Post-traumatic stress disorder

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Post-traumatic stress disorder
PTSD.png
SymptomsDisturbing thoughts, feelings, or dreams related to the event; mental or physical distress to trauma-related cues; efforts to avoid trauma-related situations; increased fight-or-flight response[1]
ComplicationsSelf-harm, suicide[2]
Duration> 1 month[1]
CausesExposure to a traumatic event[1]
Diagnostic methodBased on symptoms[2]
TreatmentCounseling, medication
MedicationSelective serotonin reuptake inhibitor
Frequency8.7% (lifetime risk); 3.5% (12-month risk) (US)[1]

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event.

A person with PTSD is at a higher risk of suicide and intentional self-harm. Their ability to function successfully in their work environment and to maintain family relationships may be severely impaired.

Fortunately, most people who experience traumatic events do not develop PTSD. However, especially among military personnel who experienced combat during war time, the rate of PTSD occurrence is sufficiently high to be detrimental to society as a whole. If the occurrence of traumatic events is not reduced, then their effects need to be better understand and efforts to improve treatment options continue to be necessary.

Terminology

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life.[1]

The Diagnostic and Statistical Manual of Mental Disorders (DSM) does not hyphenate "post" and "traumatic," thus, the DSM-5 lists the disorder as posttraumatic stress disorder. However, the ICD-10 does hyphenate the name of the disorder, viz., "post-traumatic stress disorder,"[3] as do many scientific journal articles and other scholarly publications.

Classification

PTSD was classified as an anxiety disorder in the DSM-IV. It has since been reclassified as a "trauma and stressor-related disorder" in the DSM-5.[1]

ICD-10 classifies PTSD under "Reaction to severe stress, and adjustment disorders (F43)."[3]

History of the terminology

Symptoms of trauma-related mental disorders have been documented since at least the time of the ancient Greeks.[4] Several instances of post-traumatic illness have been noted in the seventeenth and eighteenth centuries, such as Samuel Pepys's description of intrusive and distressing symptoms following the 1666 Fire of London.[5] In a similar vein, psychiatrist Jonathan Shay has proposed that Lady Percy's soliloquy in William Shakespeare's play Henry IV, Part 1 (act 2, scene 3, lines 40โ€“62), written around 1597, represents an unusually accurate description of the symptom constellation of PTSD.[6]

The 1952 edition of the DSM-I includes a diagnosis of "gross stress reaction," which has similarities to the modern definition and understanding of PTSD. Gross stress reaction is defined as a normal personality using established patterns of reaction to deal with overwhelming fear as a response to conditions of great stress. The diagnosis includes language which relates the condition to combat as well as to "civilian catastrophe."[7]

Early in 1978, the diagnosis term "post-traumatic stress disorder" was first recommended in a working group finding presented to the Committee of Reactive Disorders.[8] The condition was officially recognized by the American Psychiatric Association in 1980 in DSM-III as "posttraumatic stress disorder."[9]

The term "post-traumatic stress disorder" came into use in the 1970s in large part due to the diagnoses of U.S. military veterans of the Vietnam War.[10] Owing to its association with the war in Vietnam, PTSD has become synonymous with many historical war-time diagnoses such as "railway spine," stress syndrome, nostalgia, "soldier's heart," shell shock, battle fatigue, combat stress reaction, traumatic war neurosis, "war nerves," neurasthenia, and "combat neurosis."[11][12]

Statue, Three Servicemen, Vietnam Veterans Memorial

The correlations between combat and PTSD are undeniable:

It is now known that soldiers on a battlefield can hope to preserve their psychological equilibrium for only several months at best; the strict selection process notwithstanding, one-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and after thirty-five days of uninterrupted combat, 98 percent of them manifested psychiatric disturbances in varying degrees.[13]

A study based on personal letters from soldiers of the eighteenth-century Prussian Army concludes that combatants may have had PTSD.[14] Aspects of PTSD in soldiers of ancient Assyria have been identified using written sources from 1300 to 600 B.C.E. These Assyrian soldiers would undergo a three-year rotation of combat before being allowed to return home, and were reported to have faced immense challenges in reconciling their past actions in war with their civilian lives.[15] Connections between the actions of Viking berserkers and the hyper-arousal of post-traumatic stress disorder have also been drawn.[16]

The initial overt focus on PTSD was as a combat related disorder when it was first fleshed out in the years following the war in Vietnam. However, other traumas may also result in similar psychological disturbance. For example, Ann Wolbert Burgess and Lynda Lytle Holmstrom defined Rape Trauma Syndrome (RTS) in order to draw attention to the striking similarities between the experiences of soldiers returning from war and of victims of rape.[17]

