Post-traumatic stress disorder (PTSD) is a debilitating mental disorder that follows experiencing or witnessing an extremely traumatic, tragic, or terrifying event. People with PTSD usually have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to.
PTSD, once referred to as "shell shock" or battle fatigue, was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. These include kidnapping, serious accidents such as car or train wrecks, natural disasters such as floods or earthquakes, violent attacks such as a mugging, rape, or torture, or being held captive. The event that triggers it may be something that threatened the person's life or the life of someone close to him or her. Or it could be something witnessed, such as mass destruction after a plane crash.
Most people with posttraumatic stress disorder repeatedly re-live the trauma in the form of nightmares and disturbing recollections during the day. The nightmares or recollections may come and go, and a person may be free of them for weeks at a time, and then experience them daily for no particular reason. They may also experience sleep problems, depression, feeling detached or numb, or being easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Seeing things that remind them of the incident may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the event are often very difficult.
PTSD can occur at any age, including childhood. The disorder can be accompanied by depression, substance abuse, or anxiety. Symptoms may be mild or severe -- people may become easily irritated or have violent outbursts. In severe cases, they may have trouble working or socializing. In general, the symptoms seem to be worse if the event that triggered them was initiated by a person -- such as a murder, as opposed to a flood.
Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A flashback may make the person lose touch with reality and reenact the event for a period of seconds or hours, or very rarely, days. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, usually believes that the traumatic event is happening all over again.
Posttraumatic stress disorder can be treated, usually with a combination of psychotherapy and medications (for specific symptom relief, such as for the common accompanying depressive feelings). People with PTSD should seek out a therapist or psychologists with specific experience and background in treatment posttraumatic stress disorder.
What Causes PTSD?
By Harold Cohen, Ph.D.
Explanations of PTSD focus primarily on the way that the mind is affected by traumatic experiences. Theorists speculate upon facing overwhelming trauma, the mind is unable to process information and feelings in a normal way. It is as if the thoughts and feelings at the time of the traumatic event take on a life of their own, later intruding into consciousness and causing distress.
Pre-traumatic psychological factors (for example, low self-esteem) may make this process worse (for example, low self-esteem may be reinforced by a brutal rape). Post-traumatic reactions by others (for example, a raped woman who is viewed by family as “dirty”) and by the self (for example, physical discomfort caused by memories of the rape) may also play a role in influencing whether such symptoms persist. It is hypothesized that only after successful reprocessing of the traumatic event(s) do PTSD symptoms decrease.
In addition, powerful new techniques for studying the brain, its structures and its chemicals are providing scientists with information on the how both brain and mind are important in the development of PTSD. Recent brain imaging studies place emphasis on two brain structures: the amygdala and hippocampus. The amygdala is involved with how we learn about fear, and there is some evidence that this structure is hyperactive in people with PTSD (this can be conceptualized as a “false alarm”). The hippocampus plays an important role in the formation of memory, and there is some evidence that in people with PTSD there is a loss of volume in this structure, perhaps accounting for some of the memory deficits and other symptoms in PTSD.
Other research has focused on the neurochemicals that may be involved in PTSD. For example, there is evidence that a hormonal system known as the hypothalamic-pituitary-adrenal (HPA) axis becomes disrupted in people with PTSD. This system is involved in normal stress reactions, and its disruption in people with PTSD can again be conceptualized as a kind of “false alarm”. Some scientists have suggested that dysfunction of the HPA system results in hippocampal damage in people with PTSD. Medication presumably acts to reverse neurochemical dysfunction in PTSD; it is as if these agents switch off the “false alarms” of which this condition is comprised.
Ultimately, it may even be possible to predict the development of PTSD based on the early psychological and neurochemical changes in people who have been exposed to a traumatic event. Continued research also offers the promise of new treatments for PTSD in the future.
Symptoms & Diagnosis of PTSD
By Sara Staggs, LICSW, MSW, MPHClinicians use the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a guide in understanding clusters of symptoms so that they know how to treat different clients. The DSM has gone through a number of revisions through the years, and recently the 5th edition was released. Posttraumatic Stress Disorder (PTSD) was one of the diagnoses that received some revisions (PDF).
PTSD used to be considered a type of anxiety disorder and in this edition was moved into a new category: “Trauma and Stress-related Disorders”. This could help de-stigmatize PTSD since it is no longer an anxiety related mental illness, but a disorder connected to an external event.
