Post Traumatic Stress Disorder
Definition
Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that may develop after exposure to a terrifying event or ordeal in which severe physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or unnatural disasters, accidents, or military combat.
Those who may experience PTSD include military troops who served in wars; rescue workers for catastrophes like the 2001 terrorist attacks on New York City and Washington, D.C.; survivors of the Oklahoma City bombing; survivors of accidents, rape, physical or sexual abuse, and other crimes; immigrants fleeing violence in their countries; survivors of earthquakes, floods, and hurricanes; and those who witness traumatic events. Family members of victims can develop the disorder as well.
PTSD affects about 7.7 million American adults, but it can occur at any age, including childhood. Women are more likely to develop the disorder than men, and there is some evidence that it may run in families. PTSD is frequently accompanied by depression, substance abuse, or anxiety disorders. When other conditions are appropriately diagnosed and treated, the likelihood of successful treatment increases.
Roughly 30 percent of Vietnam veterans developed PTSD. The disorder also has been detected among veterans of the Gulf War, with some estimates running as high as 8 percent.
Complex PTSD
Complex PTSD, also known as disorder of extreme stress, is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. Research shows that many brain and hormonal changes may occur as a result of early, prolonged trauma, and contribute to troubles with learning, memory, and regulating emotions. Combined with a disruptive, abusive home environment, these brain and hormonal changes may contribute to severe behavioral difficulties such as eating disorders, impulsivity, aggression, inappropriate sexual behavior, alcohol or drug abuse, and other self-destructive actions, as well as emotional regulation (such as intense rage, depression, or panic) and mental difficulties (such as scattered thoughts, dissociation, and amnesia). As adults, these individuals often are diagnosed with depressive disorders, personality disorders, or dissociative disorders. Treatment may progress at a much slower rate, and requires a sensitive and structured program delivered by a trauma specialist.
Symptoms Many people with PTSD tend to re-experience the ordeal that set the disease in motion, especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event can also trigger symptoms. People with PTSD also experience emotional numbness, sleep disturbances, anxiety, intense guilt, depression, irritability, or outbursts of anger. Most people with PTSD try to avoid any reminders or thoughts of the ordeal. PTSD is diagnosed when symptoms last more than one month.
Symptoms associated with reliving the traumatic event:
- Having bad dreams about the event or something similar
- Behaving or feeling as if the event were actually happening all over again (known as flashbacks)
- Having a lot of emotional feelings when reminded of the event
- Having a lot of physical sensations when reminded of the event (heart pounds or misses a beat, sweating, difficulty breathing, feeling faint, feeling a loss of control)
Symptoms related to avoidance of reminders of the traumatic event:
- Avoiding thoughts, conversations, or feelings about the event
- Avoiding people, activities, or places associated with the event
- Having difficulty remembering an important part of the original trauma
Changes frequently made after the event:
- Loss of interest in things previously considered important
- Feeling detached from people
- Feeling emotionally numb and finds it hard to have loving feelings even toward those who are close
- Difficulty falling or staying asleep
- Irritability and anger
- Difficulty concentrating
- Feeling that one is not going to live long and there is no reason to plan for the future
- Feeling easily startled
- Always on guard
Medical or emotional issues:
- Stomach problems
- Intestinal problems
- Gynecological problems
- Weight gain or loss
- Chronic pain (back, neck, pelvic area in women)
- Problems getting to sleep
- Problems staying asleep
- Headaches
- Skin rashes and other problems
- Irritability, quick temper, other anger problems
- Nightmares
- Depression
- Lack of energy, chronic fatigue
- Alcoholism and other substance use problems
- General anxiety
- Panic attacks
Causes People who have suffered childhood abuse or other previous traumatic experiences are more likely to develop the disorder. And people who experience emotional distancing may be more prone to PTSD.
Studies in animals and humans have pinpointed the brain areas involved in anxiety and fear, which are important for understanding anxiety disorders such as PTSD. Fear, an emotion that evolved to deal with danger, causes an automatic, rapid protective response in the body. The fear response is coordinated by a small structure deep inside the brain, called the amygdala. The amygdala, is a complicated structure, and research suggests that posttraumatic stress disorder may be associated with abnormal activation of the amygdala.
Once fear is conditioned in the amygdala, it is hard to change. However, the neural pathways from the amygdala to the hippocampus and to cortical regions such as the frontal lobes allow its suppression until triggered. Fear quickly returns when the individual is re-exposed. An increase in stressors seems to affect the fear-inducing and the fear-inhibiting pathways. High stress levels decrease the capacity to suppress fear, while increasing the ability to induce it. Thus, the fear induced by re-exposure to traumatic material indicates a failure of inhibition on the part of the hippocampus, and is evidence that the traumatic episode is not integrated as a narrative, spatio-temporal event in autobiographical memory. Furthermore, the heightened sensitivity of exposure of PTSD patients to trauma-related material results in an increase in fearfulness in response to stimuli that are not truly life threatening.
