Post-Traumatic Stress Disorder

last authored: Nov 2013, David LaPierre
last reviewed:

 

 

 

Introduction

Post-Traumatic Stress Disorder, PTSD, is an anxiety disorder that can develop after exposure to a terrifying event in which grave physical harm has occurred or was threatened.

Directly experienced traumatic events include the following examples:

• violent sexual assault
• violent physical assault
• combat
• kidnapping
• natural disasters (e.g., fire, tornado, earthquake)
• catastrophic accident (e.g., auto, airplane, mining)

Witnessed traumatic events include the following examples:

• seeing another person violently killed or injured
• unexpectedly seeing a dead body or body parts

When people feel scared or threatened, there’s a natural response that triggers changes in the body to help get ready to avoid any danger. This is a healthy response to the danger. But in PTSD, this reaction is changed or damaged. People who have PTSD may the same fear, stress and danger, even when they are no longer in any harm.

 

PTSD was first recognized after the American Civil War and became far more common over WWII and the 1942 Coconut Grove Fire in Boston.

 

PTSD has likely been around for centuries, but only as recently as 1980 has the American Psychiatric Association (APA) officially added PTSD to its Diagnostic Manual of Mental Disorders (DSM).

 

DSM-V Definition of PTSD

 

Alterations

• changes in cognition or mood
• amnesia
• negative beliefs regarding self, others, or the world
• etc
• etc

 

The APA has the following criteria to successfully diagnose the condition:

• A person has been exposed to a disastrous event involving actual or perceived death or injury. This event must be characterized by intense fear.
• The PTSD symptoms last at least one month.
• The person experiences considerable work-related, social or other distresses as a result of the PTSD.
• The person starts to avoid anything that will cause them to re-experience the event. He will also experience a generalized insensitivity to things around him. This hurts personal relationships.
• The person tends to be in a state of hyper arousal (extreme awareness) that results in him being startled very easily and being watchful to the point of being paranoid.
• The shocking event continues as a controlling psychological experience, the person usually having flashbacks of the event.

Before PTSD was defined as true psychological problem, doctors and certain leaders in the field attributed it to personal weakness. The symptoms of PTSD were first seen during and after the American Civil War and became more frequent after the World Wars. In modern times, it is stated that 7% of the population will get PTSD, affecting 10-30% for those who have experienced a traumatic event. One in six soldiers returning from the Middle East will suffer from PTSD and women serving are more likely to endure a more severe and debilitating form of PTSD

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The Case of...

The following by Matthew A. Friedman, Ph.D., M.D. source

Robert J worked the night shift at a small convenience store in rural New England. He was a happily married, Caucasian, 42-year-old father of three school-aged children who was in excellent health and who had neither a personal nor a family history of psychiatric illness, alcoholism, or substance abuse. One night in November, 1995, two men wearing ski masks entered his store while he was alone. Each had a gun. The taller man placed the barrel of his gun against Robert's temple and ordered him to hand over all the money in the cash register. When this had been done, he was pushed towards the interior of the store, between two stacks of shelves and pushed face-down onto the floor. He was gagged, his hands and feet were tied, and the first robber again placed his gun against Robert's head and said, "I'm going to blow your brains out!" Robert's terror was overwhelming. He didn't want to die. He had so much to live for. His heart raced, he perspired profusely, and his whole body shook. He took a deep breath, heard the click of the hammer against the empty chamber of the gun, and his whole body slumped with disbelief when he realized that he had literally been the butt of the cruelest kind of joke. He vaguely remembers the gruff laughter of the two robbers before they made their escape. Then he passed out.

 

At first, Robert could only think about how happy he was to still be alive. He regarded his wife and children with new found love and appreciation. But as grateful as he felt about a second chance in life, he also experienced growing discomfort during his tour of duty at the convenience store. He really didn't want to go to work because he kept replaying the robbery in his mind, visualizing the men in ski masks, feeling the gun against his head, and re-experiencing the panic that had engulfed him during this episode. In response to advice from his family doctor, he took a month's leave of absence to "settle his nerves." When he returned to the store, however, he was worse than before. The familiar sights of the cash register and merchandise displayed on the shelves, all reminded him of how terrified he'd been during the hold-up. Sometimes, he even thought he saw men in ski masks lurking in the shadows behind the shelves, although he knew that his mind was playing tricks on him. He started making serious errors at the cash register, pressing the wrong keys, or giving the wrong change because he couldn't concentrate on the task at hand—so absorbed was he in his repetitive recollections of the robbery. Nightmares occurred at least four times a week that were reenactments of the crime. In the most frequent and vivid nightmare, he saw himself bound and gagged face down on the floor when a man in a ski mask shot him in the head and he woke up screaming. It got so bad that he was afraid to go to sleep at night, so great was his dread of this nightmare.

