Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) can be a very serious and debilitating condition that occurs after a person has been exposed to a terrifying event or ordeal in which grave physical danger happened or was threatened. The kinds of traumatic events triggering PTSD in people include violent personal assaults (rape, mugging), natural disasters (hurricanes, tornadoes), man-made disasters (bombings), accidents or military combat. People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair a person’s daily life. PTSD is a complicated illness by the act that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health.
PTSD is not a new disorder. There are many written accounts of similar symptoms that go back to ancient times. There is also clear documentation in the historical medical literature starting with the Civil War, when a PTSD-like disorder was known as “Ad Costa’s Syndrome.” There are also good descriptions of PTSD in medical literature based on combat veterans of World War II and on Holocaust survivors. In 1980, the American Psychiatric Association added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) nosologic classification scheme. The key to understanding PTSD is the concept of trauma. A traumatic event was seen as a catastrophic stressor that was outside the range of usual human experience. The original diagnosis was made due to events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters, and human-made disasters. They considered traumatic events to be clearly different from the painful stressors of every day events such as divorce, failure, rejection, serious illness, and financial reverses. Because all people handle stress on different levels it is very had to determine who will suffer from PTSD when exposed to traumatic events.
Diagnostic criteria for PTSD include a history of exposure to a traumatic event and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. A fifth criterion concerns duration of the symptoms. Recent data from the national comorbidity survey indicates PTSD prevalence rates are 5% and 10% respectively among American men and women (Kessler et al., 1996). Rates of PTSD are much higher in post-conflict settings such as Algeria (37%), Cambodia (28%), Ethiopia (16%), and Gaza (18%)(de Jong et al., 2001).
The first stressor criterion specifies that a person has been exposed to a catastrophic event involving actual or threatened death or injury. The second criterion, or intrusive recollection, includes symptoms that are distinctive and easily identified of PTSD. These emotions manifest in daytime fantasies, traumatic nightmares, and psychotic reenactments know as flashbacks. The third criteria, avoidant/numbing, consists of symptoms that reflect behavioral, cognitive, or emotional strategies the PTSD patients use in an attempt to reduce the likelihood that they will expose themselves to trauma-related stimuli. The fourth criteria, hyper-arousal, most closely resembles those seen in panic and generalized anxiety disorders. While symptoms such as insomnia and irritability are generic anxiety symptoms, hyper-vigilance and startle are more characteristic of PTSD. The fifth criteria, duration, specifies how long symptoms must persist in order to qualify for a PTSD diagnosis.
The last criteria, functional significance, specify that the survivor must experience significant social, occupational, or other distress as a result of these symptoms. Since 1980, there has been a great deal of attention devoted to the development of instruments for assessing PTSD. Keane and associates (1987) working, with Vietnam war-zone veterans, have developed both psychometric and psycho physiologic assessment techniques that have proven to be valid and reliable. Other investigators have modified such assessment instruments and used them with natural disaster victims, rape/incest survivors, and other traumatized individuals. Research has shown that PTSD can become a chronic psychiatric disorder and can persist for decades and sometimes for a lifetime. People with chronic PTSD often exhibit a course marked by remissions and relapses.
The many therapeutic approaches offered to PTSD patients are presented in Foa, Keane, and Freidman’s (2000) comprehensive book on treatment. The most successful interventions are cognitive-behavioral therapy (CBT) and medication. Excellent results have been obtained with some CBT combinations of exposure therapy and cognitive restructuring, especially with female victims of childhood or adult sexual trauma. Sertraline (Zoloft) and paroxetine (Paxil) are selective serotonin reuptake inhibitors (SSRI) that are the first medications to have received FDA approval as indicated treatments for PTSD. Perhaps the best therapeutic option for mildly to moderately affected PTSD patients is group therapy. In such a setting, the PTSD patient can discuss traumatic memories, PTSD symptoms, and functional deficits with others who have had similar experiences.
There is great interest in rapid interventions for acutely traumatized individuals, especially with respect to civilian disasters, military deployments, and emergency personnel (medical personnel, police, and firefighters). This has become a major policy and public health issue since the massive traumatization caused by the September 11 terrorist attacks on the World Trade Center. Currently there is controversy over which interventions work best during the immediate aftermath of a trauma. Research on critical incident stress debriefing, an intervention that is used widely, has brought disappointing results with respect to its efficacy to attenuate posttraumatic distress. Promising results have been shown with brief cognitive-behavioral therapy.
This involves working with cognitions to change emotions, thoughts, and behaviors. Exposure therapy is one form of cognitive-behavioral therapy that is unique to trauma treatment. It uses careful, repeated imagining of the trauma in a safe controlled context to help the survivor face and gain control of the fear and distress that was overwhelming during the trauma. In some cases trauma memories can be confronted all at once. For other individuals, it is safer to work up to the most severe trauma gradually by using relaxation techniques and by starting with less upsetting life stresses.
Complex PTSD (sometimes called “Disorder of extreme Stress”) is found among individuals who have been exposed to prolonged traumatic circumstances, especially during young childhood, such as childhood sexual abuse. Developmental research is revealing that many brain and hormonal changes may occur as a result of early, prolonged trauma, and these changes contribute to difficulties with memory, learning, and regulating impulses and emotions. Combined with a disruptive, abusive home environment that does not foster healthy interaction, these brain and hormonal changes may contribute to severe behavioral difficulties, emotional difficulties, and mental difficulties.
As adults, these individuals often are diagnoses with depressive disorders, personality disorders, or dissociative disorders. Treatment often takes much longer than with regular PTSD, and progresses at a slower rate, and requires a sensitive and structured treatment program by a trauma specialist.
With new research and medical developments happening at such a fast pace, the treatment plans for PTSD are constantly changing, but more importantly, the treatment is always geared towards each individual person.
De Jong, J., Komproe, T.V.M., Ivan, H., von Ommeren, M., El Masri, M., Khaled, N., van de Put, W., & somasundarem, D.J. (2001). Lifetime events and Posttraumatic Stress Disorder in 4 Postconflict settings. Journal of the American Medical Association, 286 (5), 555-562.
Freidman, M.J., Charney, D.S. & Deutch, A.Y. (1995) Neurobiological and clinical consequences of stress: From Normal Adaptation to PTSD.Philadelphia: Lippincott-Raven.
Keane, T.M., Wolfe, J., & Taylor, K.I. (1987) Post-traumatic Stress Disorder: Evidence for diagnostic validity and methods of psychological assessment. Journal of Clinical Psychology, 43, 32-43.
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M. & Nelson, C.B.(1996). Posttraumatic Stress Disorder in the National Comorbibity Survey. Archives of General Psychiatry, 52,1048-1060.