Post-traumatic stress disorder

Post-traumatic stress disorder
Specialty	Psychiatry, clinical psychology

Posttraumatic stress disorder (PTSD) is the term for a severe and ongoing emotional reaction to an extreme psychological trauma. The latter may involve someone's actual death or a threat to the patient's or someone else's life, serious physical injury, or threat to physical and/or psychological integrity, to a degree that usual psychological defenses are incapable of coping.

In some references, "PTSD" is hyphenated ("post-traumatic stress disorder"). "Posttraumatic Stress Disorder," without the hyphen, is the official spelling in "DSM-IV" — the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition. (DSM idiosyncratically capitalizes every word of a diagnostic entity.)

PTSD is sometimes called post-traumatic stress reaction, to emphasize that it is a result of traumatic experience rather than a manifestation of a pre-existing psychological condition. The presence of a PTSD response is influenced by the intensity of the experience, its duration, and the individual person involved.

Overview

As indicated in DSM-IV, it is possible for individuals to experience traumatic stress without developing posttraumatic stress disorder. Indeed, most people who suffer psychological trauma do not develop PTSD. For most, the emotional effects of such events subside after several months.

PTSD is thought to be primarily an anxiety disorder (possibly closely related to panic disorder) and should not be confused with normal grief and adjustment after traumatic events.

PTSD symptoms may include: nightmares, flashbacks, emotional detachment or numbing of feelings (emotional self-mortification or dissociation), insomnia, avoidance of reminders and extreme distress when exposed to the reminders ("triggers"), loss of appetite, irritability, hypervigilance, memory loss (may appear as difficulty paying attention), excessive startle response, clinical depression, and anxiety.

A person suffering from PTSD may also exhibit one or more comorbid psychiatric disorders. These may include clinical depression (or bipolar disorder), general anxiety disorder, and a variety of addictions.

According to DSM-IV, symptoms that appear within the first month of the trauma are not called PTSD but Acute stress disorder. If there is no improvement of symptoms after a month, PTSD is diagnosed. PTSD is divided into three categories: Acute PTSD subsides within three months. If symptoms persist, the diagnosis is changed to chronic PTSD. The third category, delayed-onset PTSD, may occur months, years or even decades after the traumatic event.

History

The first documented case of psychological distress was reported in 1900 BC, Egypt by an Egyptian physician who described a "hysterical" reaction to trauma (Veith 1965).

Railway spine was a nineteenth-century diagnosis for the post-traumatic symptoms of passengers involved in railroad accidents. The first full length medical study of the condition was John Eric Erichsen's On Railway and Other Injuries of the Nervous System, published in 1864. For this reason, railway spine is often known as "Erichsen's disease". Many physicians thought that the symptoms were due to the "excessive speeds" (about 30 mph) of the trains, and that the human body could not cope with speeds that fast. It was later found to be purely psychological in origin, and no longer exists as a valid disorder.

There have been numerous reports of military veterans suffering from PTSD-like symptoms for well over 100 years. For example, veterans of the US Civil War who suffered emotional problems were diagnosed as being afflicted with "soldier's heart" or “Da Costa’s Syndrome” which shares many symptoms like PTSD. Shell shock was a term used to describe the condition of veterans of World War I who seemed emotionally disturbed in a similar fashion. In World War II, these symptoms were classified as "battle fatigue" or "combat fatigue". Other terms used to describe military-related mood disturbances include "nostalgia", "not yet diagnosed nervous", "irritable heart", "effort syndrome", "war neurosis", and "operational exhaustion".

Hysteria was also related to "traumatic reminiscences" a century ago (Janet 1901). At that time, Sigmund Freud's pupil, Kardiner, was the first to describe what later became known as symptoms of post-traumatic stress disorder (Lamprecht & Sack 2002).

Stress is often defined as the reaction to a situation that threatens the balance or homeostasis of a system (Antonovsky 1981). The situation causing the stress reaction is defined as the "stressor", but the stress reaction and not the stressor is what jeopardizes the homeostasis (Aardal-Eriksson 2002). Post-traumatic stress can thus be seen as a chemical imbalance of neurotransmitters, according to stress theory.