Complex PTSD

Complex post-traumatic stress disorder (C-PTSD or CPTSD; also known as complex trauma disorder)[18] is a psychological disorder that may develop in response to exposure to a series of traumatic events in a context in which the individual perceives little or no chance of escape, and particularly where the exposure is prolonged or repetitive. It is not yet recognized by the American Psychiatric Association or the DSM-5 as a valid disorder. However, the DSM-5 does list a sub-type of post-traumatic stress disorder (PTSD) called dissociative PTSD that seems to encompass C-PTSD symptoms.[19] C-PTSD was added to the eleventh revision of the International Classification of Diseases (ICD-11).[20] Complex PTSD is also recognized by the United States Department of Veterans Affairs (VA), Healthdirect Australia (HDA), and the British National Health Service (NHS).

C-PTSD was first described in 1992 by American psychiatrist and scholar Judith Lewis Herman in her book Trauma & Recovery, in which she described C-PTSD as distinct from, but similar to, PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder.[11]

Children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver.[21] The term Developmental Trauma Disorder (DTD) has been proposed as the childhood equivalent of C-PTSD. This developmental form of trauma places children at risk for developing psychiatric and medical disorders.[21] Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame.[22]

Symptoms

Symptoms of PTSD generally begin within the first three months after the inciting traumatic event, but may not begin until years later.[1] A person with PTSD is at a higher risk of suicide and intentional self-harm.[2]

Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. The DSM-5 diagnostic criteria for PTSD include four symptom clusters: re-experiencing, avoidance, negative alterations in cognition/mood, and alterations in arousal and reactivity.[1] Young children are less likely to show distress but instead may express their memories through play.[1]

In the typical case, the individual with PTSD persistently avoids either trauma-related thoughts and emotions or discussion of the traumatic event and may even have amnesia of the event.[1] However, the event is commonly relived by the individual through intrusive, recurrent recollections, dissociative episodes of reliving the trauma ("flashbacks"), and nightmares.[23] While it is common to have symptoms after any traumatic event, these must persist to a sufficient degree, causing dysfunction in life or clinical levels of distress, for longer than one month after the trauma to be classified as PTSD (clinically significant dysfunction or distress for less than one month after the trauma may be acute stress disorder).[1]

The ICD-10 criteria for PTSD include re-experiencing, avoidance, and either increased reactivity or inability to recall certain details related to the event.

The ICD-11 diagnostic description for PTSD contains three components or symptom groups (1) re-experiencing, (2) avoidance, and (3) heightened sense of threat; ICD-11 no longer includes verbal thoughts about the traumatic event as a symptom.[24]

ICD-11 also proposes identifying a distinct group with complex post-traumatic stress disorder (C-PTSD), who have more often experienced several or sustained traumas and have greater functional impairment than those with PTSD.[24]

In addition to the symptoms of PTSD, an individual with C-PTSD experiences emotional dysregulation, negative self-beliefs and feelings of shame, guilt, or failure regarding the trauma, and interpersonal difficulties.[20] C-PTSD relates to the trauma model of mental disorders and is associated with chronic sexual, psychological, and physical abuse or neglect, or chronic intimate partner violence, bullying, victims of kidnapping and hostage situations, indentured servants, victims of slavery and human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, and prisoners kept in solitary confinement for a long period of time, or defectors from authoritarian religions. Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.[11]

Risk factors

Persons considered at risk include combat military personnel, victims of natural disasters, concentration camp survivors, and victims of violent crime. Persons employed in occupations that expose them to violence (such as soldiers) or disasters (such as emergency service workers) are also at risk.

Trauma

PTSD has been associated with a wide range of traumatic events. The risk of developing PTSD after a traumatic event varies by trauma type, and most people who experience traumatic events do not develop PTSD.[2]

People who experience interpersonal violence such as rape, other sexual assaults, being kidnapped, stalking, physical abuse by an intimate partner, and incest or other forms of childhood sexual abuse are more likely to develop PTSD than those who experience non-assault based trauma, such as accidents and natural disasters.[25] Those who experience prolonged trauma, such as slavery, concentration camps, or chronic domestic abuse, may develop complex post-traumatic stress disorder (C-PTSD).

