Post-traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) is an emotional illness classified as a trauma- and stressor-related disorder as of the most recent edition of the diagnostic reference for mental health disorders, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 or DSM-V). This condition usually develops because of a terribly frightening, life-threatening, or otherwise highly unsafe experience. PTSD sufferers re-experience the traumatic event or events in some way, tend to avoid places, people, or other things that remind them of the event (avoidance), and are exquisitely sensitive to normal life experiences (hyperarousal).

Although not specifically described in the DSM-5, complex post-traumatic stress disorder (C-PTSD) is recognized in the international manual for diseases, called the International Statistical Classification of Diseases and Related Health Problems (ICD-10). It usually results from prolonged exposure to a traumatic event or series thereof and is characterized by long-lasting problems with many aspects of emotional and social functioning. Compared to people who suffer from PTSD, those who have C-PTSD are at higher risk of engaging in self-harm, including suicide attempts and completion.

Statistics regarding this illness indicate that a low percentage of people in the United States will likely develop PTSD in their lifetime. Combat veterans and rape victims have a lifetime prevalence of PTSD. Somewhat higher rates of this disorder occur in African Americans, Hispanics, and Native Americans compared to Caucasians in the United States. Some of those differences are thought to be due to higher rates of dissociation soon before and after the traumatic event (peritraumatic), a tendency for individuals from minority ethnic groups to blame themselves, have less social support, and an increased exposure to racism for those ethnic groups, as well as differences between how ethnic groups may express distress. In military populations, many of the differences have been found to be the result of increased exposure to combat at younger ages for minority groups.

Other important facts about PTSD include the estimate of 8 million people who suffer from PTSD at any one time in the United States and the fact that women are twice as likely as men to develop PTSD.

Almost half of individuals who use outpatient mental health services suffer from PTSD. As evidenced by the occurrence of stress in many individuals in the United States in the days following the 2001 terrorist attacks, not being physically present at a traumatic event does not guarantee that one will not suffer from traumatic stress that can lead to the development of PTSD.

Virtually any trauma, defined as an event that is life threatening or that severely compromises the physical or emotional well-being of an individual or causes intense fear, may cause PTSD. Such events often include either

• experiencing or witnessing a severe accident or physical injury; 
• receiving a life-threatening medical diagnosis;
• being the victim of kidnapping or torture; 
• exposure to community violence, war combat, or to a natural disaster; 
• exposure to other disaster (for example, plane crash) or terrorist attack;
• being the victim of rape, mugging, robbery, or assault;
• enduring physical, sexual, emotional, or other forms of abuse; and
• involvement in civil conflict.

Although the diagnosis of PTSD currently requires that the sufferer has a history of experiencing a traumatic event as defined here, people may develop PTSD in reaction to events that may not qualify as traumatic but can be devastating life events like divorce or unemployment.

Issues that tend to put people at higher risk for developing PTSD include

• increased duration of a traumatic event;
• higher number of traumatic events endured;
• higher severity of the trauma experienced; 
• having an emotional condition prior to the event; or
• having little social support in the form of family or friends.

In addition to those risk factors, children and adolescents, females, minority groups and people with learning disabilities or violence in the home seem to have a greater risk of developing PTSD after a traumatic event.

According to the DSM-5, the following three groups of symptom criteria are required to assign the diagnosis of PTSD in the context of an individual who has a history of being exposed to an actual or perceived threat of death, serious injury, or sexual violence to self or others that does not involve exposure through media unless that is work related:

• Recurrent re-experiencing of the trauma (for example, troublesome memories, flashbacks usually caused by reminders of the traumatic events, recurring nightmares about the trauma and/or dissociative reliving of the trauma): In children, this may include repetitive play about the trauma.
• Avoidance to the point of having a phobia of places, people, and experiences that remind the sufferer of the trauma, or a general numbing of emotional responsiveness
• Negative changes in thinking and trouble remembering important aspects of the trauma, holding negative beliefs about him or herself, a tendency to blame oneself for the trauma, a persistently negative emotional state, inability to have positive emotions, low interest or participation in significant activities, and feeling detached from others
• Significant changes in arousal and reactivity related to the traumatic event(s), including sleep problems, trouble concentrating, irritability, anger, poor concentration, blackouts or difficulty remembering things, reckless or self-destructive behavior, increased tendency and reaction to being startled, and hypervigilance (excessive watchfulness) to threat

The emotional numbing of PTSD may present as a lack of interest in activities that used to be enjoyed (anhedonia), emotional deadness, distancing oneself from people, and/or a sense of a foreshortened future (for example, not being able to think about the future or make future plans, not believing one will live much longer). At least one re-experiencing symptom, one avoidance symptom, two negative changes in mood or thinking, and two hyperarousal (fight or flight) symptoms must be present for at least one month and must cause significant distress or impairment in functioning in order for the diagnosis of PTSD to be assigned.