The criteria for PTSD include specifying qualifying experiences of traumatic events, four sets of symptom clusters, and two subtypes. There are also requirements around duration of symptoms, how it impacts one’s functioning, and ruling out substance use and medical illnesses. Also, there is now a pre-school diagnosis for PTSD, so the following description is for people ages 7 and older.
Criterion A: Traumatic event
Trauma survivors must have been exposed to actual or threatened:
- death
- serious injury
- sexual violence
The exposure can be:
- direct
- witnessed
- indirect, by hearing of a relative or close friend who has experienced the event—indirectly experienced death must be accidental or violent
- repeated or extreme indirect exposure to qualifying events, usually by professionals—non-professional exposure by media does not count
Many professionals who work in trauma differentiate between “big T-traumas,” the ones listed above, and “little-t traumas.” Little-t traumas can include complicated grief, divorce, non-professional media exposure to trauma, or childhood emotional abuse, and clinicians recognize that these can result in post-traumatic stress, even if they don’t qualify for the PTSD diagnosis.
There is no longer a requirement that someone had to have an intense emotional response at the time of the event. This requirement excluded many veterans and sexual assault survivors in the past.
Criterion B: Intrusion or Re-experiencing
These symptoms envelope ways that someone re-experiences the event. This could look like:
- Intrusive thoughts or memories
- Nightmares related to the traumatic event
- Flashbacks, feeling like the event is happening again
- Psychological and physical reactivity to reminders of the traumatic event, such as an anniversary
Criterion C: Avoidant symptoms
Avoidant symptoms describe ways that someone may try to avoid any memory of the event, and must include one of the following:
- Avoiding thoughts or feelings connected to the traumatic event
- Avoiding people or situations connected to the traumatic event
Criterion D: Negative alterations in mood or cognitions
This criterion is new, but captures many symptoms that have long been observed by PTSD sufferers and clinicians. Basically, there is a decline in someone’s mood or though patterns, which can include:
- Memory problems that are exclusive to the event
- Negative thoughts or beliefs about one’s self or the world
- Distorted sense of blame for one’s self or others, related to the event
- Being stuck in severe emotions related to the trauma (e.g. horror, shame, sadness)
- Severely reduced interest in pre-trauma activities
- Feeling detached, isolated or disconnected from other people
Criterion E: Increased arousal symptoms
Increased arousal symptoms are used to describe the ways that the brain remains “on edge,” wary and watchful of further threats. Symptoms include the following:
- Difficulty concentrating
- Irritability, increased temper or anger
- Difficulty falling or staying asleep
- Hypervigilance
- Being easily startled
Criteria F, G and H
These criteria all describe the severity of the symptoms listed above. Basically, they have to have lasted at least a month, seriously affect one’s ability to function and can’t be due to substance use, medical illness or anything except the event itself.
Subtype: Dissociation
Dissociation has now been set apart from the symptom clusters, and now its presence can be specified. While there are several types of dissociation, only two are included in the DSM:
- Depersonalization, or feeling disconnected from oneself
- Derealization, a sense that one’s surroundings aren’t real
About this description
This description of the diagnosis is not meant to help people diagnose themselves, but to better understand what PTSD is, and how it can impact someone’s life. If you feel that you may have PTSD, please see a professional who can talk with you about your experiences, and offer you ways to receive treatment and support. Many thanks to the National Center for PTSD for providing the criteria for PTSD on their website.
Sara Staggs, LICSW, MSW, MPH is the Senior Trauma Therapist at the DC Rape Crisis Center. She is trained in Cognitive Behavioral Therapy, Trauma-Focused CBT, Dialectical Behavior Therapy, Mindfulness Based Stress Reduction and EMDR. She has experience working with adults who have severe, persistent mental illness, addictions and complex PTSD. She currently works with survivors of sexual violence in individual and group settings, supervises several graduate students and provides trainings on working with survivors of sexual violence in the DC metro area.
APA Reference
Staggs, S. (2013). Symptoms & Diagnosis of PTSD. Psych Central. Retrieved on August 7, 2014, from http://psychcentral.com/lib/symptoms-and-diagnosis-of-ptsd/000158
Differential Diagnosis of PTSD Symptoms
By Harold Cohen, Ph.D.While the symptoms of posttraumatic stress disorder (PTSD) may seem similar to those of other disorders, there are differences. For example, PTSD symptoms may seem similar to those of anxiety disorders, such as acute stress disorder or obsessive-compulsive disorder. However, there are distinct differences between these disorders.
In general, the symptoms of acute stress disorder must occur within four weeks of a traumatic event and come to an end within that four-week time period. If symptoms last longer than one month and follow other patterns common to PTSD, a person’s diagnosis may change from acute stress disorder to PTSD.
