What is post-traumatic stress disorder?

Causes and Symptoms

Post-traumatic stress disorder (PTSD) is believed to manifest following either direct or indirect exposure to actual or threatened death, serious injury, or sexual violence. Events such as natural disasters (earthquakes, mudslides, fires, floods, tsunamis, tornados), war, domestic violence, rape, violent crime, accidents, and medical procedures may trigger the development of PTSD. PTSD is included as part of a new chapter on trauma and stress disorders in the 2013 revision of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5. (The DSM-5 is compiled by the American Psychiatric Association and describes all currently identified mental health problems that may receive a formal medical diagnosis in the United States.) According to the US Department of Veterans Affairs's National Center for PTSD's 2015 data, approximately seven or eight out of every one hundred people will experience PTSD at some point in their lives and about eight million people suffer from PTSD annually.

PTSD involves reexperiencing the trauma, avoidance of things that are reminders of the trauma, and an uncomfortable state of arousal usually connected to readiness to avoid reexperiencing a trauma. Reexperiencing includes recurrent and intrusive thoughts, recurrent distressing dreams and nightmares, feeling as if the event is happening again, intense psychological distress at exposure to any reminders (internal or external) of the event, or intense physical reactivity to any reminders of the event. Persistent avoidance includes anything associated with the event as well as a numbing of general responsiveness. Such numbing may be indicated by several of the following: avoiding thoughts, feelings, or conversations associated with the event; avoiding activities, places, or people that are reminders of the event; forgetting an important aspect of the event; experiencing markedly diminished interest or participation in significant activities; feeling detached or estranged from others; having a restricted range of feelings, such as not being able to love; or feeling that the future is foreshortened. Increased arousal includes at least two of the following: difficulty with sleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; self-destructive or reckless behavior; or exaggerated startle response. The reexperiencing, avoidance, and arousal start after the traumatic event, last more than one month, and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The course of the disorder varies, with some individuals not experiencing symptoms until years later, but most individuals experience symptoms within three months of the initial trauma. If the trauma occurs early in life, it may have profound effects on stress response throughout the individual’s lifetime.

Persons with PTSD may describe painful guilt feelings about surviving when others did not or about what they had to do to survive. Their phobic avoidance of situations or activities that resemble or symbolize the original trauma may interfere with interpersonal relationships and lead to marital conflict, divorce, or job loss.

The likelihood of developing PTSD increases as intensity and physical proximity to the event increase. Recent immigrants from countries where there is considerable social unrest and civil conflict may have elevated rates of PTSD. The disorder may occur at any age. Women are more likely to develop PTSD than men.

Not everyone who experiences a significant trauma will develop PTSD. Individual differences in terms of immediate post-trauma assistance and support, long-term social support, stress response, physical health, and other biological factors may explain a lack of occurrence in some individuals.

Treatment and Therapy

Treatments for PTSD include individual therapy, group therapy, antianxiety and antidepressant drugs, and eye movement desensitization and reprocessing (EMDR). Combinations of therapies can also be effective. In general, the sooner the victim of PTSD receives treatment, the greater are the chances of complete recovery. It is important to note, however, that complex techniques such as trauma debriefing and critical incident debriefing should be attempted only by well-trained persons. Discussing traumatic events in a way that is not sensitive to the experience of the victim may retraumatize them, so caution is advised. For untrained persons, the best way to help someone affected by a trauma is to help them get to a qualified treatment professional as quickly as possible. This is especially important because research has suggested that treatment delivered soon after the trauma may reduce the overall negative impacts of the trauma.

Psychotherapy can help the person come to grips with the traumatic event. Different approaches are used, including exposure (or imagined) therapy, anxiety management/relaxation training, cognitive therapy, and supportive psychotherapy. Also, hypnosis, journaling (such as thought diaries and grief letters), creative arts and art therapy, and a critical-incident stress debriefing may be used in treating PTSD, either alone or in conjunction with psychotherapy.

Group therapy, in which victims of PTSD can share their experiences and gain support from others, is especially helpful. Groups are typically small (six to eight persons) and are often composed of individuals who have undergone similar experiences. Also, marital and family therapy or parent training may be used in treating PTSD.

In general, the goals of psychotherapy include facilitating victims’ emotional engagement with the trauma memory, helping them organize a personal trauma narrative, assisting them in correcting dysfunctional cognitions that often follow trauma, helping them develop increased trust in others, and decreasing their emotional and social isolation. The therapist typically provides empathy, validation, safety, consistency, and sensitivity to cultural and ethnic identity issues.

Antianxiety and antidepressant drugs can relieve the physiological symptoms of PTSD. The major pharmacological agents include benzodiazepines, serotonin
receptor partial agonists, tricyclic antidepressants, MAO inhibitors, and selective serotonin reuptake inhibitors (SSRIs). Because of the many biological abnormalities presumed to be associated with PTSD, and because of the overlap between symptoms of PTSD and other comorbid disorders, almost every class of psychotropic agent has been administered to PTSD patients. Whether it includes individual or group therapy, drugs, or some combination of these three, the treatment approach must be tailored to the individual PTSD sufferer and his or her unique situation.

