Post-traumatic stress disorder

Definition

Post-traumatic stress disorder (PTSD) is a debilitating psychological condition trigged by a traumatic event, such as rape, war, a terrorist act, sudden or violent death of a loved one, natural disaster, or catastrophic accident. It is marked by recurring memories or thoughts of the event, "blunting" of emotions, increased arousal, and sometimes severe personality changes.

Description

Officially termed post-traumatic stress disorder since 1980, descriptions of post-traumatic stress were documented as early as the Civil War and in nineteenth century train crash victims. In the period between World War I and II, a condition known as "shell shock" or "battle fatigue" was recognized. Initially, it was thought that shrapnel entered the brain during battle explosions and caused small brain hemorrhages. When symptoms occurred in war veterans who had not been exposed to explosions, it was then often viewed as a character flaw.

In the 1970s, during and after the Vietnam War, post-traumatic stress received more serious research and documentation. In 1989, the National Center for Post-traumatic Stress Disorder was established in the U.S. Department of Veterans Affairs. Another benchmark was its addition to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) published by the American Psychiatric Association. In the past 20 years, those who have been diagnosed with PTSD have been rape victims, victims of violent crimes, and survivors of natural disasters, terrorist attacks, and random shootings in schools and the workplace.

Although people of all ages, cultures, and socioeconomic backgrounds can develop PTSD if exposed to a life-threatening event, statistics gathered from past events indicate that the risk of PTSD increases in order of the following factors:

  • female gender
  • middle-aged (40 to 60 years old)
  • little or no experience coping with traumatic events
  • ethnic minority
  • lower socioeconomic status
  • children in the home
  • women with spouses exhibiting PTSD symptoms
  • pre-existing psychiatric conditions
  • primary exposure to the event including injury, life-threatening situation, and loss
  • living in a traumatized community

For example, over a third of the survivors of the 1995 Murrah Federal Building bombing in Oklahoma City developed PTSD and over half showed signs of anxiety, depression, and alcohol abuse. More than a year later, Oklahomans in general had an increased use of alcohol and tobacco products, as well as PTSD symptoms.

Children are also susceptible to PTSD and their risk is increased exponentially as their exposure to the event increases. Children experiencing abuse, the death of a parent, or those located in a community suffering a traumatic event can develop PTSD. Two years after the Oklahoma City bombing, 16% of children in a 100-mile radius of Oklahoma City with no direct exposure to the bombing had increased symptoms of PTSD. Weak parental response to the event, having a parent suffering from PTSD, and increased exposure to the event via the media all increase the possibility of the child developing PTSD symptoms.

Causes & symptoms

Specific causes for the onset of post-traumatic stress disorder are not clearly defined, although experts suspect 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 event was expected. First response emergency personnel and those directly involved in the event or families who have lost loved ones in the event are most like to experience PTSD.

People exposed to mass destruction or death, toxic contamination, the sudden or violent death of a loved

Post-traumatic stress disorder
COMMON CHARACTERISTICS THAT INCREASE THE RISK OF DEVELOPING PTSD
Female
Middle-aged (40 to 60 years old)
No experience coping with traumatic events
Ethnic minority
Lower socioeconomic status
Children
Women with PTSD spouses
Pre-existing psychiatric condition
Primary exposure to the trauma
Living in traumatized community

one, or the loss of home or community, are also at high risk for PTSD. Victims of human-caused trauma have a higher incidence of PTSD than those of natural disasters. Among rape and Holocaust survivors, the rate of PTSD is 50%.

A sampling of the types of traumatic events and the percentage of those exposed to them who develop PTSD includes:

  • natural disaster, 4–5%
  • mass shooting, 28%
  • plane crash into hotel, 29%
  • bombing, 34%

For men, events most likely to trigger PTSD are rape, combat exposure, childhood neglect, and childhood physical abuse. For women, these events are rape, sexual molestation, physical attack, threat with a weapon, and childhood physical abuse.

