What is post-traumatic stress disorder?

From Brain.com


 Post-traumatic stress disorder (PTSD) is an extremely debilitating condition that can occur after exposure to a terrifying event or ordeal in which grave physical harm was threatened or occurred. Traumatic events that can trigger PTSD include violent personal assaults such as rape or mugging, natural or man made disasters, car accidents, or military combat.

Military troops who served in Vietnam and the Gulf Wars; rescue workers involved in the aftermath of the Oklahoma City bombing; survivors of accidents, rape, physical and sexual abuse, and other crimes; immigrants fleeing violence in their countries; survivors of the 1994 California earthquake, the 1997 South Dakota floods, and hurricanes Hugo and Andrew; and people who witnesses traumatic events are among the people who develop PTSD. Families of victims can also develop the disorder.

Prevention


At least 4 percent of U.S. adults (5.7 million people) have PTSD during the course of a year. About 30 percent of the men and women who have spent time in war zones experience PTSD. One million war veterans developed PTSD after serving in Vietnam. PTSD has also been detected among veterans of the Persian Gulf War, with some estimates running as high as 8 percent.

PTSD is treatable, and once diagnosed treatment can help prevent or lessen future occurrences of it. Since the cause of PTSD disorder is trauma, there is currently no simple preventative measure for avoiding its onset, but early diagnosis and treatment can help prevent ongoing and deepening symptoms. Eliminating the causes (warfare, rape and other traumatic events) would prevent PTSD. The likelihood of developing that preventative measure is unfortunately remote.

Signs & Symptoms


Many people with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event can also trigger symptoms. People with PTSD also experience emotional numbness and sleep disturbances, depression, anxiety, and irritability or outbursts of anger. Feelings of intense guilt are also common. Most people with PTSD try to avoid any reminders or thoughts of the ordeal. PTSD is diagnosed when symptoms last more than one month.

PTSD can develop at any age, including childhood. Symptoms of PTSD typically begin within 3 months following a traumatic event, although occasionally symptoms do not begin until years later. Once PTSD develops, the duration of the illness varies. Some people recover within 6 months while others may suffer much longer.

Co-occurring depression, alcohol or other substance abuse, or another anxiety disorder are not uncommon. The likelihood of treatment success is increased when these other conditions are appropriately diagnosed and treated as well.

Causes


People who have been abused as children or who have had other previous traumatic experiences are more likely to develop the disorder. Research is continuing to pinpoint other factors that may lead to PTSD.

PTSD is linked to structural neurochemical changes in the central nervous system which may have a direct biological effect on health, such as vulnerability to hypertension and atherosclerotic heart disease; abnormalities in thyroid and other hormone functions; increased susceptibility to infections and immunologic disorders; and problems with pain perception, pain tolerance, and chronic pain. PTSD is associated with significant behavioral health risks, including smoking, poor nutrition, conflict or violence in intimate relationships, and anger or hostility.

Treatment


Treatment for PTSD includes cognitive-behavioral therapy, group psychotherapy, and medications (including antidepressants). Various forms of exposure therapy (such as systemic desensitization and imaginal flooding) have all been used with PTSD patients. Exposure treatment for PTSD involves repeated reliving of the trauma, under controlled conditions, with the aim of the processing of the trauma.

Group treatment is practiced in Veterans Affairs PTSD Clinics and for military veterans and in mental health and crisis clinics for victims of assault and abuse. A group of peers provides an ideal therapeutic setting because trauma survivors are able to risk sharing traumatic material with the safety, cohesion, and empathy provided by other survivors. It is often much easier to accept confrontation from a fellow sufferer who has impeccable credentials as a trauma survivor than from a professional therapist who never went through those experiences first-hand.

As group members achieve greater understanding and resolution of traumatic themes, they often feel more confident and able to trust. As they work through trauma-related shame, guilt, rage, fear, doubt, and self-condemnation, they prepare themselves to focus on the present rather than the past. Telling one's story (the "trauma narrative") and directly facing the grief, anxiety, and guilt related to trauma enables many survivors to go on with their lives rather than getting stuck in unspoken despair and helplessness.

Brief psychodynamic psychotherapy focuses on the emotional conflicts caused by the traumatic event. Through the retelling of the traumatic event to a calm, empathic, compassionate and non-judgmental therapist, the patient achieves a greater sense of self-esteem, develops effective ways of thinking and coping, and more successfully deals with the intense emotions that emerge during therapy. The therapist helps the patient identify current life situations that set off traumatic memories and worsen PTSD symptoms.

There are two cognitive-behavioral approaches, exposure therapy and cognitive-behavioral therapy. Exposure therapy involves therapeutically confronting a past trauma by either (a) repeatedly imagining it in great detail, or (b) going to places that are strong reminders of the trauma experience(s). Exposure therapy is intended to help the patient face and gain control of the fear and distress that was overwhelming in the trauma, and must be done very carefully in order not to re-traumatize the patient.