However, PTSD in and of itself is a relatively recent diagnosis in psychiatric nosology, first appearing in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. It has been said that development of the PTSD concept has, in part, socio-economic and political implications (Mezey & Robbins 2001). War veterans are the most publicly-recognized victims of PTSD; long-term psychiatric illness was formally observed in World War I veterans. The syndrome entered wide public consciousness after the Vietnam War. PTSD patients had difficulties receiving veterans' disability benefits because there was no psychiatric diagnosis available by which veterans could claim indemnity. This situation has changed during the last two decades and PTSD is now one of several psychiatric diagnoses for which a veteran can receive compensation, such as a war veteran indemnity pension, in the U.S. (see below: Mezey & Robbins 2001)

PTSD has also been recognized as a problem for marginalized groups within societies. One such group is Australian Aboriginal peoples, and other Indigenous peoples around the world. In these cases the repeated history of childhood and adult trauma, removal of children from their families, interpersonal violence and substance abuse, and early death, results in generations of people with high levels of PTSD.

Natural history

Traumatic experiences

Main article: Psychological trauma

• childhood physical, emotional, or sexual abuse, including prolonged or extreme neglect; also, witnessing such abuse inflicted on another child or an adult
• Experiences and interactions that are experienced as psychological "attacks"; for example a continual perception of psychological force, invalidation or annihilation.
• experiencing (including witnessing) an event perceived as life-threatening, such as:

1. a serious accident,
2. medical complications,
3. violent physical assaults or surviving or witnessing such an event, including torture
4. adult experiences of sexual assault or rape
5. warfare, Policing and other occupations exposed to violence or disaster
6. violent, life threatening, natural disasters
7. incarceration

Cancer

PTSD is normally associated with trauma such as violent crimes, rape, and war experience. However, there have been a growing number of reports of PTSD among cancer survivors and their relatives (Smith 1999, Kangas 2002). Most studies deal with survivors of breast cancer (Green 1998, Cordova 2000, Amir & Ramati 2002), and cancer in children and their parents (Landolt 1998, Stuber 1998), and show prevalence figures of between five and 20%. Characteristic intrusive and avoidance symptoms have been described in cancer patients with traumatic memories of injury, treatment, and death (Brewin 1998). There is yet disagreement on whether the traumas associated with different stressful events relating to cancer diagnosis and treatment actually qualify as PTSD stressors (Green 1998). Cancer as trauma is multifaceted, includes multiple events that can cause distress, and like combat, is often characterized by extended duration with a potential for recurrence and a varying immediacy of life-threat (Smith 1999).

Diagnostic criteria

The diagnostic criteria for PTSD, according to Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), are stressors listed from A to F. The current diagnostic criteria for the PTSD published in the Diagnostic and Statistical Manual of Mental Disorders may be found DSM-IV-TR here.

Notably, the stressor criterion A is divided into two parts. The first (A1) requires that "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." The second (A2) requires that "the person’s response involved intense fear, helplessness, or horror." The DSM-IV A criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience." Since the introduction of DSM-IV, the number of possible PTSD-traumas has increased and one study suggests that the increase is around 50% (Breslau & Kessler 2001).

Symptoms

Symptoms can include general restlessness, insomnia, aggressiveness, depression, dissociation, emotional detachment, and nightmares. A potential symptom is memory loss about an aspect of the traumatic event. Amplification of other underlying psychological conditions may also occur. Young children suffering from PTSD will often re-enact aspects of the trauma through their play and may often have nightmares that lack any recognizable content.

One patho-psychological way of explaining PTSD is by viewing the condition as secondary to deficient emotional or cognitive processing of a trauma. This view also helps to explain the three symptom clusters of the disorder:

Intrusion: Since the sufferers are unable to process the extreme emotions brought about by the trauma, they are plagued by recurrent nightmares or daytime flashbacks, during which they graphically re-experience the trauma. These re-experiences are characterized by high anxiety levels and make up one part of the PTSD symptom cluster triad called intrusive symptoms.

Hyperarousal: PTSD is also characterized by a state of nervousness with the patient being prepared for "fight or flight". The typical hyperactive startle reaction, characterized by "jumpiness" in connection with loud unexpected sounds or fast motions, is typical for another part of the PTSD cluster called hyperarousal symptoms and could also be secondary to an incomplete processing, similar to a reflex.

Avoidance: The hyperarousal and the intrusive symptoms are eventually so distressing that the individual strives to avoid contact with everything and everyone, even their own thoughts, which may arouse memories of the trauma and thus provoke the intrusive and hyperarousal states. The sufferers isolate themselves, becoming detached in their feelings with a restricted range of emotional response and can experience so-called emotional detachment ("numbing"). Many Veterans with PTSD may also use avoidance as a technique to avoid losing control and harming others. This avoidance behavior is the third part of the symptom triad that makes up the PTSD criteria.