A related condition, Acute Stress Disorder (ASD), which occurs two days to four weeks after a traumatic event, is thought to be an indicator of the occurrence of PTSD. This is especially true if the following factors are present:

  • lack of emotional and social support
  • the presence of other stressors such as fatigue, cold, hunger, fear, uncertainty, and loss
  • continued difficulties at the scene of the event
  • lack of information about the event
  • lack of self-determination
  • treatment given in an authoritarian or impersonal manner
  • lack of follow-up

PTSD symptoms are distinct and prolonged stress reactions that naturally occur during a highly stressful event. Common symptoms are:

  • hyperalertness
  • fear and anxiety
  • nightmares and flashbacks
  • sight, sound, and smell recollection
  • avoidance of recall situations
  • anger and irritability
  • guilt
  • depression
  • increased substance abuse
  • negative world view
  • decreased sexual activity

Symptoms 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.

Among the most troubling symptoms of PTSD are flashbacks, which can be triggered by sounds, smells, feelings, or images. During a flashback, the person relives the traumatic event and may completely lose touch with reality, suffering through the trauma for minutes or hours at a time, believing that the traumatizing event is actually happening all over again.

Research conducted in the late 20th century suggests that PTSD sufferers undergo neurological and physiological changes stemming from altered brain activity. A decrease in size of the hippocampus (one of two seahorse-shaped parts of the brain generally believed by scientists to pay an essential role in formation of new memories) may affect the processing and integration of memory while abnormal activation of the amygdala (almondshaped parts of the brain believed to have strong connections to mental and physical reactions) may be tied to fear response. This altered brain activity can lead to hyper-arousal of the sympathetic nervous system, increased sensitivity of the startle reflex, and sleep abnormalities.

The hormone levels of PTSD patients may also show abnormalities: for example, high levels of thyroid, epinephrine, and natural opiates coupled with low levels of cortisol. Blunted, or depressed, responses to a trauma may be the result of the body's increased production of opiates (narcotic-like hormones that induce mental lethargy), which masks the emotional pain.

People with post traumatic stress disorder are also like to suffer from other psychiatric disorders. Eighty-eight percent of men and 79% of women with PTSD meet the diagnostic criteria for other disorders. Physical ailments such as headaches, gastrointestinal ailments, immune system weaknesses, dizziness, chest pain, and general body discomfort are also common in PTSD sufferers.

Diagnosis

Consultation with a mental health professional for diagnosis and a plan of treatment is always advised. Many of the responses to trauma, such as shock, terror, irritability, blame, guilt, grief, sadness, emotional numbing, and feelings of helplessness, are natural reactions. For most people, resilience is an overriding factor and trauma effects diminish within six to sixteen months. It is when these responses continue or become debilitating that PTSD is often diagnosed. The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) outlined three forms of the disorder:

  • Acute: onset within six months of the event and lasting less than six months
  • Chronic: symptoms lasting six months or more
  • Delayed: onset at least six months after the event

As outlined in DSM-IV, the exposure to a traumatic stressor means that an individual experienced, witnessed or was confronted by an event or events involving death or threat of death, serious injury or the threat of bodily harm to oneself or others. The individual's response must involve intense fear, helplessness, or horror. A two-pronged approach to evaluation is considered the best way to make a valid diagnosis because it can gauge under-reporting or over-reporting of symptoms. The two primary forms are structured interviews and self-report questionnaires. Spouses, partners and other family members may be interviewed. Because the evaluation may involve subtle reminders of the trauma in order to gauge a patient's reactions, individuals should ask for a full description of the evaluation process beforehand. Asking what results can be expected from the evaluation is also advised.