EMDR is a newer therapy for PTSD. It combines many aspects of the other therapies described and works to facilitate reprocessing of traumatic information and experience. Guided discussion and therapeutic work may involve specific eye movements while remembering different aspects of the traumatic event. It is suggested that this type of activity creates an orienting response that facilitates trauma processing. The technique requires a high level of skill and sophistication and should be used only by appropriately trained professionals. EMDR is very highly recommended for trauma and remains a topic of great research interest.

It is important to remember that PTSD, like many other mental health disorders, may not occur in isolation. Comorbidity, or the presence of more than one disorder, is the rule rather than the exception with PTSD. Depressive disorders, substance use disorders, and other anxiety disorders are the disorders most likely to occur with PTSD. Treatment must address the comorbid conditions when they are present. PTSD can be reliably assessed through semi-structured interview and self-report measures. Treatment typically occurs on an outpatient basis, but it also may occur on an inpatient basis if the symptoms are severe.

Perspective and Prospects

PTSD was observed in World War I after many soldiers had intense anxiety reactions to the horrors they were experiencing. At that time, it was called combat neurosis, shell shock, or battle fatigue. It was formally diagnosed as an anxiety-based personality disorder in the 1960s among Vietnam War veterans, but it is no longer considered a personality disorder and is instead seen as a trauma or stress related disorder. It is also now known that traumatic events may include not only war but also violent personal or sexual assault, kidnapping, terrorist attacks, torture, natural or human-made disasters, severe automobile accidents, or different aspects of life-threatening illness. For children, sexually traumatic events may include sexual experiences that were developmentally inappropriate, even if no threatened or actual violence occurred. PTSD may be especially severe when the trauma is of human origin (for example, torture) and directly related to damage to one’s person.

Promising research identifying change to the stress response system in younger persons following trauma as well as gender differences in trauma response are expected to fuel greater understanding of the mechanisms of trauma response. Such knowledge will in turn be useful for developing new medical, biological, and interpersonal therapies for children and adults and for both women and men.

As part of an effort to bring greater awareness to this serious disorder, the US Senate proclaimed in 2010 that June 27th would serve as National PTSD Awareness Day. In addition, the National Center for PTSD declared that the entire month of June would be PTSD Awareness Month.

Because more and more states have legalized marijuana for medical use, debates have occurred over whether PTSD should fall under the category of conditions that qualify for a prescription for this treatment. Studies have been underway to officially determine whether marijuana has any effectiveness in treating PTSD, and a handful of states, such as New Mexico and Maine, have started allowing doctors and Veterans Affairs Hospitals to begin prescribing medical marijuana in this capacity.

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Arlington: Amer. Psychiatric Assoc., 2013. Print.

Araújo, A. X., et al. "Comorbid Depressive Symptoms in Treatment-Seeking PTSD Outpatients Affect Multiple Domains of Quality of Life." Comprehensive Psychiatry 55.1 (2014): 56–63. Print.

Bremner, Douglas J. Does Stress Damage the Brain? Understanding Trauma-Related Disorders from a Neurological Perspective. New York: Norton, 2002. Print.

"Diseases and Conditions: Post-Traumatic Stress Disorder (PTSD)." Mayo Clinic. Mayo Foundation for Medical Education and Research, 15 Apr. 2014. Web. 20 Aug. 2014.

Emerson, David. Trauma-Sensitive Yoga in Therapy: Bringing the Body into Treatment. New York: Norton, 2015. Print.

Foa, Edna B., Terence M. Keane, and Matthew J. Friedman, eds. Effective Treatments for PTSD: Practice Guidelines from the Society for Traumatic Stress Studies. 2nd ed. New York: Guilford, 2009. Print.

Ford, Julian, and Christine A. Courtois. Treating Complex Traumatic Stress Disorders in Children and Adolescents: Scientific Foundations and Therapeutic Models. New York: Guilford, 2013. Print.

Foreman, Edward, and Jay Fuller. Post-Traumatic Stress Disorder: New Research. New York: Nova Science, 2013. Print.

Horowitz, Mardi J., ed. Essential Papers on Post-Traumatic Stress Disorder. New York: New York UP, 1999. Print.

"How Common Is PTSD?" National Center for PTSD. US Dept. of Veterans Affairs, 17 June 2015. Web. 5 Aug. 2015.

Levi, Ofir. "Individual Therapy via the Phenomenon of Hope for Treating Chronic and Complex PTSD." Psychoanalytic Social Work 20.0 (2013): 150–73. Print.

McNally, Richard J. Remembering Trauma. Rev. ed. Cambridge: Harvard UP, 2005. Print.

Rizzo, Johnna. "Could Pot Help Veterans with PTSD?" Newsweek. Newsweek, 2 Aug. 2015. Web. 5 Aug. 2015.

Schiraldi, Glenn R. Post-Traumatic Stress Disorder Sourcebook. 2nd ed. New York: McGraw, 2009. Print.

Shapiro, Francine. Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy. Emmaus: Rodale, 2012. Print.

"What Is Post-Traumatic Stress Disorder (PTSD)?" National Institute of Mental Health. NIH, n.d. Web. 20 Aug. 2014.