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Post-traumatic stress disorder

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Post-traumatic stress disorder
SpecialtyPsychiatry, clinical psychology Edit this on Wikidata

Post-traumatic stress disorder (PTSD) is a term for certain psychological consequences of exposure to, or confrontation with, stressful experiences that the person experiences as highly traumatic. [1] The experience must involve actual or threatened death, serious physical injury, or a threat to physical and/or psychological integrity. It is occasionally called post-traumatic stress reaction to emphasize that it is a routine result of traumatic experience rather than a manifestation of a pre-existing psychological weakness on the part of the patient.

It is possible for individuals to experience Traumatic Stress without manifesting a full-blown Post Traumatic Stress Disorder, as indicated in the Diagnostic and Statistical Manual of Mental Disorders.

Symptoms of PTSD can include the following: Nightmares, flashbacks, emotional detachment or numbing of feelings (emotional self-mortification or dissociation), insomnia, avoidance of reminders and extreme distress when exposed to the reminders ("triggers"), irritability, hypervigilance, memory loss, and excessive startle response.

Experiences likely to induce the condition include:

For most people, the emotional effects of traumatic events will tend to subside after several months. If they last longer, then diagnosing a psychiatric disorder is generally advised. Most people who experience traumatic events will not develop PTSD. PTSD is thought to be primarily an anxiety disorder, and should not be confused with normal grief and adjustment after traumatic events. There is also the possibility of simultaneous suffering of other psychiatric disorders (i.e. comorbidity). These disorders often include major depression, general anxiety disorder and a variety of addictions.

PTSD may have a "delayed onset" of years, or even decades, and may even be triggered by a specific body movement if the trauma was stored in the procedural memory, by another stressful event, such as the death of a family member or someone else close, or by the diagnosis of a life-threatening medical condition.

Also, doctors have conducted clinical studies indicating traumatized children with PTSD are more likely to later engage in criminal activities than those who do not have PTSD.

Background

Psychological distress after trauma was reported in 1900 BCE by an Egyptian physician who described hysterical reactions to trauma (Veith 1965). Hysteria was also related to "traumatic reminiscences" a century ago (Janet 1901). At that time, Sigmund Freud's pupil, Kardiner, was the first to describe what later became known as post-traumatic stress disorder symptoms (Lamprecht & Sack 2002).

Hippocrates utilized a homeostasis theory to explain illness, and stress is often defined as the reaction to a situation that threatens the balance or homeostasis of a system (Antonovsky 1981). The situation causing the stress reaction is defined as the "stressor", but the stress reaction, and not the stressor is what jeopardizes the homeostasis (Aardal-Eriksson 2002). Post-traumatic stress can thus be seen as a chemical imbalance of neurotransmitters, according to stress theory.

However, PTSD in and of itself is a relatively recent diagnosis in psychiatric nosology, first appearing in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. It is said development of the PTSD concept partly has socio-economic and political implications (Mezey & Robbins 2001). War veterans are the most publicly-recognised victims of PTSD: long-term psychiatric illness was formally observed in World War 1 veterans but did not appear to enter the public consciousness until the aftermath of the Vietnam War. However, victims had difficulties receiving economic compensation since there was no psychiatric diagnosis available by which veterans could claim indemnity.

This situation has changed during the last two decades, and PTSD is now one of several psychiatric diagnoses for which a veteran can receive compensation, such as a war veteran indemnity pension, in the US (Mezey & Robbins 2001). However this practice is under review in the United States. In 2005, the US Department of Veterans Affairs Veterans Benefits Administration began a review of claims after it noted a reported 30% increase in PTSD claims in recent years. Because of the negative effect on the budget and the apparent inconsistency in the rate of rewards by different rating offices of the Department, they undertook this review. There was broad political backlash from veterans rights groups and some highly publicized suicides by veterans who feared loss of their benefits (which served often as their only source of income). In response to these events, on November 10, 2005, the Secretary of the US Department of Veterans affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for post-traumatic stress disorder..."

However the feeling of reprieve experienced by some veterans and veteran advocates was short-lived. Soon thereafter, the Department of Veterans Affairs announced that it had contracted with the Institute of Medicine (IOM) to conduct a[nother] study on Post-Traumatic Stress Disorder (PTSD). The Committee will review and comment on the objective measures used in the diagnosis of PTSD and known risk factors for the development of PTSD. The committee will also "review the utility and objectiveness of the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), and will comment on the validity of current screening instruments and their predictive capacity for accurate diagnoses." The committee will also "review the literature on various treatment modalities (including pharmacotherapy and psychotherapy) and treatment goals for individuals with PTSD [and] ... comment on the prognosis of individuals diagnosed with PTSD and existing comorbidities." Some veteran advocates expressed concern that this was merely a backdoor method of reducing benefits to veterans who have served and currently service in Iraq and the Persian Gulf. On the other hand, conservative groups such as psychiatrist Sally Satel, who is affiliated with the conservative American Enterprise Institute, say "an underground network advises veterans where to go for the best chance of being declared disabled." The institute organized a recent meeting to discuss PTSD among veterans. Read more on the politics of PTSD at [1]