A number of structured interview forms have been devised to facilitate the diagnosis of post traumatic stress disorder:

  • The Clinician Administered PTSD Scale (CAPS) developed by the National Center for PTSD
  • The Structured Clinical Interview for DSM (SCID)
  • Anxiety Disorders Interview Schedule-Revised (ADIS)
  • PTSD-Interview
  • Structured Interview for PTSD (SI-PTSD)
  • PTSD Symptom Scale Interview (PSS-I)

Self-reporting checklists provide scores to represent the level of stress experienced. Some of the most commonly used checklists are:

  • The PTSD Checklist (PCL), which has one list for civilians and one for military personnel and veterans
  • Impact of Event Scale-Revised (IES-R)
  • Keane PTSD Scale of the MMPI-2
  • The Mississippi Scale for Combat Related PTSD and the Mississippi Scale for Civilians
  • The Post Traumatic Diagnostic Scale (PDS)
  • The Penn Inventory for Post-Traumatic Stress
  • Los Angeles Symptom Checklist (LASC)

Treatment

A definitive treatment does not yet exist for PTSD nor is there a known cure. However, a number of therapies such as cognitive-behavior therapy, group therapy, and exposure therapy are showing promise. Cognitive-behavioral therapy focuses on changing specific actions and thoughts with the help of relaxation training and breathing techniques. In exposure therapy, the person relives the traumatic event repeatedly in a controlled environment and then works through the trauma.

A treatment technique known as eye movement desensitization and reprocessing (EMDR) has been employed with some success to treat PTSD. EMDR involves desensitizing the patient to his or her traumatic memories by associating a series of eye movements with both negative and positive events and emotions. The specific eye movements associated with the negative memories are thought to help the brain process the event and come to terms with the trauma. EDMR should only be performed by a healthcare practitioner, usually a clinical psychologist, certified in the technique.

Relaxation training, which is sometimes called anxiety management training, includes breathing exercises and similar techniques intended to help the patient prevent hyperventilation and relieve the muscle tension associated with the fight-or-flight reaction of anxiety. Yoga, aikido, t'ai chi, and dance therapy help patients work with the physical as well as the emotional tensions that either promote anxiety or are created by the anxiety.

Other alternative or complementary therapies are based on physiological and/or energetic understanding of how the trauma is imprinted in the body. These therapies affect a release of stored emotions and resolution of them by working with the body rather than merely talking through the experience. One example of such a therapy is Somatic Experiencing (SE), developed by Dr. Peter Levine. SE is a short-term, biological, body-oriented approach to PTSD or other trauma. This approach heals by emphasizing physiological and emotional responses, without re-traumatizing the person, without placing the person on medication, and without the long hours of conventional therapy.

When used in conjunction with therapies that address the underlying cause of PTSD, relaxation therapies such as hydrotherapy, massage therapy, and aromatherapy are useful to some patients in easing PTSD symptoms. Essential oils of lavender, chamomile, neroli, sweet marjoram, and ylang-ylang are commonly recommended by aromatherapists for stress relief and anxietyreduction.

Research into the prevention of PTSD is also undergoing intensive research. The National Mental Health Association provides RAPID grants that allow researchers to visit disaster scenes to study acute effects and the effectiveness of early intervention. Rapid disaster relief and positive community response appear to be key. Not identifying individual survivors as "victims" also seems to help. Debriefing survivors as quickly as possible after the event can stem the development of PTSD symptoms.

Allopathic treatment

As of mid-2004, allopathic (medical practice that combats disease with remedies to produce effects different from those produced by the disease) treatment consists of a combination of medication along with supportive and cognitive-behavioral therapies. Effective medications include anxiety-reducing medications and antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft). In 2001, the U.S. Food and Drug Administration (FDA) approved Zoloft as a long-term treatment for PTSD. In a controlled study, Zoloft was effective in safely improving symptoms of PTSD over a period of 28 weeks and reducing the risk of relapse. Sleep problems can be lessened by brief treatment with an anti-anxiety drug such as a benzodiazepine like alprazolam (Xanax). However, long-tem use of these drugs can lead to disturbing side effects, such as increased anger. The new research into the biological changes manifested in PTSD patients is leading to additional research on drugs used to monitor hormone levels and brain activity.