 

Eventually, he had to quit his job, so terrified had he become at work. Later he found that he couldn't even go near the convenience store, because just seeing the scene of the crime evoked intolerable feelings of terror and recollections of the robbery. He found himself obsessed with fear about personal safety. Whereas he had previously been an open, easy-going, happy-go-lucky individual who was extremely popular, he was now fearful, withdrawn, irritable, jumpy, suspicious, and unable to focus on any task long enough to work at a steady job. He also found any intense (positive or negative) emotional experience intolerable and withdrew from his wife and children as well.

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Causes and Risk Factors

It is possible for those of any age get PTSD. Not everyone with PTSD has been through a dangerous event, even though that seems to be most of the cases. Even an unexpected death of a family member or other loved one can cause PTSD. Many who are within police forces and those working in areas which they help those in need, like missionaries or shelter workers, can experience PTSD.

 

Risk factors for PTSD include:

• previous trauma
• a mental health condition that was on going before the event
• the type and severity of the traumatic event
• the lack of post- trauma support

The psychological history of a person may include risk factors for developing PTSD after a traumatic event. Those who suffer already from disorders, such as borderline personality disorder or dependent personality disorder, as well as low self-esteem or a previous trauma are seen at higher risk for PTSD. People with borderline personality disorder often come with a past of physical and/or sexual abuse, neglect, hostile conflict, and a loss of a parent. Dependent personality disorder is characterized by low self-esteem, fear of separation, and the unwarranted need to be cared for by others. These factors influence a person to develop PTSD. As well, people who have seen a trauma or shocking event in progress are more inclined to develop PTSD. Repeated traumatic viewing releases the stress trigger opiates in the brain to make PTSD more apparent.

 

Symptoms and duration of PTSD may be more severe if there is a lack of support from family and/or community. For example, a rape victim who either is blamed for the assault or not believed (example of the case of rape by a family member) may be at greater risk for developing PTSD.

 

Try to remember that not all people who go through a terrible experience will get PTSD. As we’ve gone over, many factors are at play when PTSD develops. Some of these are risk factors that make a person more likely to get PTSD. Other factors, called ‘resilience factors’, can help reduce the risk of the disorder and to help people ‘bounce back’. Some of these factors are present before the trauma and others become important during and after a traumatic event

 

Risk factors for PTSD include: Living through dangerous events and traumas Having a history of mental illness Getting hurt Seeing people hurt or killed Feeling horror, helplessness, or extreme fear Having little or no social support after the event Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home.

 

Resilience factors that may reduce the risk of PTSD include: Seeking out support from other people, such as friends and family Finding a support group after a traumatic event Feeling good about one’s own actions in the face of danger Having a coping strategy, or a way of getting through the bad event and learning from it Being able to act and respond effectively despite feeling fear.

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Pathophysiology

When people feel scared or threatened, there’s a natural response that triggers changes in the body to help get ready to avoid any danger. This is a healthy response to the danger. But in PTSD, this reaction is changed or damaged. People who have PTSD may the same fear, stress and danger, even when they are no longer in any harm (NIMH)

 

Though usually associated with soldiers, many people who have lived through extremely stressful events may also develop this emotional disorder.

 

There also may be a biological component to insensitivity, or numbing and other comparable symptoms of PTSD. When people experience a prolonged trauma, or are reminded in any way about that trauma, the brain releases opiates (e.g., endorphins, enkephalins) that can produce emotional nonresponsiveness, and amnesia. Also it is known that serotonin depletion in the brain may result from repeated exposure to severe stress and trauma, which may be a factor in the development of irritability and violent outbursts in people with PTSD.

 

There is a structure in the brain called the amygdala, which is part of the limbic system. This helps the expression of emotion, (fear, especially), heart rate, blood pressure, and emotional memory. Changes or disturbances in this area may produce symptoms of PTSD.

 

Stress hormones, such as epinephrine, are released when the body in trauma. When this trauma is severe and on going, the physical response become over stimulated and the intrusive symptoms of PTSD may occur.

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Signs and Symptoms

Diagnosis: The development of characteristic symptoms that last for more than one month, along with difficulty functioning after exposure to a life-threatening experience.

 

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Investigations

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Differential Diagnosis

The differential diagnosis includes:

• acute stress disorder (less than 4 weeks)
• obsessive-compusive disorder
• major depressive disorder
• substance abuse
• panic disorder

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Treatments

following an acute trauma, presence is the best thing for survivors. Don't necessarily try to do anything or fix everything, just be there through the experience.