Intimate partner violence

An individual that has been exposed to domestic violence is predisposed to the development of PTSD. However, being exposed to a traumatic experience does not automatically indicate that an individual will develop PTSD.[26]

PTSD symptoms include re-experiencing the assault, avoiding things associated with the assault, numbness, and increased anxiety and an increased startle response. The likelihood of sustained symptoms of PTSD is higher if the rapist confined or restrained the person, if the person being raped believed the rapist would kill them, the person who was raped was very young or very old, and if the rapist was someone they knew. The likelihood of sustained severe symptoms is also higher if people around the survivor ignore (or are ignorant of) the rape or blame the rape survivor.[27]

War-related trauma

While active military service is a serious risk factor for developing PTSD, refugees are also at an increased risk for PTSD due to their exposure to war, hardships, and traumatic events. While the stresses of war affect everyone involved, displaced persons have been shown to be more so than others.[28]

Unexpected death of a loved one

Sudden, unexpected death of a loved one is the most common traumatic event type reported in cross-national studies.[25][22] However, the majority of people who experience this type of event will not develop PTSD. An analysis from the WHO World Mental Health Surveys found a 5.2 percent risk of developing PTSD after learning of the unexpected death of a loved one.[22] Because of the high prevalence of this type of traumatic event, unexpected death of a loved one accounts for approximately 20 percent of PTSD cases worldwide.[25]

Medical trauma

Medical conditions associated with an increased risk of PTSD include cancer,[29] heart attack, and stroke. Intensive-care unit (ICU) hospitalization is also a risk factor for PTSD.[30] Some women experience PTSD from their experiences related to breast cancer and mastectomy.[29] Loved ones of those who experience life-threatening illnesses are also at risk for developing PTSD, such as parents of child with chronic illnesses.[31]

Women who experience miscarriage are at risk of PTSD, and those who experience subsequent miscarriages have an increased risk of PTSD compared to those experiencing only one.[32]

Genetics

There is evidence that susceptibility to PTSD is hereditary. Approximately 30 percent of the variance in PTSD is caused from genetics alone.[33] Research has also found that PTSD shares many genetic influences common to other psychiatric disorders. Panic and generalized anxiety disorders and PTSD share 60 percent of the same genetic variance. Alcohol, nicotine, and drug dependence share greater than 40 percent genetic similarities.[33]

Diagnosis

Evidence-based assessment principles, including a multimethod assessment approach, form the foundation of PTSD assessment.[34] There are a number of PTSD screening instruments for adults, such as the PTSD Checklist for DSM-5 (PCL-5).[35]

There are also several screening and assessment instruments for use with children and adolescents, such as the Child PTSD Symptom Scale (CPSS) and the Child Trauma Screening Questionnaire. In addition, there are also screening and assessment instruments for caregivers of very young children (six years of age and younger), including the Young Child PTSD Screen, the Young Child PTSD Checklist, and the Diagnostic Infant and Preschool Assessment.

PTSD can be difficult to diagnose, for several reasons:

  • the subjective nature of most of the diagnostic criteria (although this is true for many mental disorders);
  • the potential for over-reporting, such as while seeking disability benefits, or when PTSD could be a mitigating factor at criminal sentencing
  • the potential for under-reporting, due to stigma, pride, or fear that a PTSD diagnosis might preclude certain employment opportunities;
  • symptom overlap with other mental disorders such as obsessive compulsive disorder and generalized anxiety disorder;[36]
  • association with other mental disorders such as major depressive disorder and generalized anxiety disorder;
  • substance use disorders, which often produce some of the same signs and symptoms as PTSD; and
  • substance use disorders can increase vulnerability to PTSD or exacerbate PTSD symptoms or both; and
  • PTSD increases the risk for developing substance use disorders.
  • the differential expression of symptoms culturally (specifically with respect to avoidance and numbing symptoms, distressing dreams, and somatic symptoms)[1]

Differential diagnosis

A diagnosis of PTSD requires that the person has been exposed to an extreme stressor. Any stressor can result in a diagnosis of adjustment disorder and it is an appropriate diagnosis for a stressor and a symptom pattern that does not meet the criteria for PTSD.

