Post-Traumatic Stress Disorder

Although it is always kicked off by a terrifying event, PTSD may have roots in biology as much as in experience. Exposure therapy and other psychotherapy, and medication, all have a role in treating the flashbacks, anger outbursts, physical distress and other signs of the 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.

Anyone who has gone through a life-threatening event can develop PTSD including 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 in as many as 10% of Gulf War (Desert Storm) veterans, about 6% to 11% of veterans of the Afghanistan war, and about 12% to 20% of veterans of the Iraq war.

Other factors in a combat situation can add more stress to an already stressful situation and may contribute to PTSD and other mental health problems. These factors include what you do in the war, the politics around the war, where it's fought, and the type of enemy you face.Another cause of PTSD in the military can be military sexual trauma (MST). This is any sexual harassment or sexual assault that occurs while you are in the military. MST can happen to men and women and can occur during peacetime, training, or war. Among veterans using VA health care, about 23 out of 100 women (23%) reported sexual assault when in the military, 55 out of 100 women (55%) and 38 out of 100 men (38%) have experienced sexual harassment when in the military.

PTSD is diagnosed when the stress symptoms following exposure have persisted for at least a month. When symptoms develop immediately after exposure, the condition may be called acute stress disorder.

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• Emotional "numbing," or feeling as though you don't care about anything • Feelings of detachment • Lack of interest in normal activities • Less expression of moods • Sense of having no future

Arousal symptoms:

• Sleeping Difficulties including trouble falling or staying asleep• Irritability and outbursts of anger• Difficulty concentrating• Feeling easily startled• Excess Awareness (hypervigilance)

Medical or emotional issues:

• Stomach upset, trouble eating• Trouble sleeping & exhaustion• Pounding heart, rapid breathing, edginess• Severe headache if thinking of the event, sweating• Failure to engage in exercise, diet, safe sex, regular health care• Excess smoking, alcohol, drugs, food• Worsening of chronic medical problems

Symptoms of Complex PTSD are quite different. The first requirement for the diagnosis is that the individual experienced a prolonged period (months to years) of total control by another. The other criteria are symptoms that tend to result from chronic victimization. Those symptoms include alterations in emotional regulation which may include persistent sadness, suicidal thoughts, explosive anger, or inhibited anger, alterations in consciousness such as forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body as well as changes in self-perception which may include a sense of helplessness, shame, guilt, stigma, and a sense of being completely different than other human beings. Other symptoms are alterations in the perception of the perpetrator which may include attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge and alterations in relations with others which may include variations in personal relations including isolation, distrust, or a repeated search for a rescuer. Finally, changes in one's system of meanings may include a loss of sustaining faith or a sense of hopelessness and despair.

Causes

The cause of PTSD is unknown, but psychological, genetic, physical, and social factors are involved. PTSD changes the body's response to stress. It affects the stress hormones and chemicals that carry information between the nerves (neurotransmitters). Having been exposed to trauma in the past may increase the risk of PTSD. 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.

Many factors play a part in whether a person will get PTSD. 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. Some of these risk and resilience factors are present before the trauma and others become important during and after a traumatic event. Risk factors 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 and 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 and being able to act and respond effectively despite feeling fear.

Treatments

Treatment for PTSD typically begins with a detailed evaluation, and development of a treatment plan that meets the unique needs of the survivor. The main treatments for people with PTSD are psychotherapy ("talk" therapy), medications, or both. Everyone is different, 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 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. PTSD-specific-treatment begins only when the survivor is safely removed from the crisis situation. Other ongoing problems can include panic disorder, depression, substance abuse, and feeling suicidal.

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

The U.S. Food and Drug Administration (FDA) has approved two medications for treating adults with PTSD, sertraline (Zoloft) and paroxetine (Paxil) which are selective serotonin reuptake inhibitors (SSRIs). Both of these medications are antidepressants, which are also used to treat depression. They may help control PTSD symptoms such as sadness, worry, anger, and feeling numb inside. Taking these medications may make it easier to go through psychotherapy. 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. An adjustment in dosage or a switch to another SSRI will usually correct problems. It is important to discuss side effects with your doctor.

Sometimes people taking these medications have side effects. The effects can be annoying, but they usually go away. However, medications affect everyone differently. Any side effects or unusual reactions should be reported to a doctor immediately.