In sum, the diagnosis is highly controversial because of the strong connection with compensation seeking behavior and efforts and the uncertainty about the effect of this on objective diagnosis of those who may have been subjected to trauma. See recent article at [2]

While PTSD-like symptoms were recognized in combat veterans following many historical conflicts, the modern understanding of the condition dates to the 1980s. Reported OEF/OIF cases of combat-PTSD incidents are currently being compiled in ePluribus Media's PTSD Timeline: [3]

Diagnostic Criteria

The diagnostic criteria for PTSD, according to Diagnostic and Statistical Manual of Mental Disorders -IV (DSM-IV), are stressors listed from A to F.

Due to copyright issues and editorial concerns the reference to the DSM-IV-TR is outlinked. The current diagnostic criteria for the PTSD published in the Diagnostic and Statistical Manual of Mental Disorders may be found here:

DSM-IV-TR Diagnostic Criteria: Post-traumatic stress disorder

Notably, the stressor criterion A is divided into two parts. The first (A1) requires that "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others." The second (A2) requires that "the person’s response involved intense fear, helplessness, or horror." The DSM-IV A criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience." Since the introduction of DSM-IV, the number of possible PTSD-traumas has increased, and one study suggests that the increase is around 50% (Breslau & Kessler 2001).

Symptoms and their possible explanations

Symptoms can include general restlessness, insomnia, aggressiveness, depression, dissociation, emotional detachment, or nightmares. A potential symptom is the memory loss about an aspect of the traumatic event. Amplification of other underlying psychological conditions may also occur. Young children suffering from PTSD will often enact aspects of the trauma through their play, and may often have nightmares that lack any recognizable content.

One patho-psychological way of explaining PTSD is by viewing the condition as secondary to deficient emotional or cognitive processing of a trauma (Cordova 2001). This view also helps to explain the three symptom clusters of the disorder (Shalev 2001):

Intrusion: Since the sufferer cannot process difficult emotions in a normal way, they are plagued by recurrent nightmares, or daytime flashbacks, while realistically re-experiences the trauma. These re-experiences are characterized by high anxiety levels, and make up one part of the PTSD symptom cluster triad called intrusive symptoms.

Hyperarousal: PTSD is also characterized by a state of nervousness with the organism being prepared for "fight or flight". The typical hyperactive startle reaction, characterized by "jumpiness" in connection with high sounds or fast motions, is typical for another part of the PTSD cluster called hyperarousal symptoms, and could also be secondary to an incomplete processing.

Avoidance: The hyperarousal and the intrusive symptoms are eventually so distressing that the individual strives to avoid contact with everything, and everyone, even to their own thoughts, that can arouse memories of the trauma and thus cause the intrusive and hyperarousal states to go on. The sufferer isolates themselves, becoming detached in their feelings with a restricted range of emotional response, and can experience so-called emotional detachment ("numbing"). This avoidance behavior is the third and most important part of the symptom triad that makes up the PTSD criteria.

Biology of PTSD

Neurochemistry

PTSD displays biochemical changes in the brain and body, which are different from other psychiatric disorders such as major depression.

In PTSD patients, the dexamethasone cortisol suppression is strong, while it is weak in patients with major depression. In most PTSD patients the urine secretion of cortisol is low, at the same time as the catecholamine secretion is high, and the norepinephrine/cortisol ratio is increased. Brain catecholamine levels are low, and corticotropin-releasing factor (CRF) concentrations are high. There is also an increased sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis, with a strong negative feedback of cortisol, due to a generally increased sensitivity of cortisol receptors (Yehuda, 2001).

The response to stress in PTSD is abnormal with long-term high levels of norepinephrine, at the same time as cortisol levels are low, a pattern associated with facilitated learning in animals. Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response (Yehuda 2002). With this deduction follows that the clinical picture of hyperreactivity and hyperresponsiveness in PTSD is consistent with the sensitive HPA-axis.

Swedish United Nations soldiers serving in Bosnia with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels (Aardal-Eriksson 2001).

Another possible factor in PTSD is that a persistence of depressive symptoms may be caused by an underlying biochemical disorder, associated with insulin resistance (dysglycemia), that can be treated by a hypoglycemic diet.

Neuroanatomy

In animal research as well as human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. Neuroimaging studies in humans have revealed both morphological and functional aspects of PTSD. The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex and the hippocampus. Further animal and clinical research into the amygdala and fear conditioning may suggest additional treatments for the condition.