The symptom pattern for acute stress disorder must occur and be resolved within four weeks of the trauma. If it lasts longer, and the symptom pattern fits that characteristic of PTSD, the diagnosis may be changed.[23]

Obsessive compulsive disorder may be diagnosed for intrusive thoughts that are recurring but not related to a specific traumatic event.[23]

In extreme cases of prolonged, repeated traumatization where there is no viable chance of escape, survivors may develop complex post-traumatic stress disorder. This occurs as a result of layers of trauma rather than a single traumatic event, and includes additional symptomatology, such as the loss of a coherent sense of self.[11]

Pathophysiology

Neuroendocrinology

PTSD symptoms may result when a traumatic event causes an over-reactive adrenaline response, which creates deep neurological patterns in the brain. These patterns can persist long after the event that triggered the fear, making an individual hyper-responsive to future fearful situations.[26] During traumatic experiences, the high levels of stress hormones secreted suppress hypothalamic activity that may be a major factor toward the development of PTSD.[37]

PTSD causes biochemical changes in the brain and body, that differ from other psychiatric disorders such as major depression. Most people with PTSD show a low secretion of cortisol and high secretion of catecholamines in urine, with a norepinephrine/cortisol ratio consequently higher than comparable non-diagnosed individuals.[38] This is in contrast to the normative fight-or-flight response, in which both catecholamine and cortisol levels are elevated after exposure to a stressor.[39]

Brain catecholamine levels are high, and corticotropin-releasing factor (CRF) concentrations are high.[40] Together, these findings suggest abnormality in the hypothalamic-pituitary-adrenal (HPA) axis.

Hyperresponsiveness in the norepinephrine system can also be caused by continued exposure to high stress. Overactivation of norepinephrine receptors in the prefrontal cortex can be connected to the flashbacks and nightmares frequently experienced by those with PTSD. A decrease in other norepinephrine functions (awareness of the current environment) prevents the memory mechanisms in the brain from processing the experience, and emotions the person is experiencing during a flashback are not associated with the current environment.[41]

Neuroanatomy

Regions of the brain associated with stress and post-traumatic stress disorder

Structural MRI studies have found an association with reduced total brain volume, intracranial volume, and volumes of the hippocampus, insula cortex, and anterior cingulate in PTSD in those exposed to the Vietnam War.[40] People with PTSD have decreased brain activity in the dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex, areas linked to the experience and regulation of emotion.[42]

The amygdala is strongly involved in forming emotional memories, especially fear-related memories. During high stress, the hippocampus, which is associated with placing memories in the correct context of space and time and memory recall, is suppressed. According to one theory this suppression may be the cause of the flashbacks that can affect people with PTSD. When someone with PTSD undergoes stimuli similar to the traumatic event, the body perceives the event as occurring again because the memory was never properly recorded in the person's memory.[33]

The amygdalocentric model of PTSD proposes that the amygdala is very much aroused and insufficiently controlled by the medial prefrontal cortex and the hippocampus, in particular during extinction. This is consistent with an interpretation of PTSD as a syndrome of deficient extinction ability.[43]

Associated medical conditions

Trauma survivors often develop depression, anxiety disorders, and mood disorders in addition to PTSD.[44]

Substance use disorder, such as alcohol use disorder, commonly co-occur with PTSD.[45] Recovery from post-traumatic stress disorder or other anxiety disorders may be hindered, or the condition worsened, when substance use disorders are comorbid with PTSD.

In children and adolescents, there is a strong association between emotional regulation difficulties (such as mood swings, anger outbursts, temper tantrums) and post-traumatic stress symptoms, independent of age, gender, or type of trauma.[46]

Prevention

Prevention may be possible when counseling (psychotherapy) is targeted at those with early symptoms but has not been shown to be effective when provided to all trauma-exposed individuals whether or not symptoms are present.[2] Modest benefits have been seen from early access to cognitive behavioral therapy.

Trauma-exposed individuals often receive treatment called psychological debriefing in an effort to prevent PTSD, which consists of interviews that are meant to allow individuals to directly confront the event and share their feelings with the counselor and to help structure their memories of the event. However, several meta-analyses find that psychological debriefing is unhelpful and is potentially harmful.[47]

Management

The main treatments for people with PTSD are counseling (psychotherapy) and medication.[48] Four interventions are strongly recommended, all of which are variations of cognitive behavioral therapy (CBT): Cognitive Behavioral Therapy (CBT), Cognitive Processing Therapy (CPT), Cognitive Therapy, and Prolonged Exposure. Additionally, three psychotherapies and four medications are conditionally recommended: Brief Eclectic Psychotherapy, Eye Movement Desensitization and Reprocessing (EMDR) Therapy, Narrative Exposure Therapy (NET), and the four medications sertraline, paroxetine, fluoxetine, and venlafaxine.[49]

Benefits from medication are less than those seen with counseling; it is not known whether using medications and counseling together has greater benefit than either method separately.[2]