While both PTSD and obsessive-compulsive disorder have recurrent, intrusive thoughts as a symptom, the types of thoughts are one way to distinguish these disorders. Thoughts present in obsessive-compulsive disorder do not usually relate to a past traumatic event. With PTSD, the thoughts are invariably connected to a past traumatic event.
PTSD symptoms can also seem similar to adjustment disorder because both are linked with anxiety that develops after exposure to a stressor. With PTSD, this stressor is a traumatic event. With adjustment disorder, the stressor does not have to be severe or outside the “normal” human experience.
Who is Typically Diagnosed with PTSD?
By Harold Cohen, Ph.D.There is no “typical” demographic profile for a person with PTSD. While military doctors first identified PTSD as “shell shock” or “battle fatigue,” today it is recognized as a disorder that affects people of all ages and from all social, economic, and ethnic backgrounds. For example, children who experience physical or sexual abuse, adolescents who witness drive-by shootings and adults who live through natural disasters may be diagnosed with PTSD.
Several recent studies have indicated that exposure to trauma is surprisingly common in the United States. One study notes that significant traumatic events occur for more than half of all persons during the course of their lifetimes. The events most commonly associated with PTSD in women are rape and sexual abuse. In men, the traumatic event most commonly associated with PTSD is combat exposure. Domestic violence is a common precipitant of PTSD, but is arguably not sufficiently recognized as extremely common.
Impairments in personal adjustment, lack of supportive relationships, family history of PTSD, previous traumatic experiences and other existing mental disorders may also play a role in vulnerability to developing PTSD. Additional research is needed, however, to further clarify how different vulnerability and resilience factors interact in the development of PTSD.
As noted earlier, while PTSD is a common disorder, the majority of persons exposed to a traumatic event cope reasonably well. While many may develop symptoms (such as insomnia) for a short time, only a small percentage (less than 10 percent) go on to develop PTSD. Thus PTSD is not simply a “normal response” to an abnormal event; rather it is an anxiety disorder that involves specific kinds of physical and mental changes.
Treatment of PTSD
By Harold Cohen, Ph.D.There are two primary types of treatment for posttraumatic stress disorder (PTSD) — psychotherapy and medications.
Psychotherapy for PTSD
Most people who experience post-traumatic stress disorder undergo some type of psychotherapy (most commonly either cognitive-behavioral therapy or group psychotherapy, or combination of the two). You can learn more about psychotherapy for PTSD now.
Psychotherapy techniques commonly prescribed include group psychotherapy, cognitive-behavioral therapy, EMDR and hypnotherapy.
Medications for PTSD
Medications are nearly always used in conjunction with psychotherapy for PTSD, because while medications may treat some of the symptoms commonly associated with the disorder, they will not relieve a person of the flashbacks or feelings associated with the original trauma. If one is receiving a medication from a general practitioner or their doctor, they should nearly always seek a psychotherapy referral in addition to the prescription.
Antidepressants
The most commonly prescribed class of medications for PTSD (and the one approved by the U.S. Food and Drug Administration) are the selective serotonin reuptake inhibitor (SSRI) antidepressants. These include drugs such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). Research shows that this group of medicines tends to decrease anxiety, depression, and panic associated with PTSD in many people. These types of antidepressants may also help reduce aggression, impulsivity, and suicidal thoughts that can occur in people with PTSD.
This class of antidepressants generally takes 6 to 8 weeks to work, so patience is needed when taking them. Many people don’t always respond to the first type of antidepressant tried, so another antidepressant may need to be tried if the first one is ineffective. A relapse of posttraumatic stress disorder is less likely if antidepressants are prescribed for at least a year. Antidepressants are particularly useful in patients who also suffer from depression (although they can be useful even in the absence of depression). They are also useful when there is a history of abuse of alcohol or other substances,
Other Medications
There are a variety of other medications often prescribed to try and help reduce the symptoms associated with PTSD. The most common alternative to antidepressants are the atypical antipsychotics. Atypical antipsychotics include medications such as risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). Antipsychotic medicines seem to be most useful in the treatment of PTSD in those who suffer from agitation, dissociation, hypervigilance, intense suspiciousness (paranoia), or brief breaks in being in touch with reality (brief psychotic reactions).
Other less directly effective but nevertheless potentially helpful medications for managing PTSD include mood stabilizers like lamotrigine (Lamictal), tiagabine (Gabitril), and divalproex sodium (Depakote). Medicines that help decrease the physical symptoms associated with PTSD include drugs such as clonidine (Catapres), guaneficine (Tenex), and propranolol.
