Post-Traumatic Stress Disorder (PTSD)

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PTSD

Post-traumatic stress disorder (PTSD) is a mental disorder that develops in people who have experienced or witnessed traumatic events. PTSD as a disorder was initially associated with veterans who have been in combat and experienced or witnessed war atrocities, but it has since been seen to affect people in the general population who have experienced other kinds of traumatic events. Humans are constantly exposed to natural and social occurrences such as death, injury, violence, sexual assault, murder, disasters, accidents which create fear, shock and even horror in most individuals. The response to these feelings and coping mechanisms differ from person to person. While some people will recover from traumatic events over time, with or without treatment, others will require major therapy to be able to overcome the trauma. In cases where symptoms persist or get worse over time after the traumatic event, the individual may develop PTSD.

Symptoms

The symptoms of PTSD vary from one individual to another and are usually those associated with the traumatic event. PTSD symptoms are usually experienced within three months of the traumatic event but may also begin later. Symptoms must last for at least a month to be considered PTSD.  The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) has characterized PTSD symptoms into persistent re-experiencing, avoidance, hyperarousal, and cognition.

Re-experiencing: Involves reliving the traumatic experience and includes symptoms such as recurrent distressing memories, dreams, flashbacks of the traumatic event and prolonged psychological distress and reactions to situations that bring to mind the traumatic event.

Avoidance: Persistent avoidance of memories, thoughts, and feelings as well as people, places and activities related to the traumatic event.

Hyperarousal: Symptoms include irritable behavior and angry outbursts, verbal or physical aggression towards people or objects, reckless or self-destructive behavior, being easily startled and on edge, difficulty concentrating and sleep disturbance.

Cognition: Symptoms include alteration of one’s mental process of reasoning and comprehension, knowledge, judgment, memory and attention. There may be persistent negative emotions and detached feelings as well as having trouble remembering aspects of the traumatic event.

Causes

Although stress-related events have been shown to be associated with several mental disorders including PTSD, the actual cause of the disorder is not very clear.  Some possibilities include:

  • Type and severity of the trauma
  • Biological factors including hormones that regulate the body’s reaction to stress as well as genes and inherited traits from family such as anxiety, depression, temperament.
  • Changes in the size of the part of the brain (hippocampus) that regulates memory and emotions. In PTSD, this part appears to be smaller and is thought to be related to some of the symptoms experienced after a traumatic event including anxiety, flashbacks, and memory problems.

Risk Factors

Factors that increase the risk of developing PTSD can be two-fold.  Firstly, there is the risk of exposure to traumatic events.  Secondly is the risk among those who are exposed to traumatic events to develop PTSD.

Factors that influence exposure to traumatic events may include but are not limited to:

  1. Being military personnel, which exposes an individual to being deployed to a war zone where they may experience or witness war atrocities.
  2. First responders who witness accidents, deaths, and murder in the course of performing their duties.
  3. Living in a war zone predisposes people to experience and witness violence, injuries, and even deaths.
  4. Children growing up in homes where domestic violence is persistent.
  5. Children and even adults living in violent neighborhoods and/or in communities where drug abuse is prevalent.

It is important to note that not everyone who is at risk of being exposed to a traumatic event eventually witnesses or experiences it and not everyone who experiences or witnesses a traumatic event will develop PTSD. For those who are exposed and eventually experience trauma, certain factors cause some people to be more susceptible to developing PTSD than others.

These factors include:

  1. Gender – women are more likely to develop PTSD than men.
  2. Race – being a minority may be a contributing factor.
  3. The severity of trauma and other previous traumatic events such as child abuse or domestic violence.
  4. Socioeconomic status – lack of education and low socioeconomic status can increase risk.
  5. Individual and/or family psychiatric history.
  6. Little or no social support particularly from family and friends.

While the above factors increase the risk of developing PTSD, there are certain factors that may help reduce the risk of developing the disorder. These are called resilience factors and are mostly individual abilities such as the ability to seek treatment and support after a traumatic experience, ability to come up with coping strategies and to act and respond courageously in the face of fear.

Complications

PTSD has a serious negative effect on the everyday life of an individual and may increase the risk of other health conditions including:

  • Anxiety, depression, psychosis: These may occur secondary to the exposure to trauma
  • Drug and/or alcohol abuse: Some individuals try to cope with the symptoms of PTSD by abusing alcohol, drugs and other substances.
  • Psychological problems: In certain cases, it may arise from exposure to therapy
  • Suicide: Although rare, it is a potential complication of PTSD in that some individuals nurture suicidal thoughts.

Diagnosis

It is important to differentiate between PTSD and other mental disorders in order to recommend appropriate treatment. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines the criteria for the diagnosis of PTSD. The criteria require that an individual has been exposed to such traumatic events as death, violence or serious injuries through:

  • Personal experience of the traumatic event
  • Being a witness to the event
  • Learning that the traumatic event occurred to a close relative or friend and
  • Experiencing repeated exposure to the painful details of the traumatic event.

Diagnosis of PTSD involves performing a physical examination to determine the cause of the symptoms, a psychological evaluation of the different symptoms (re-experiencing, avoidance, hyperarousal, and cognition) and the use of the DSM-5 criteria.

Treatments

PTSD can be treated with medication, psychotherapy or both. Experienced mental health professionals will decide on the best treatment for their patients based on the symptoms they present with.

Psychotherapy: Psychotherapy is a method that uses both verbal and nonverbal communication to treat patients with mental disorders. In PTSD, psychotherapy targets the symptoms, with the best-supported therapy being cognitive behavioral therapy (CBT). CBT is divided into exposure and non-exposure therapies. In exposure therapy, the therapist helps the patient overcome fear through a gradual and safe process of exposure to the avoided traumatic event using images, writings or even live events to an extent where such events no longer cause trauma and are no longer avoided by the patient. Non-exposure therapy focuses on current life events and interpersonal relationships. In general, psychotherapy techniques that help in relaxation and anger control, as well as provide tips for exercising, improved nutrition and sleep, as well as identifying and dealing with negative feelings can go a long way towards treating PTSD.

Medication: The most used and studied medications for PTSD are antidepressants which are used to alleviate symptoms such as sadness, anger, and numb feelings. Antipsychotic agents, anti-anxiety, and sedatives, as well as drugs that target insomnia and nightmares, are also used to treat patients with PTSD.

 

Written by Asongna T. Folefoc

References

(1) Shalev A, Liberzon I and Marmar C. Post-Traumatic Stress Disorder. N Engl J Med. 2017 Jun 22;376(25):2459-2469. doi: 10.1056/NEJMra1612499.
(2) Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. 2013 Fifth Edition DSM-5.
(3) Post-Traumatic Stress Disorder (PTSD). U.S. Department of Health and Human Services, National Institutes of Health (NIH) Publication No. QF 16-6388.