Dissociation: Dissociation is another "defense" that includes a variety of symptoms including feelings of depersonalization and derealization, disconnection between memory and affect so that the person is "in another world," and in extreme forms can involve apparent multiple personalities and acting without any memory ("losing time").

Treatment

Early intervention after a traumatic incident, known as Critical Incident Stress Management (CISM) is often used to reduce traumatic effects of an incident, and potentially prevent a full-blown occurrence of PTSD. However recent studies regarding CISM seem to indicate iatrogenic effects (Carlier, Lamberts, van Uchelen & Gersons 1998) (Mayou, Ehlers & Hobbs 2000).

There have been scores of treatments suggested for the treatment of PTSD. One psychotherapeutic (non-medical) method, specifically targeted at the disorder PTSD, is Eye Movement Desensitization and Reprocessing (EMDR).

Relationship based treatments are also often used. Johnson, S., (2002). Emotionally Focused Couples Therapy with Trauma Survivors. NY: Guilford, is one example. These, and other approaches, use attachment theory and an attachment model of treatment. The treatment of complex trauma often requires a multi-modal approach.

PTSD is commonly treated using a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and psychotropic drug therapy (antidepressant or atypical antipsychotics, e.g. brand names such as Prozac (fluoxetine), Effexor (venlafaxine), Zoloft (sertraline), Remeron (mirtazapine), Zyprexa (olanzapine), or Seroquel (quetiapine)). Recently Lamotrigine has been reported to be useful in treating some people with PTSD.

According to some studies, the most effective psychotherapeutic treatment for PTSD is Eye Movement Desensitization and Reprocessing (EMDR) q.v. Talk therapy may prove useful, but only insofar as the individual sufferer is enabled to come to terms with the trauma suffered and successfully integrate the experiences in a way that does not further damage the psyche. Forbes, et al, (2001) have shown that a technique of "rewriting" the content of nightmares through imagery rehearsal so that they have a resolution can not only reduce the nightmares but also other symptoms. The US Food and Drug Administration (FDA) recently approved a clinical protocol that combines the drug MDMA with talk therapy sessions.

Basic counseling for PTSD includes education about the condition and provision of safety and support (Foa 1997). Cognitive therapy shows good results (Resick 2002), and group therapy may be helpful in reducing isolation and Stigma (Foy 2002).

Dr. Jan Bastiaans of the Netherlands has developed a form of psychedelic psychotherapy involving LSD, with which he has successfully treated concentration camp survivors who suffer from PTSD.[1]

Propranolol, a beta blocker which appears to inhibit the formation of traumatic memories by blocking adrenaline's effects on the amygdala, has been used in an attempt to reduce the impact of traumatic events.

Recently, the use of Virtual reality and Integrated reality experiences applied as a new type of exposure therapy methods to come types of PTSD (specifically military related patients) has been gaining recognition. Some of this work is done at the CAREN VR LAB at the SHEBA rehabilitation hospital in Israel. The ideas behind this methods is based on introducing PTSD causes in a gradual manner, inside a safe environment, the hope is that training in VR in this manner will reduce stress and transfer to daily reality. A similar system is recently installed at the BAMC (Brooke Army Medical Center ) In the USA.

PTSD is often co-morbid with other psychiatric disorders such as depression and substance abuse. Currently under scrutiny is the inclusion of Complex Post Traumatic Stress in the 2006 revision of the DSM-IV-TR. This is a variant of PTSD that includes the breakthrough of Borderline Personality traits.

Pathophysiology

Neurochemistry

PTSD displays biochemical changes in the brain and body, which are different from other psychiatric disorders such as major depression.

In PTSD patients, the dexamethasone cortisol suppression is strong, while it is weak in patients with major depression. In most PTSD patients the urine secretion of cortisol is low, at the same time as the catecholamine secretion is high, and the norepinephrine/cortisol ratio is increased. Brain catecholamine levels are low, and corticotropin-releasing factor (CRF) concentrations are high. There is also an increased sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis, with a strong negative feedback of cortisol, due to a generally increased sensitivity of cortisol receptors (Yehuda, 2001).

Cortisol

The association of PTSD with cortisol levels is controversial within the medical community.

Some researchers have associated the response to stress in PTSD with long-term high levels of norepinephrine, at the same time as cortisol levels are low, a pattern associated with facilitated learning in animals. Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response (Yehuda 2002). With this deduction follows that the clinical picture of hyperreactivity and hyperresponsiveness in PTSD is consistent with the sensitive HPA-axis.