Expected results

With appropriate medication, emotional support, and counseling, most people show significant improvement. Behavior therapies can help reduce negative thought patterns and self talk. The patient typically moves back and forth through three recovery phases:

  • Phase One, Safety: the elimination and/or management of dangerous behaviors and/or relationships. Becoming less fearful of thoughts, feelings, and dissociative (separated from the main stream of consciousness) episodes
  • Phase Two: resolution of traumatic memory processing. Developing a narrative account of the trauma without becoming re-traumatized
  • Phase Three: personality re-integration and rehabilitation

Successful treatment depends in part on whether or not the trauma was unexpected, the severity of the trauma, if the trauma was chronic (such as for victims of sexual abuse), and the person's inherent personality and genetic makeup. However, 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.

Resources

BOOKS

Knaster, Mirka. Discovering the Body's Wisdom: A Guide to Exploring Bodyways. New York: Bantam Books, 1996.

Shapiro, Francine, Ph.D., and Margot Silk Forrest. The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma. New York: Basic Books, 1997.

PERIODICALS

DiGiovanni, C. "Domestic Terrorism with Chemical or Biological Agents: Psychiatric Aspects." American Journal of Psychiatry (1999): 1500 – 1505.

Kessler, R., et al. "Post-traumatic Stress Disorder in the National Comorbidity Survey." Archives of General Psychiatry (1996): 1048 – 1060.

North, C., S. Nixon, S. Hariat, S. Mallonee et al. "Psychiatric Disorders Among Survivors of the Oklahoma City Bombing." Journal of the American Medical Association (1999): 755 – 762.

Pfefferbaum, B., R. Gurwitch, N. McDonald et al. "Posttraumatic Stress Among Children After the Death of a Friend or Acquaintance in a Terrorist Bombing." Psychiatric Services (2000): 386 – 388.

"Sertraline HCI Approved for Long-Term Use." Women's Health Weekly (September 20, 2001).

Sloan, M. "Response to Media Coverage of Terrorism." Journal of Conflict Resolution (2000): 508 – 522.

Smith, D, E., Christiansen, R. Vincent, and N. Hann. "Population Effects of the Bombing of Oklahoma City." Journal of Oklahoma State Medical Association (1999): 193 – 198.

ORGANIZATIONS

American Psychiatric Association. 1000 Wilson Blvd., Ste. 1825, Arlington, VA 22209-3901. (703) 907-7300. http://www.psych.org.

Anxiety Disorders Association of America. 8730 Georgia Ave., Ste. 600, Silver Spring, MD 20910. (240) 485-1001. <http://www.adaa.org>.

Freedom From Fear. 308 Seaview Ave., Staten Island, NY 10305. (718) 351-1717. <http://www.freedomfromfear.com>.

International Society for Traumatic Stress Studies, 60 Revere Dr., Ste. 500, Northbrook, IL 60062. (847) 480-9028. <http://www.istss.org>.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166. <http://www.lexington-on-line.com>.

National Institute of Mental Health. 6001 Executive Blvd, Rm. 8184, MSC 9663, Bethesda, MD 20892. (866) 615-6464. <http://www.nimh.nih.org>.

National Mental Health Association. 2001 N. Beauregard St., 12th floor, Alexandria, VA 22311. (800) 969-NMHA. <http://www.nmha.org>.

OTHER

"Effects of Traumatic Stress in a Disaster Situation." National Center for PTSD. [cited May 2, 2004]. <http://www.ncptsd.org/facts/disasters/fs_effects_disaster.html>.

"How is PTSD Measured?" National Center for PTSD. [cited May 2, 2004]. <http://www.ncptsd.org/facts/treatment/fs/lay/assess.html>.

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