In some cases, trauma memories or reminders can be confronted all at once ("flooding"), while for other individuals or traumas it is preferable to work gradually up to the most severe trauma by using relaxation techniques and either starting with less upsetting life stressors or by taking the trauma one piece at a time ("desensitization"). Cognitive-behavioral therapy involves learning skills for coping with anxiety (such as breathing retraining or biofeedback) and negative thoughts ("cognitive restructuring"), managing anger, preparing for stress reactions ("stress inoculation"), handling future trauma symptoms and urges to use alcohol or drugs when they occur ("relapse prevention"), and communicating and relating effectively with people ("social skills" or marital therapy). Exposure and cognitive-behavioral therapies are often used together, although it is important not to use too many different therapy methods because this can cause the patient to feel overwhelmed and confused.

Finally, drug therapy can reduce the anxiety, depression, and insomnia often experienced with PTSD, and in some cases may help relieve the distress and emotional numbness caused by trauma memories. Several kinds of antidepressant drugs have achieved improvement in most (but not all) clinical trials, and some other classes of drugs have shown promise. At this time no particular drug has emerged as a definitive treatment for PTSD, although medication is clearly useful for symptom relief thereby making it possible for patients to participate in group, psychodynamic, cognitive-behavioral, or other forms of psychotherapy.

Diagnosis


Headaches, gastrointestinal complaints, immune system problems, dizziness, chest pain, or discomfort in other parts of the body are common in those suffering with PTSD. Often, doctors treat the symptoms without being aware that they stem from PTSD. The National Institute of Mental Health (NIMH), through its education program, is encouraging primary care providers to ask patients about experiences with violence, recent losses, and traumatic events, especially if symptoms keep recurring.

As awareness of PTSD has grown, diagnosis of the disorder has simplified. PTSD is often diagnosed based on a patient's explanation that s/he has been badly traumatized and believes that such exposure has caused current psychological problems. A PTSD diagnosis provides an attractive explanatory model for many people's suffering because it places responsibility for it outside themselves on factors over which they had neither responsibility nor control.

However, detection of PTSD can be difficult because of patient fears that therapy will reactivate intolerable symptoms, because of the many disorders that frequently accompany PTSD, and because some patients may be too fragmented, amnestic, dissociative, and otherwise impaired to participate in therapy. Assessment can only succeed in a safe therapeutic environment that promotes a comprehensive review of each patient's trauma history at a pace and intensity that is tolerable.

Research


NIMH and the Veterans Administration sponsor a wide range of basic, clinical, and genetic studies of PTSD. In addition, NIMH has a special funding mechanism, called RAPID Grants, which allows researchers to immediately visit the scenes of disasters, such as plane crashes or floods and hurricanes, to study the acute effects of the event and the

Research has shown that PTSD clearly alters a number of fundamental brain mechanisms. Because of this, abnormalities have been detected in brain chemicals that mediate coping behavior, learning, and memory among people with the disorder. Recent brain imaging studies have detected altered metabolism and blood flow as well as anatomical changes in people with PTSD.

The following are also recent research findings: Some studies show that debriefing people very soon after a catastrophic event may reduce some of the symptoms of PTSD. A study of 12,000 schoolchildren who lived through a hurricane in Hawaii found that those who got counseling early on were doing much better two years later than those who did not.

People with PTSD tend to have abnormal levels of key hormones involved in response to stress. Cortisol levels are lower than normal and epinephrine and norepinephrine are higher than normal. Scientists have also found that people with this condition have alterations in the function of the thyroid and in neurotransmitter activity involving serotonin and opiates.

When people are in danger, they produce high levels of natural opiates, which can temporarily mask pain. Scientists have found that people with PTSD continue to produce those higher levels even after the danger has passed; this may lead to the blunted emotions associated with the condition. It used to be believed that people who tend to dissociate themselves from a trauma were showing a healthy response, but now some researchers suspect that people who experience dissociation may be more prone to PTSD.

Animal studies show that the hippocampus -- a part of the brain critical to emotion-laden memories -- appears to be smaller in cases of PTSD. Brain imaging studies indicate similar findings in humans. Scientists are investigating whether this is related to short-term memory problems. Changes in the hippocampus are thought to be responsible for intrusive memories and flashbacks that occur in people with this disorder. Research to understand the neurotransmitter system involved in memories of emotionally charged events may lead to discovery of drugs that, if given early, could block the development of PTSD symptoms.

Levels of CRF, or corticotropin releasing factor--the ignition switch in the human stress response--seem to be elevated in people with PTSD, which may account for the tendency to be easily startled. Because of this finding, scientists now want to determine whether drugs that reduce CRF activity are useful in treating the disorder.



From brain.com, the National Institutes of Health and the Department of Veterans Affairs

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