Low cortisol levels are also discussed as a possible pre-existing condition that neurochemically predisposes a person to PTSD. Swedish United Nation soldiers serving in Bosnia with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels (Aardal-Eriksson 2001).

There is considerable controversy within the medical community regarding the neurobiology of PTSD. A review of existing studies on this subject showed no clear relation between cortisol levels and PTSD. For example, only a slight majority of studies have found a decrease in cortisol levels; many others have found no effect or even an increase.

Neuroanatomy

In animal research as well as human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. Neuroimaging studies in humans have revealed both morphological and functional aspects of PTSD. The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex and the hippocampus. Further animal and clinical research into the amygdala and fear conditioning may suggest additional treatments for the condition.

Prevalence

PTSD may be experienced following any traumatic experience, or series of experiences which satisfy the criteria and that do not allow the victim to readily recuperate from the detrimental effects of stress. It is believed that of those exposed to traumatic conditions between 5% and 80% will develop PTSD depending on the severity of the trauma and personal vulnerability.

The National Comorbidity Survey Report provided the following information about PTSD in the general adult population: The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.[2]

In recent history, the Indian Ocean Tsunami Disaster, which took place December 26, 2004 and took hundreds of thousands of lives, the September 11, 2001 attacks on the World Trade Center and The Pentagon, and the impact and effects of Hurricane Katrina may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as the Red Cross and the Salvation Army provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder.

Other agencies, such as the National Meditation Center for World Peace [3], have created similar special programs. The NMC trains agencies such as crisis centers NGOs and works with international agencies to prevent trauma to children.

Cultural aspects

Veterans and politics

In the United States, the provision of compensation to veterans for PTSD is under review by the Department of Veterans Affairs. The review was begun in 2005 after the V.A. had noted a 30% increase in PTSD claims in recent years. The V.A. undertook the review because of budget concerns and apparent inconsistencies in the awarding of compensation by different rating offices.

This led to a backlash from veterans'-rights groups, and to some highly-publicized suicides by veterans who feared losing their benefits, which in some cases constituted their only income. In response, on November 10, 2005, the Secretary of Veterans Affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for post-traumatic stress disorder..."

Soon after, the V.A. announced that it had contracted with the Institute of Medicine (IOM) to conduct a study on PTSD. The committee will review risk factors for developing PTSD and comment on procedures used in its diagnosis. It will also "review the utility and objectiveness of the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and will comment on the validity of current screening instruments and their predictive capacity for accurate diagnoses." The committee will also "review the literature on various treatment modalities (including pharmacotherapy and psychotherapy) and treatment goals for individuals with PTSD and... comment on the prognosis of individuals diagnosed with PTSD and existing comorbidities."

Some veterans' advocates expressed concern that this was a back-door way to reduce benefits to veterans who have served in Iraq and the Persian Gulf. On the other hand, psychiatrist Sally Satel, affiliated with the American Enterprise Institute, asserts that an underground network advises veterans where to go for the best chance of being declared disabled. The Institute organized a meeting to discuss PTSD with veterans.

The diagnosis of PTSD is regarded by some as controversial due to its association with compensation-seeking behavior and due to uncertainties in objectively diagnosing those who may have been exposed to trauma. [4] A psychiatry professor recounts an interview with a veteran who reported to a V.A. medical center after receiving a leaflet listing PTSD symptoms and encouraging affected veterans to apply for compensation. During the interview, the veteran complained to the psychiatrist of "survivor quilt." Asked what that was, he replied, "I don't know, Doc, but I've got it bad." It transpired that the leaflet had misprinted "survivor guilt" as "survivor quilt," and the veteran had duly quoted the symptom in his campaign to win PTSD compensation.

While PTSD-like symptoms have been recognized in combat veterans of many military conflicts, the modern understanding of PTSD dates from the 1980s. Reported cases of Operation Enduring Freedom and Operation Iraqi Freedom combat-related PTSD are being compiled in ePluribus Media's PTSD Timeline

Canadian Veterans

Veterans Affairs Canada, VAC [5]. The new program includes rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support [6]

Law

If an individual suffering from PTSD commits a crime, there may be uncertainty about whether the individual can be held responsible for that act. In extreme cases, the defense of automatism, where the defendant was unable to control his actions, may be available. PTSD may produce an internal defect of reason within the meaning of the M'Naghten Rules (which defines the mental disorder defence in some criminal jurisdictions). The difference is that whereas defenses that rely on automatism result in an acquittal, since no guilt can be assigned to a party unable to control their actions; insanity or mental disorder leaves the "offender" available for sentencing by the court.