Studies using MRI in PTSD have measured volume of the hippocampus, a brain structure involved in learning and memory. Patients with combat-related PTSD had an 8 percent decrease in right hippocampal volume when compared with controls. A decrease of 12 percent in left hippocampal volume was found in patients with a history of PTSD related to severe childhood physical and sexual abuse. Reduced hippocampal volume was associated with dissociative symptoms in women who had a history of childhood sexual abuse.
People with PTSD tend to have abnormally high levels of key hormones involved in response to stress. A person in danger produces high levels of natural opiates, which can temporarily mask pain. Scientists have found that people with PTSD continue to produce those higher levels even after the danger has passed, which might lead to the blunted emotions associated with the condition.
Some studies have shown that cortisol levels are lower than normal and epinephrine and norepinephrine are higher than normal. Norepinephrine is a neurotransmitter released during stress, and one of its functions is to activate the hippocampus, the brain structure involved with organizing and storing information for long-term memory.
This action of norepinephrine is thought to be one reason why people can remember emotionally arousing events better than other situations. Under the extreme stress of trauma, norepinephrine may act longer or more intensely on the hippocampus, leading to the formation of abnormally strong memories that are then experienced as flashbacks or intrusions.
Treatment Treatment for PTSD typically begins with a detailed evaluation, and development of a treatment plan that meets the unique needs of the survivor. PTSD-specific-treatment begins only when the survivor is safely removed from the crisis situation. Other strategies for treatment include:
- Educating trauma survivors and their families about how persons get PTSD, how PTSD affects survivors and their loved ones, and other problems commonly associated with PTSD symptoms. Understanding that PTSD is a medically recognized anxiety disorder is essential for effective treatment.
- Exposure to the event via imagery allows the survivor to re-experience the event in a safe, controlled environment. A professional can carefully examine reactions and beliefs in relation to that event.
- Examining and resolving strong feelings such as shame, anger, or guilt, which are common among survivors of trauma.
- Teaching the survivor to cope with post-traumatic memories, reminders, reactions, and feelings without becoming overwhelmed or emotionally numb. Trauma memories usually do not go away entirely as a result of therapy, but new coping skills can make them more manageable.
Medications
A number of medications that were originally approved for depression have been found effective in healing post-traumatic stress disorder. If an antidepressant is prescribed, it will need to be taken for several weeks before symptoms start to fade. It is important not to get discouraged and stop taking these medications before they’ve had a chance to work.
Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. These medications act in the brain on a chemical messenger called serotonin. SSRIs tend to have fewer side effects than older antidepressants. While some patients report feeling slightly nauseated or jittery when taking SSRIs, symptoms disappear with time. Some people also experience sexual dysfunction when using some of these medications. An adjustment in dosage or a switch to another SSRI will usually correct problems. It is important to discuss side effects with your doctor.
Fluoxetine, sertraline, fluvoxamine, paroxetine, and citalopram are among the SSRIs commonly prescribed for PTSD. These medications are given at a low dose and gradually increased until they reach a therapeutic level.
Similarly, antidepressant medications called tricyclics are given at low doses and gradually increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating anxiety disorders. They are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics sometimes cause dizziness, dry mouth, drowsiness, and weight gain.
Psychotherapy
Cognitive-behavioral therapy (CBT) works to change emotions, thoughts, and behaviors. Exposure therapy is one form of CBT unique to trauma treatment—this uses careful, repeated, detailed imagining of the trauma in a safe, controlled context. In some cases, trauma memories or reminders can be confronted all at once (flooding). And in other cases, it is preferable to work gradually up to the most severe trauma by using relaxation techniques and by taking the trauma one piece at a time (desensitization).
Along with exposure, CBT includes learning skills for coping with anxiety (for example, breathing retraining or biofeedback) and negative thoughts (cognitive restructuring), managing anger, preparing for stress reactions (stress innoculation), handling future trauma symptoms, as well as addressing urges to use alcohol or drugs (relapse prevention), and communicating and relating effectively with people (social skills or marital therapy).
Eye movement desensitization and reprocessing (EMDR) is a relatively new treatment of traumatic memories that involves elements of exposure therapy and cognitive behavioral therapy, combined with techniques (sounds, eye movements, hand taps) that create an alteration of attention. There is some evidence that the therapeutic element unique to EMDR, attentional alteration, may be helpful in accessing and processing traumatic material.
Group treatment is an ideal therapeutic setting because trauma survivors are able to risk sharing traumatic material in a safe environment. As group members achieve greater understanding and resolution of their trauma, they often feel more confident and able to trust. As they discuss and share trauma-related shame, guilt, fear, rage, doubt, and self-condemnation, they prepare themselves to focus on the present rather than the past. Telling one’s story and directly facing the grief, guilt, and anxiety related to trauma enables many survivors to cope with their symptoms, memories, and other aspects of life.
Brief psychodynamic psychotherapy focuses on the emotional conflicts caused by the traumatic event, particularly in relation to early life experiences. Through the retelling of the traumatic event to a calm and empathic counselor, the survivor achieves a greater sense of self-esteem, develops effective ways of thinking and coping, and more successfully deals with the intense emotions that emerge during therapy. The therapist helps the survivor identify current life situations that set off traumatic memories and worsen PTSD symptoms.