 

Treatments for PTSD are varied, but the most important thing treatment for PTSD is talking about it, and having someone there for the suffering person. Talking is essential for opening up grounds for complete healing. This talking is therapeutic, but also it helps a caring person keep an eye on the person, to make sure that they maintain stability. The main treatments for people with PTSD are psychotherapy, medications, or both. Everyone is different, and they deal with events differently, so a treatment that works for one person may not work for another.

 

It is important for anyone with PTSD to be treated by a trained therapist or other certified mental health care provider who is experienced with PTSD. Some people with PTSD need to try different treatments to find what works for their symptoms. If someone with PTSD is going through an ongoing trauma, such as being in an abusive relationship, both of the problems need to be treated.

 

While controversial, evidence is suggesting that critical incidence stress debriefing (CISD) is not helpful in the first 6-8 weeks, allowing natural healing to take place. In fact, therapy during this immediate time can actually do harm (ref available on padesky.com under clinical corner). Psychological first aid is the preferred approach of many, providing support with work, finances, etc.

 

Psychotherapy- talking with a mental health professional to treat a mental illness. Psychotherapy can happen one-on-one or in a group. Talk therapy treatment for PTSD usually lasts 6 to 12 weeks, but more time is given if required. Support from caring friends and family can help psychotherapy aid the person to health. There are many types of therapy that can help people deal with PTSD. Some therapies target symptoms directly; others target the social or job-related problems. The doctor or therapist may combine different therapies depending on each person’s needs.

 

 

 

Self-Awareness

It is important to

 

 

Talk therapies teach people healthy ways to react to terrifying events that trigger their PTSD symptoms. Based on this general goal, different types of therapy may:

• Teach about trauma in general and it’s effects on people
• Use relaxation and anger control management
• Provide guidelines for better sleep, diet, and exercise habits.
• Helps people focus on changing who they react in situations. For example, some therapies could help people visit people or locations that remind them of the event.

Medications

Antidepressants including sertraline (Zoloft) and paroxetine (Paxil) have been used to alleviate the feelings of sadness, anger, worry and the numbing insensitivity. These medications may aid in going through psychotherapy.

 

Other treatments can be used, but their effectiveness is unknown. For example, interest in building around a movement called psychological first aid. The ambition of this movement is to help people in crisis situations feel secure, connect them to health care and other resources, and to lessen their stress reactions. Treatment guides are available, but it is uncertain if it actually helps prevent or treat PTSD.

 

Advice for Family and Friends

To help a friend or relative, you can:

• Offer emotional support.
• Try to encourage them and be positive.
• Research and learn about PTSD so you can understand what your loved one is going through.
• Listen to feelings your loved one expresses and be understanding of situations that may trigger PTSD symptoms.
• Invite your friend or relative out for positive distractions. Like short walks, watching a favorite movie, or going to familiar places.

 

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Consequences and Course

With all the therapy, medications, love and support about 50% of those who have acute onset of symptoms recover within 6 months. Approximately 30% develop chronic symptoms that may affect them for the rest of their lives.

Immediate Onset

• Better response to treatment
• Better prognosis (i.e., less severe symptoms)
• Fewer associated symptoms or complications
• Symptoms are resolved within 6 months

Delayed Onset

• Associated symptoms and conditions develop
• Condition more likely to become chronic
• Possible repressed memories
• Worse prognosis

Some consequences of PTSD are mental disturbances such as repressed memories. Similar to flashbacks, people who experience a crisis or traumatic event sometimes repress their memories of the event to keep away the pain of remembering them. Children deal with this often. These so-called repressed memories can come to light during psychotherapy sessions, or they may be triggered by an every day occurrence that reminds them of the repressed event. Many therapists don’t like working with this controversial disturbance, because they cannot confirm if these memories are truth or make-believe. These memories are usually retrieved by hypnosis, which most therapists deem an unreliable method of exploring the mind.

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Resources and References

The Journal of the American Medical Association patient education page

 

National Institute of Mental Health

 

Eric Lindemann "Symptomatology and Management of Acute Grief" 1944.

 

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC: American Psychiatric Association.

 

Am J Psychiatry. 1990 Jun;147(6):729-33. Causes of Posttraumatic Stress Disorder (PTSD)

 

Risk Factors for Posttraumatic Stress Disorder, Edited by Rachel Yehuda, Ph.D., American Psychiatric Publishing, 1999.

 

Stephen R. Paige. Current Perspectives on Posttraumatic Stress Disorder: From the Clinic and the Laboratory Integrative Physiological and Behavioral Science, 32, 5-8.

 

 

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Topic Development

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