In the event that a death has resulted, diminished responsibility may be available as an alternative to insanity. This defense reduces what would otherwise have been murder to manslaughter. In the specific instance of spousal abuse, this is often called battered woman syndrome and, more generally, the abuse defense in the U.S.

Trauma and the arts

In recent decades, with the concept of trauma, and PTSD in particular, becoming just as much a cultural phenomenon as a medical or legal one, artists have begun to engage the issue in their work. An important breakthrough in this was the publication of Maus: A Survivor's Tale (1972) by Art Spiegelman. There is now a genre of art that focuses on, exposes, and comments on survivors and survivor-tales. Some want to see art as part of a process of healing, and in this they work in a manner akin to art therapy or the older twentieth century notion of art psychology. There are others who resist the implicit mandate that art should be put into the service of psychological repair. These artists tend to work in a direction that links trauma to questions of memory, identity and politics.

As an example of the latter, one could point to the various Holocaust memorials in Germany, most of which were made beginning in the 1980s and which coincided with the increased awareness about trauma and its representational needs. These memorials have provoked a good deal of debate about the role of public space. Jochen Gertz and Esther Shavlev-Gertz's anti-fascism memorial in Harburg, Germany is a good example. Erected in 1986, it consisted of a single pillar enrobed in lead so that visitors could scratch their names and thoughts into the surface. The pillar was designed to sink beneath the ground in stages, to mirror the progress of human memories. It did so, and now can be viewed only through a glass wall. But what started as an idea to bring the community together in a repudiation of fascism turned into something altogether different when people began to write anti-semitic slogans on the pillar, and city fathers began to see the monument as an embarrassment.

The recently opened Memorial to the Murdered Jews of Europe in Berlin that was designed by Peter Eisenman was held up for years because of controversies. James Young discusses the history of what are now called "anti-memorial memorials" in Germany. The term "counter-monument" is also now in common usage in the art community to describe memorials that deal with difficult topics.

In more recent work, an example is that of Krzysztof Wodiczko who teaches at MIT and who is known for interviewing people and then projecting these interviews onto large public buildings. Wodiczko wants to bring trauma not merely into public discourse but to have it contest the presumed stability of cherished urban monuments. His work has brought to life issues such as homelessness, rape, and violence. Other artists who engage the issue of trauma are Everlyn Nicodemus of Tanzania and Milica Tomic of Serbia.

See also

• List of fictional characters with posttraumatic stress disorder
• Glossary of trauma terms

• Psychoneuroimmunology
• Acute stress reaction
• Dissociative Amnesia (formerly Psychogenic Amnesia) (DSM-IV Dissociative Disorders 300.12)
• Biological psychiatry
• Chemical imbalance theory
• Complex post-traumatic stress disorder
• EMDR
• Emotional dysregulation

• Post-abduction syndrome
• Mental health
• Rape
• Somatic Experiencing
• Survivor guilt
• Survivor syndrome
• Trauma model of mental disorders
• Critical incident stress Management
• Trauma and the Arts

Further reading

• Moving a Nation to Care: Post-Traumatic Stress Disorder and America's Returning Troops, by Ilona Meagher, Introduction by Penny Coleman, Foreword by Robert Roerich, M.D.
• A War of Nerves. Soldiers and psychiatrists 1914-1994 by Ben Shephard. Jonathon Cape: London 2000. 475 pp. Written by UK historian and producer, presents as a well researched, easy to read book with ++ references. Traces history of PTSD as a diagnosis wrt war service, as a problem for many: sufferer, psychiatrists both military and non-military, strategists, war office and politicians etc in various countries using eg patient accounts, war office accounts from doctors and military/political figures.

External links

• National Center for PTSD
• Post-Traumatic Stress Disorder and the Military: A Selected Bibliography (2005)
• New Scientist, 25 August 2005, "Trauma of war hits troops years later"
• The Ex-Services Mental Welfare Society (Combat Stress) - UK charity Caring for veterans suffering from a variety of psychological problems such as combat related Post Traumatic Stress Disorder (PTSD).
• "Wisconsin Public Television PTSD series" Full video from Wisconsin Public Television's in-depth series about Post Traumatic Stress Disorder