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Post-traumatic stress disorder (PTSD) is a term for the psychological consequences of exposure to, or confrontation with, stressful experiences which involve actual or threatened death, serious physical injury, or a threat to physical and/or psychological integrity, and which the person experienced as highly traumatic. It is occasionally called post-traumatic stress reaction, to emphasize that it is a routine result of a traumatic experience, rather than a manifestation of a pre-existing psychological weakness on the part of the patient.
Symptoms can include re-experiencing phenomena, such as nightmares and flashbacks, emotional detachment or numbing of feelings (emotional self-mortification) combined with regular hyperarousal and possibly sleep abnormalities (insomnia), avoidance of reminders and extreme distress when exposed to the reminders ("triggers"), with irritability and excessive startle.
Experiences likely to induce the condition include:
- childhood physical/emotional or sexual abuse
- adult's experiences of rape, war and combat exposure
- violent attacks
- natural catastrophes
- life-threatening childbirth complications
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).
PTSD may have a "delayed onset" of years, or even decades, and may be triggered by even a specific body movement (if the trauma was stored in the procedural memory mainly), or 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. Once PTSD reaches the criteria for diagnosis, the untreated course is generally for some worsening and then stability of the level of symptomatology over many years.
Also, doctors have conducted clinical studies indicating truamatized 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 BC 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 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 per se 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 were to a great deal incapacitated by psychiatric illness, including post-traumatic stress in the aftermath of the Vietnam War. However, they had difficulties receiving economic compensation since there was no psychiatric diagnosis available by which veterans could claim indemnity. This situation has changed, 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). While PTSD-like symptoms were recognized in combat veterans following many historical conflicts, the modern understanding of the condition dates to the 1980s.
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. 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. 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 person cannot process difficult emotions in a normal way, he/she is plagued by recurrent nightmares, or daytime flashbacks, while he/she realistically reexperiences 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 his/her own thoughts, that can arouse memories of the trauma and thus cause the intrusive and hyperarousal states to go on. He/She isolates him/herself, being detached in his/her 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. Brain imaging 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 [1], 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
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)1 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. (This doesn't mean Ecstasy has proven efficacy for treating PTSD.)
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.[2] (This doesn't mean that LSD has proven efficacy for treating PTSD.)
PTSD is often comorbid with other psychiatric disorders with depression and substance abuse being the most common.
There have been scores of other treatments suggested for the treatment of PTSD. Two of these controversial techniques are Eye Movement Desensitisation and Reprocessing (EMDR) and Traumatic Incident Reduction (TIR)(this doesn't mean that (EMDR) has proven efficacy for treating PTSD).
Israel military is experimentally treating PTSD with Marijuana. [3] [4] [5]
See also
Fiction
Movies
Non-Fiction
- Spike Milligan: Mussolini: His Part in My Downfall. 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 appallingly unsympathetic treatment he received at the hands of military doctors.
References
1 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
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.
External links
Neurobiological background info and studies about medication
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