Benzodiazepines (commonly referred to as minor tranquilizers, sleeping tablets, or anti-anxiety medications) are sometimes prescribed for certain symptoms of PTSD because they provide rapid relief of anxiety, but are also associated with dependence. In general, there is far more evidence for the use of antidepressants in PTSD than for the use of benzodiazepines. There is even a small amount of data indicating that although the benzodiazepines can provide immediate relief of symptoms, over the long haul they can exacerbate PTSD.
In general, medications should be prescribed for PTSD only by a psychiatrist. Specialists may prescribe two medications at the same time for people with PTSD who fail to respond to various single medications.
Myths & Facts about PTSD
By Sara Staggs, LICSW, MSW, MPHExposure myths
Myth: Everyone who experiences a life-threatening event will develop PTSD
Actually, most people who are exposed to qualifying events will not get PTSD at all, and many see a natural decrease in symptoms over the months following an incident. The number of people who receive a diagnosis after a PTSD-level event ranges from less than 10% of individuals after more than 12 months of exposure to general trauma to 37% of people exposed to intentional trauma (an attack as opposed to an accident or natural disaster).
Myth: Only people who are weak get PTSD
It’s not really clear why some people get PTSD and others don’t. Women are twice as likely to be diagnosed with it than men are, however women are more likely to be diagnosed with many mental disorders because they are more likely to seek help, and therefore receive a diagnosis. People who are exposed to interpersonal trauma, such as sexual assault or warfare, are more likely to have PTSD symptoms than survivors of accidents or natural disasters. Social support is also important to trauma resilience. None of these factors have anything to do with inner strength though. In fact, it’s possible that an especially strong defense symptom is the culprit.
Symptoms and coping myths
Myth: After a certain amount of time, I should be over my trauma
Trauma, by its nature, hangs around. And sometimes a person can be going along just fine but something triggers the memories and they find themselves plagued by symptoms. Also, as people age activity that keeps long term memory shelved away from the rest of the brain begins to decrease, exposing the individual to more and more of their older memories. If some of these are trauma memories, they may find themselves overwhelmed by things that didn’t bother them for decades.
Myth: My trauma was so long ago that it’s too late to do anything about it
The good news is that it’s never too late to address your trauma. In fact, most of my clients are middle-age survivors of childhood sexual abuse. There are a lot of reasons that someone would wait to get treatment, but the decades separating them from their trauma are not an obstacle at all. In fact, in some ways it is easier treating this group than individuals whose event was less than a year ago—much of their identity around the trauma has been settled, and to some degree so has the meaning of the event in their lives.
Myth: I should be able to handle this myself
Often it takes more strength to get help than to struggle on alone, particularly for certain groups. Examples of people who may be especially reluctant to reach out are men, who’ve been conditioned by our culture to not express feelings and be vulnerable, marginalized populations who have a more difficult time finding someone who can relate to them, and those who have been burned by clinicians in the past. Getting help does not mean that you’re crazy or that you’ll always need help or that you failed in coping alone.
PTSD Therapy Myths
Myth: I feel so anxious, I just need to process this trauma and then I’ll be fine
Often, by the time that someone gets help, they are incredibly anxious to purge the memory and be done with it. And while that is a crucial step, it is not the only step that takes place. The treatment protocol agreed upon by the leading bodies of trauma research and treatment has three phases:
- Safety and coping
- Review of trauma memories (the processing piece)
- Integration
Depending on the severity of the trauma experience and the symptoms, the first phase can range from a few sessions (for single incident trauma in an otherwise highly functioning individual) to a year or more (for a survivor with years of complex trauma and severe dissociative symptoms). Talk with your trauma therapist about where you are in your treatment and what you can expect. While it’s not always possible to give an exact timeline, your therapist should be able to tell you how she thinks you’re doing and how you both will know that you are ready, such as what skills need to be developed before moving forward.
Myth: If I can’t remember the abuse, I won’t be able to process the trauma
There are actually several therapies, including evidence-based ones that do not rely on a coherent memory to process the trauma. The field is recognizing more and more that trauma is stored in the body and that trauma can by processed by helping the survivor connect with what their body is feeling.
I was at an EMDR training last year where the instructor shared a case study. Her client was processing memories of being locked in a small dark space for long periods of time as a small child. The client’s trauma memories were void of sight and sound. There was no coherent story. However, the client could remember the terror, and it was still present in the body. By connecting with the feelings, they were able to process out the trauma and the client ceased having PTSD symptoms.
No comments:
Post a Comment