Prevalence

PTSD may be experienced following any traumatic experience, or series of experiences which satisfy the criteria, and that do not allow the victim to readily recuperate from the detrimental effects of stress. It is believed that of those exposed to traumatic conditions between 5% (life threatening disease such as cancer) and 80% (rape) will develop PTSD depending on the severity of the trauma and personal vulnerability.

In peacetime, 30% of those that suffer will go on to develop a chronic condition; in wartime, the levels of disorder are believed to be higher.

In recent history, the Indian Ocean Tsunami Disaster, which took place December 26, 2004 and took hundreds of thousands of lives, as well as the September 11, 2001 attacks on the World Trade Center and The Pentagon, may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as The Red Cross and the Salvation Army provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder.

Other agencies, such as the National Meditation Center for World Peace [4], have created special programs. The NMC trains agencies such as crisis centers NGOs and works with international agencies to prevent trauma to children.

Cancer as PTSD-trauma

PTSD is normally associated with trauma such as violent crimes, rape, and war experience. However, there have been a growing number of reports of PTSD among cancer survivors and their relatives (Smith 1999, Kangas 2002). Most studies deal with survivors of breast cancer (Green 1998, Cordova 2000, Amir & Ramati 2002), and cancer in children and their parents (Landolt 1998, Stuber 1998), and show prevalence figures of between five and 20%. Characteristic intrusive and avoidance symptoms have been described in cancer patients with traumatic memories of injury, treatment, and death (Brewin 1998). There is yet disagreement on whether the traumas associated with different stressful events relating to cancer diagnosis and treatment actually qualify as PTSD stressors (Green 1998). Cancer as trauma is multifaceted, includes multiple events that can cause distress, and like combat, is often characterized by extended duration with a potential for recurrence and a varying immediacy of life-threat (Smith 1999).

Treatment

Early intervention after a traumatic incident, known as Critical incident stress Management (CISM) is often used to reduce traumatic effects of an incident, and potentially prevent a full-blown occurrence of PTSD.

There have been scores of treatments suggested for the treatment of PTSD. One technique specifically targeted at the disorder is Eye Movement Desensitisation and Reprocessing (EMDR) [2]. Traumatic Incident Reduction is another, more controversial targeted method of treatment.

Relationship based treatments are also often used. Johnson, S., (2002). Emotionally Focused Couples Therapy with Trauma Survivors. NY: Guilford, is one example. These, and other approaches, such as Dyadic Developmental Psychotherapy use attachment theory and an attachment model of treatment. The treatment of complex trauma often requires a multi-modal approach

PTSD is usually treated by a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and psychotropic drug therapy (antidepressant or atypical antipsychotics, e.g. brand names such as Prozac (fluoxetine), Effexor (venlafaxin), Zoloft (sertraline), Remeron (mirtazapine), Zyprexa (olanzapine), or Seroquel (quetiapine)). Talk therapy may prove useful, but only insofar as the individual sufferer is enabled to come to terms with the trauma suffered and successfully integrate the experiences in a way that does not further damage the psyche. Forbes, et al, (2001) [3] have shown that a technique of "rewriting" the content of nightmares through imagery rehearsal so that they have a resolution can not only reduce the nightmares but also other symptoms. The US Food and Drug Agency (FDA) recently approved a clinical protocol that combines the drug MDMA ("Ecstasy") with talk therapy sessions.

Basic counseling for PTSD includes education about the condition and provision of safety and support (Foa 1997). Cognitive therapy shows good results (Resick 2002), and group therapy may be helpful in reducing isolation and Stigma (Foy 2002).

Dr. Jan Bastiaans of the Netherlands has developed a form of psychedelic psychotherapy involving LSD, with which he has successfully treated concentration camp survivors who suffer from PTSD.[5]

PTSD is often co-morbid with other psychiatric disorders such as depression, substance abuse and other addictive behaviors. Currently under scrutiny is the inclusion of Complex Post Traumatic Stress in the 2006 revision of the DSM-IV-TR. This is a variant of PTSD that includes the breakthrough of Borderline Personality traits.

Law

If the acts and omissions of an individual suffering from PTSD result in consequences that breach the criminal law, there may be levels of confusion that prevent the formation of the relevant mens rea (the Latin for "guilty mind") so mistake or reasonable excuse may be a defence. In more extreme cases, the defence of automatism may be available, with particular conditions discussed at automatism (case law). But there is a danger that although the initial cause of the disorder will be external, it may produce an internal defect of reason or an abnormality of mind within the meaning of the M'Naghten Rules (redefined as a mental disorder defence in some criminal jurisdictions) that define insanity as an excuse. The difference is that whereas defences that negate the mens rea and automatism result in an acquittal, insanity or mental disorder leaves the "offender" available for sentencing by the court. In the event that a death has resulted, diminished responsibility may be available as an alternative to insanity. This defence reduces what would otherwise have been murder to manslaughter. For a detailed discussion of a sometimes related condition, see battered woman syndrome and, more generally, the abuse defense in the U.S.