The most common side effects of antidepressants like sertraline and paroxetine are:

• Headache, which usually goes away within a few days.• Nausea (feeling sick to your stomach), which usually goes away within a few days.• Sleeplessness or drowsiness, which may occur during the first few weeks but then goes away. Sometimes the medication dose needs to be reduced or the time of day it is taken needs to be adjusted to help lessen these side effects.• Agitation (feeling jittery).• Sexual problems, which can affect both men and women, including reduced sex drive, and problems having and enjoying sex.

There are other types of medications which doctors may also prescribe, such as the following ones. There is little information on how well these work for people with PTSD. Benzodiazepines may be given to help people relax and sleep. People who take benzodiazepines may have memory problems or become dependent on the medication. Antipsychotics are usually given to people with other mental disorders, like schizophrenia. People who take antipsychotics may gain weight and have a higher chance of getting heart disease and diabetes. Other antidepressants like fluoxetine (Prozac) and citalopram (Celexa) can help people with PTSD feel less tense or sad. For people with PTSD who also have other anxiety disorders or depression, antidepressants may be useful in reducing symptoms of these co-occurring illnesses.

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

Psychotherapy is "talk" therapy. It involves talking with a mental health professional to treat a mental illness. Psychotherapy can occur one-on-one or in a group. Talk therapy treatment for PTSD usually lasts 6 to 12 weeks, but can take more time. Research shows that support from family and friends can be an important part of therapy.

Many types of psychotherapy can help people with PTSD. Some types target the symptoms of PTSD directly. Other therapies focus on social, family, or job-related problems. The doctor or therapist may combine different therapies depending on each person's needs.

One helpful therapy is called cognitive behavioral therapy, or CBT. There are several parts to CBT, including:

• Exposure therapy: This therapy helps people face and control their fear. It exposes them to the trauma they experienced in a safe way. It uses mental imagery, writing, or visits to the place where the event happened. The therapist uses these tools to help people with PTSD cope with their feelings.• Cognitive restructuring: This therapy helps people make sense of the bad memories. Sometimes people remember the event differently than how it happened. They may feel guilt or shame about what is not their fault. The therapist helps people with PTSD look at what happened in a realistic way.• Stress inoculation training: This therapy tries to reduce PTSD symptoms by teaching a person how to reduce anxiety. Like cognitive restructuring, this treatment helps people look at their memories in a healthy way.

Other types of treatment can also help people with PTSD. People with PTSD should talk about all treatment options with their therapist.

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

• Teach about trauma and its effects.• Use relaxation and anger control skills.• Provide tips for better sleep, diet, and exercise habits.• Help people identify and deal with guilt, shame, and other feelings about the event.• Focus on changing how people react to their PTSD symptoms. For example, therapy helps people visit places and people that are reminders of the trauma.

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. This therapy helps a person understand how the past affects the way you feel now. 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.

Family therapy is a type of counseling that involves your whole family. PTSD can affect your whole family. Your kids or your partner may not understand why you get angry sometimes, or why you're under so much stress. They may feel scared, guilty, or even angry about your condition. In family therapy, a therapist helps you and your family to communicate, maintain good relationships and cope with tough emotions. Your family can learn more about PTSD and how it is treated. In such therapy, each person can express his or her fears and concerns. It's important to be honest about your feelings and to listen to others. You can talk about your PTSD symptoms and what triggers them. You also can discuss the important parts of your treatment and recovery. By doing this, your family will be better prepared to help you. You may consider having individual therapy for your PTSD symptoms and family therapy to help you with your relationships.

Sources

  • American Journal of Psychiatry
  • Journal of Psychopharmacology
  • Journal of Traumatic Stress
  • National Comorbidity Survey Replication
  • Biological Psychiatry
  • Annual Review of Psychology
  • National Institutes of Health - National Library of Medicine
  • National Institute of Mental Health
  • US Department of Health and Human Services
  • Hippocampal Volume in Women Victimized by Childhood Sexual Abuse.
  • National Center for PTSD, U.S. Department of Veterans Affairs
  • Canadian Journal of Psychiatry
  • Psychiatric Clinics of North America
Last reviewed 11/24/2014