans will experience PTSD at some point in their lifetimes. Researchers have shown that although PTSD can occur at any age, females develop PTSD at twice the rate of males regardless of their age.

PTSD is a relatively new term within the mental health field, having first appeared in the DSM in 1980. However, the concept appeared in the historical medical literature as early as during the Civil War as the term Da Costa’s Syndrome. In World War I, World War II, and the Korean War shell shock, battle fatigue, and war neurosis were used to describe the troubling symptoms experienced by combat soldiers. The U.S. government did not begin systematically to focus on the origins, symptoms, and treatment of PTSD until the era following the Vietnam War. The military research on PTSD was drawn on by those working in noncombat trauma areas to better understand the impact of various forms of trauma on individuals.

If left untreated, PTSD symptoms can have an impact on all areas of a person’s life and can cause both psychological and physical illnesses. Physical effects include chronic pain conditions, immune system disorders, and neurological system symptoms (i.e., memory loss, coordination of the fear response). Cognitive symptoms include distractedness and an inability to analyze events because of physical changes in the hippocampus (the brain region responsible for such processes). Emotional effects include grief, rage, sorrow, numbness, despair, and guilt, among others, as manifested in behaviors such as difficulties with interpersonal relationships and maintaining employment, addiction, isolation, and self-mutilation or self-injury. According to the NCPTSD, a majority of those with PTSD (88 percent of men and 79 percent of women) also met the criteria for a secondary psychiatric diagnosis, meaning that PTSD puts individuals at risk of other mental health disorders.

The National Child Traumatic Stress Network reports that children and adolescents are especially vulnerable to developing PTSD after experiencing a traumatic event because of their limited ability to process information, their lack of cognitive sophistication, and general issues of maturity. Children may exhibit additional symptoms, such as toileting problems, development of a disturbed sense of self, low self-esteem, academic struggles, or symptoms that interfere with a normal developmental task.

Although much remains unknown about PTSD, there are promising treatments that have been successful in treating individuals with PTSD. Some of these include prolonged exposure therapy, cognitive-behavioral therapy, family therapy, group therapy, and some drug therapies.

SEE ALSO Anxiety; Depression, Psychological; Disease; Emotion; Memory; Mental Health; Mental Illness; Military; Mood; Panic; Psychology; Psychotherapy; Stress; Trauma; Traumatic Bonding; War

BIBLIOGRAPHY

American Psychiatric Association. 2000. Desk Reference to the Diagnostic Criteria from the DSM-IV-TR. Washington, DC: Author.

Andreason, Nancy C., and Donald W. Black. 2006. Introductory Textbook of Psychiatry. 4th ed. Washington, DC: American Psychiatric Publishers.

Naparstek, Belleruth. 2004. Invisible Heroes: Survivors of Trauma and How They Heal. New York: Bantam Books.

National Center for Post-Traumatic Stress. U.S. Department of Veterans Affairs. 2006. What Is PTSD? http://www.ncptsd.va.gov/ncmain.

National Child Traumatic Stress Network. 2005. The Courage to Remember: Childhood Traumatic Grief Curriculum Guide with CD-ROM. Los Angeles: Author.

National Mental Health Association. 2006. Post-Traumatic Stress Disorder. http://www.mentalhealthamerica.net/go/ptsd.

Melissa D. Grady