Notable people said to have experienced PTSD

  • Richard Aldington, English poet, writer, and husband to writer and poet Hilda Doolittle, was said to have suffered tremendously from PTSD following World War I.
  • Roméo Dallaire, retired Lieutenant-General and current Canadian Senator, suffers from PTSD as a result of his presence in Rwanda during the 1994 genocide. His suffering was so acute it led him close to suicide before he started to receive treatment.
  • Tim Fischer, while the deputy prime minister of Australia, had to be escorted from a fireworks display after having flashbacks of the Vietnam War.
  • Karel Kinsky, a prince from the Austro-Hungarian empire, was believed to have suffered from PTSD after serving extensively on the Russian front during World War I.
  • Audie Murphy, the most decorated American soldier in history at the time of World War II (he received thirty-three awards, including the Medal of Honor), Hollywood actor (he starred as himself in the 1955 film version of his autobiography To Hell and Back, in addition to films such as 1951's The Red Badge of Courage, 1957's Night Passage, and 1960s The Unforgiven), and songwriter (he wrote songs for Dean Martin, among others), suffered from PTSD as a result of his experience in WWII. According to his first wife, actress Wanda Hendrix, he suffered terrible nightmares and always slept with a gun under his pillow. Murphy was one of the first people to actually speak out publicly about PTSD, and during the Vietnam War he called for more government funding to care for the returning veterans and to research the condition.
  • Marshal Ney, one of Napoleon Bonaparte's most notable commanders, is believed to have suffered from symptoms of PTSD. The decisions he made towards the end of his career were questionable, including those made during the Battle of Waterloo. It is suspected by most scholars that his exposure to extreme combat conditions eventually began to erode his mental capacities. He gained his biggest notoriety for leading rearguard actions during Napoleon's retreat from Moscow in 1812.

Non-Fiction

In this war diary, Milligan, one of Britain's greatest post-war comedians, details his descent into madness during the Italian campaign of World War II. The sequel, "Where Have All the Bullets Gone?", describes the unsympathetic treatment he received at the hands of military doctors.

PTSD in fictional works

Books

Movies

A film about the air war over Germany during World War II, starring Gregory Peck. This was considered the first film to depict PTSD, and caused much controversy as a result.

The lead character in this film, a Vietnam vet named Jacob (portrayed by Tim Robbins), suffers nightmarish visions and bizarre hallucinations as a result of his PTSD and discovers that the men who served with him also experience the same disturbing symptoms.

Several characters in this film exhibit signs and symptoms of PTSD. Most notable is Captain John Miller, played by actor Tom Hanks. He suffers from a noticeable shaking of his left hand which only occurs when he is not in combat conditions. Throughout the film the decisions he makes regarding the actions of his squad become increasingly suicidal and his men start to question his rationale. Cpt. Miller orders an assault on an isolated machine gun nest which (as pointed out by his sergeant and the other soldiers) could be avoided, and had apparently been done previously when the Captain's company had encountered some German 88's. Cpt. Miller's decision to assault the nest indicates that his constant exposure to combat conditions is beginning to override his decision-making skills. The group spends some time debating the assault's necessity, and Miller is the only one in favor of it. When the discussion becomes heated, Miller verbally redresses his Sgt. by telling him to "shut up". Inevitably, one of the soldiers in the squad is killed during the attack.

BBC TV-series focussing on the experiences of young British soldiers before, during and after their 1992 deployment as UN peacekeepers in Bosnia. Most of the main characters end up showing serious symptoms of PTSD.

Television

  • In the final episodes of the anime TV show Neon Genesis Evangelion, the character Asuka experiences flashbacks pertaining to her mother's mental breakdown and suicide, impairing her ability to pilot her Evangelion unit and later driving her to become a social recluse.
  • On Roughnecks the Tesca campaign, Johnny Rico is sent into a coma suffering with flash backs, in the next part in the DVD after he wakes up the nures belives Johnny is having PTSD

See also

References

  1. ^ David Satcher; et al. (1999). "Chapter 4.2". Mental Health: A Report of the Surgeon General. {{cite book}}: Explicit use of et al. in: |author= (help)
  2. ^ Devilly, G. J., & Spence, S. H. (1999). "The relative efficacy and treatment distress of EMDR and a cognitive behavioral trauma treatment protocol in the amelioration of post traumatic stress disorder". Journal of Anxiety Disorders, 13, 131–157.
  3. ^ Forbes, D. et al. (2001) "Brief report: treatment of combat-related nightmares using imagery rehearsal: a pilot study", Journal of Traumatic Stress 14 (2): 433-442

Neurobiological background info and studies about medication

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