Psychotherapy

Trauma-focused psychotherapies for PTSD (also known as "exposure-based" or "exposure" psychotherapies), such as prolonged exposure therapy (PE), eye movement desensitization and reprocessing (EMDR), and cognitive-reprocessing therapy (CPT) have the most evidence for efficacy and are recommended as first-line treatment for PTSD by almost all clinical practice guidelines.[50] Exposure-based psychotherapies demonstrate efficacy for PTSD caused by different trauma "types," such as combat, sexual-assault, or natural disasters.[51]

Counseling

The approaches with the strongest evidence include behavioral and cognitive-behavioral therapies such as prolonged exposure therapy, cognitive processing therapy, and eye movement desensitization and reprocessing (EMDR).[49][52] There is some evidence for brief eclectic psychotherapy (BEP), narrative exposure therapy (NET), and written exposure therapy.[53]

Children with PTSD are far more likely to pursue treatment at school (because of its proximity and ease) than at a free clinic.[54]

Cognitive behavioral therapy

The diagram depicts how emotions, thoughts, and behaviors all influence each other. The triangle in the middle represents CBT's tenet that all humans' core beliefs can be summed up in three categories: self, others, future.

Cognitive behavioral therapy (CBT) seeks to change the way a person feels and acts by changing the patterns of thinking or behavior, or both, responsible for negative emotions. Results from a 2018 systematic review found high strength of evidence that supports CBT-exposure therapy efficacious for a reduction in PTSD and depression symptoms, as well as the loss of PTSD diagnosis.[55]

In CBT, individuals learn to identify thoughts that make them feel afraid or upset and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.[56]

EMDR

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy which controls eye movements while thinking about disturbing memories.[57] This theory proposes that eye movement can be used to facilitate emotional processing of memories, changing the person's memory to attend to more adaptive information. The therapist initiates voluntary rapid eye movements while the person focuses on memories, feelings or thoughts about a particular trauma.[58]

EMDR closely resembles cognitive behavior therapy as it combines exposure (re-visiting the traumatic event), working on cognitive processes and relaxation/self-monitoring.[58] However, exposure by way of being asked to think about the experience rather than talk about it has been highlighted as one of the more important distinguishing elements of EMDR.[59]

There is moderate strength of evidence to support the efficacy of EMDR "for reduction in PTSD symptoms, loss of diagnosis, and reduction in depressive symptoms" according to a 2018 systematic review update.[55]

Medication

While many medications do not have enough evidence to support their use, four antidepressants of the SSRI or SNRI type (sertraline, fluoxetine, paroxetine, and venlafaxine) have been shown to have a small to modest benefit over placebo.[60]

With many medications, residual PTSD symptoms following treatment is the rule rather than the exception.[61]

Prazosin, an alpha-1 adrenergic antagonist, has been used in veterans with PTSD to reduce nightmares. Studies show variability in the symptom improvement, appropriate dosages, and efficacy in this population.[62]

Other

Exercise, sport, and physical activity

Physical activity, including sports and exercise, can enhance people's psychological and physical well-being. The U.S. National Center for PTSD recommends moderate exercise as a way to distract from disturbing emotions, build self-esteem, and increase feelings of being in control again. They recommend a discussion with a doctor before starting an exercise program.[63]

Play therapy for children

Play is thought to help children link their inner thoughts with their outer world, connecting real experiences with abstract thought. Repetitive play can be one way a child relives traumatic events, and that can be a symptom of trauma in a child or young person.[64] Play therapy is a form of psychotherapy which uses play to help overcome challenges andto reduce psychological harm from traumatic events.

Military programs

Many veterans of the wars in Iraq and Afghanistan have faced significant physical, emotional, and relational disruptions. In response, the United States Marine Corps has instituted programs to assist them in re-adjusting to civilian life, especially in their relationships with spouses and loved ones, to help them communicate better and understand what the other has gone through. Walter Reed Army Institute of Research (WRAIR) developed the Battlemind program to assist service members avoid or ameliorate PTSD and related problems. Wounded Warrior Project partnered with the US Department of Veterans Affairs to create Warrior Care Network, a national health system of PTSD treatment centers.[65]

Notes

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References
ISBN links support NWE through referral fees

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  • Andreasen, Nancy C. Brave New Brain: Conquering Mental Illness in the Era of the Genome. Oxford University Press, 2001. ISBN 978-0195145090
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  • Holmstrom, Lynda Lytle, and Ann Wolbert Burgess. The Victim of Rape: Institutional Reactions. Routledge, 1983. ISBN 978-0878559329
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  • O'Brien, L. Stephen. Traumatic Events and Mental Health. Cambridge University Press, 1998. ISBN 978-0521578868
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External links

All links retrieved

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