Posttraumatic Stress Disorder

Posttraumatic stress disorder (commonly known as PTSD) is a severe anxiety disorder characterized by adverse anxiety-related experiences, behaviors, and physiological responses that results from exposure to an event that causes psychological trauma. Examples of events that could lead to PTSD include the threat of harm or death to oneself or to someone else, or witnessing an event that overwhelms the individual’s ability to cope. Diagnostic symptoms for PTSD include flashbacks or nightmares, avoidance of associated stimuli, insomnia, extreme anger or sadness, and hyper-vigilance. These symptoms must last longer than one month and cause significant impairment in the individual’s everyday life to distinguish it from an acute stress disorder.

The first reports of PTSD were in the early 19th century when military medical doctors started diagnosing soldiers with “exhaustion” after the stress of battle. The only treatment for this “exhaustion” was to remove these soldiers from active duty until symptoms subsided, then return to battle. During the intense and frequently repeated stress, the soldiers became fatigued as a part of their body’s natural shock reaction. Other diagnoses that mirrored what we now know as PTSD include: railway spine, shell shock, stress syndrome, and traumatic war neurosis. In the 1970s doctors and researchers came to the modern day understanding of PTSD; however, research on this disorder is ongoing.

PTSD is caused by experiencing any of a wide range of traumatic events. Experiencing these events produces intense negative feelings of fear, helplessness or horror in the individual. These events include (but are not limited to): experiencing or witnessing childhood or adult physical, emotional, or sexual abuse; experiencing or witnessing physical assault, adult experiences of sexual assault, family violence, gang violence, accidents, drug addiction, illnesses, or medical complications; or employment in occupations exposed to war (such as soldiers) or disaster (such as emergency service workers). On the other hand, being exposed to a traumatic experience does not automatically indicate that the individual will develop PTSD. More so, it has been shown that the intrusive memories, such as flashbacks, nightmares, and the memories themselves, are greater contributors to the biological and psychological dimensions of PTSD than the event itself. These flashbacks cause the affected to have re-experiences of traumatic events that lack awareness of context and time, and make the individual feel as if it was happening in the present moment.

Evolutionary psychology leads to a root cause of PTSD, as it views different types of fears and reactions caused by fears as adaptations that may have been historically useful in order to avoid or cope with various threats, and PTSD may correspond to and be caused by the over-activation of such fear circuits. There may also be evolutionary explanations for differences in resilience to traumatic events. The biochemical changes caused by PTSD differ from other psychiatric disorders. The symptoms of PTSD generally result from the traumatic event causing an over-reactive adrenaline response, which then creates deep neurological patterns in the brain. These patterns are what keep the individual at emotional highs during future fearful situations. Additionally, most people with PTSD show low levels of cortisol secretion and high catecholamine secretion. This differs from the normative fight-or-flight response, in which both catecholamine and cortisol levels are elevated after exposure to a stressor.

There are certain risk factors that predispose an individual to developing PTSD. While 50-90 percent of people encounter a significant trauma over a lifetime, only about 20-30 percent will develop PTSD, and over half of these people will recover without treatment. Vulnerability to PTSD can stem from early childhood developmental experiences. A person that never established secure relationships and learned coping skills as a young child is more likely to develop PTSD after being exposed to a traumatic experience than one that developed good coping skills and has a support network.

The diagnostic criteria for PTSD, as summarized in the DSM-IV-TR, is: the exposure to a traumatic event, persistent re-experiencing, persistent avoidance and emotional numbing, persistent symptoms of increased arousal not present before, significant impairment, and duration of symptoms longer than one month.

Successful management of PTSD is a combination of cognitive behavioral therapy, some medications, and prevention techniques. The first form of preventive treatment is a psychological debriefing, which is given to the individual directly following an event. It consists of interviews that allow individuals to directly confront the event and share their feelings with the counselor and others involved. These types of debriefings are commonly seen among emergency service workers after a traumatic event. The therapy that has been proven most effective for PTSD is cognitive behavioral therapy. CBT seeks to change the way a trauma victim feels and acts by changing the patterns of thinking or behavior that are responsible for negative emotions. The individual learns to identify thoughts that induce fear or anxiety and replace them with less stressful thoughts. CBT has been proven to be an effective treatment for PTSD and is currently considered the standard of care for PTSD by the United States Department of Defense. Various forms of exposure therapy and eye movement desensitization and reprocessing (EMDR) have also been proven to be extremely beneficial.

Medications have also been shown to help reduce the symptoms of PTSD; however, there is no single drug treatment for the disorder. Treatment of hydrocortisone or propranolol shortly after a traumatic event has been shown to decrease the likelihood that the patient will suffer from PTSD. Medications that have successfully helped manage PTSD symptoms include (but are not limited to): selective serotonin reuptake inhibitors(SSRIS), such as citalopram, paroxetine, and sertraline; alpha-adrenergic antagonists, such as prazosin;  atypical antidepressants, such as nefazodone; beta blockers, such as propranolol; and benzodiazepines and glucocorticoids.

Image Caption: A mask, painted by a Marine who attends art therapy to relieve post-traumatic stress disorder symptoms, is displayed at an art expo May 3. Credit: Cpl. Andrew Johnston/Wikipedia