Ptsd

(PTSD) is the term for a severe and ongoing emotional reaction to an extreme psychological trauma. The latter may involve someone's actual death or a threat to the patient's or someone else's life, serious physical injury, or threat to physical and/or psychological integrity, to a degree that usual psychological defences are incapable of coping. It is important to make a distinction between PTSD and Traumatic stress, which is a similar condition, but of less intensity and duration. Formerly the condition was sometimes known as shell shock or post-traumatic stress syndrome (PTSS).

As indicated in DSM-IV, it is possible for individuals to experience traumatic stress without developing posttraumatic stress disorder. Indeed, most people who suffer psychological trauma do not develop PTSD. For most, the emotional effects of such events subside after several months.

PTSD is thought to be primarily an anxiety disorder, possibly closely related to panic disorder and should not be confused with normal grief and adjustment after traumatic events.

PTSD symptoms may include: 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"), loss of appetite, irritability, hyper vigilance, memory loss (may appear as difficulty paying attention), excessive startle response, clinical depression, and anxiety.

A person suffering from PTSD may also exhibit one or more co morbid psychiatric disorders. These may include clinical depression (or bipolar disorder), general anxiety disorder, and a variety of addictions.

According to DSM-IV, symptoms that appear within the first month of the trauma are not called PTSD but Acute stress disorder. If there is no improvement of symptoms after a month, PTSD is diagnosed. PTSD is divided into three categories: Acute PTSD subsides within three months. If symptoms persist, the diagnosis is changed to chronic PTSD. The third category, delayed-onset PTSD, may occur months, years or even decades after the traumatic event.

Natural history

Traumatic experiences

• Childhood physical, emotional, or sexual abuse, including prolonged or extreme neglect; also, witnessing such abuse inflicted on another child or an adult
• Experiences and interactions that are experienced as psychological "attacks"; for example a continual perception of psychological force, invalidation or annihilation.
• Experiencing (including witnessing) an event perceived as life-threatening, such as:

• A serious accident
• Medical complications
• Violent physical assaults or surviving or witnessing such an event, including torture
• Adult experiences of sexual assault or rape
• Warfare, policing and other occupations exposed to violence or disaster
• Violent, life threatening, natural disasters
• Incarceration


Cancer

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 characterised by extended duration with a potential for recurrence and a varying immediacy of life-threat (Smith 1999).

Symptoms

Symptoms can include general restlessness, insomnia, aggressiveness, depression, dissociation, emotional detachment, and nightmares. A potential symptom is 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 re-enact aspects of the trauma through their play and may often have nightmares that lack any recognisable content.

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

Intrusion:

Since the sufferers are unable to process the extreme emotions brought about by the trauma, they are plagued by recurrent nightmares or daytime flashbacks, during which they graphically re-experience the trauma. These re-experiences are characterised by high anxiety levels and make up one part of the PTSD symptom cluster triad called intrusive symptoms.

Hyper arousal:

PTSD is also characterised by a state of nervousness with the patient being prepared for "fight or flight". The typical hyperactive startle reaction, characterised by "jumpiness" in connection with loud unexpected sounds or fast motions, is typical for another part of the PTSD cluster called hyper arousal symptoms and could also be secondary to an incomplete processing, similar to a reflex.

Avoidance:

The hyper arousal and the intrusive symptoms are eventually so distressing that the individual strives to avoid contact with everything and everyone, even their own thoughts, which may arouse memories of the trauma and thus provoke the intrusive and hyper arousal states. The sufferers isolate themselves, becoming detached in their feelings with a restricted range of emotional response and can experience so-called emotional detachment ("numbing"). Many Veterans with PTSD may also use avoidance as a technique to avoid losing control and harming others. This avoidance behaviour is the third part of the symptom triad that makes up the PTSD criteria.

Dissociation:

Dissociation is another "defence" that includes a variety of symptoms including feelings of depersonalisation and derealisation, disconnection between memory and affect so that the person is "in another world," and in extreme forms can involve apparent multiple personalities and acting without any memory ("losing time").

Treatment

There have been scores of treatments suggested for the treatment of PTSD. One psychotherapeutic (non-medical) method, specifically targeted at the disorder PTSD, is Eye Movement Desensitisation and Reprocessing (EMDR).

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

PTSD is commonly treated using a combination of psychotherapy (cognitive-behavioural therapy, group therapy, and exposure therapy are popular) and psychotropic's: antidepressants

According to some studies, the most effective psychotherapeutic treatment for PTSD is Eye Movement Desensitisation and Reprocessing (EMDR) but this work is largely supported by those with the copyright for EMDR. Most reviews find that EMDR, Cognitive Behavioural Therapy, Exposure Therapy, and Psychodynamic Therapy are all equally effective (National Centre for PTSD Treatment Guidelines). Other forms of 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) 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.

Basic counselling 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).

PTSD is often co-morbid with other psychiatric disorders such as depression and substance abuse. 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.

Neurochemistry

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

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% and 80% will develop PTSD depending on the severity of the trauma and personal vulnerability.

The National Co morbidity Survey Report provided the following information about PTSD in the general adult population: The estimated lifetime prevalence of PTSD among adults is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.

In recent history, the Indian Ocean Tsunami Disaster, which took place December 26, 2004 and took hundreds of thousands of lives, the September 11, 2001 attacks on the World Trade Centre and The Pentagon, and the impact and effects of Hurricane Katrina may have caused PTSD in many survivors and rescue workers.