A similar disorder in terms of symptom repertoire is acute stress disorder. The major differences between the two disorders are that acute stress disorder symptoms persist from three days to one month after the trauma exposure, and a fewer number of traumatic symptoms are required to make the diagnosis as compared to PTSD.

Symptoms of PTSD that tend to be associated with C-PTSD include

• problems regulating feelings, which can result in suicidal thoughts, explosive anger, or passive aggressive behaviors;
• a tendency to forget the trauma or feel detached from one's life (dissociation) or body (depersonalization);
• persistent feelings of helplessness, shame, guilt, or being completely different from others;
• feeling the perpetrator of trauma is all powerful; and
• preoccupation with either revenge against or allegiance with the perpetrator, and;
• severe change in those things that give the sufferer meaning, like a loss of spiritual faith or an ongoing sense of helplessness, hopelessness, or despair.

For individuals who may be wondering if they should seek evaluation for PTSD by their medical or mental health professional, self-tests may be useful. The National Institute of Mental Health offers a self-test for PTSD. The assessment of PTSD can be difficult for practitioners to make since sufferers often come to the professional's office complaining of symptoms other than anxiety associated with a traumatic experience. Those symptoms tend to include body symptoms (somatization), depression, or drug addiction. Studies of Iraq war veterans indicate that these individuals tend to show more physical symptoms of PTSD as opposed to describing the associated emotional problems.

Many people with PTSD may present with a history of making suicide attempts. In addition to depression and substance-use disorders, the diagnosis of PTSD often co-occurs (is comorbid) with bipolar disorder (manic depression), eating disorders, and other anxiety disorders like obsessive compulsive disorder (OCD), panic disorder, social anxiety disorder, and generalized anxiety disorder.

Treatments for PTSD usually include trauma-focused psychological and medical interventions. Providing information about the illness, helping the individual manage the trauma by talking about it directly, teaching the person ways to manage symptoms of PTSD, and exploration and modification of inaccurate ways of thinking about the trauma are the usual techniques used in psychotherapy for this illness. Education of PTSD sufferers usually involves teaching individuals about what PTSD is, how many others suffer from the same illness, that extraordinary stress causes PTSD rather than personal weakness, how it is treated, and what to expect in treatment. This education thereby increases the likelihood that inaccurate ideas the person may have about the illness are dispelled, and any shame they may feel about having it is minimized. This may be particularly important in populations like military personnel that may feel particularly stigmatized by the idea of seeing a mental health professional and therefore avoid doing so.

Teaching people with PTSD practical approaches to coping with what can be very intense and disturbing symptoms is a useful way to treat the illness. Specifically, helping sufferers learn how to manage their anger and anxiety, improve their communication skills, and use breathing and other relaxation techniques can help individuals with PTSD gain a sense of mastery over their emotional and physical symptoms. Other types of therapy for PTSD include

• Exposure-based cognitive behavioral therapy has the person with PTSD recall their traumatic experiences using images or verbal recall while using the coping mechanisms they learned.
• Cognitive behavioral psychotherapy can help people with PTSD recognize and adjust trauma-related thoughts and beliefs by educating sufferers about the relationships between thoughts and feelings, exploring common negative thoughts held by traumatized individuals, developing alternative interpretations, and by practicing new ways of looking at things. 
• Intensive exposure therapy, which often involves multiple extensive sessions over several days followed by several weekly sessions over six months or more, is an evidence-based treatment that has been found to help people who have chronic PTSD. 
• Eye-movement desensitization and reprocessing (EMDR) is a form of cognitive therapy in which the health care professional guides the person with PTSD in talking about the trauma suffered and the negative feelings associated with the events, while focusing on the professional's rapidly moving finger during one-on-one treatment sessions. While some research indicates this treatment may be effective, it is unclear if this is any more effective than cognitive therapy done without the use of rapid eye movement.

Helping PTSD sufferers maintain their employment and other tasks of their daily lives is an important part of treatment. Occupational therapy (OT) is an important treatment modality in that regard, in that it focuses on rehabilitation and recovery through participation in activities. This can range from assisting helping people with PTSD regain independence in basic self-care to helping them reintegrate into previously held work and community roles. Another potentially powerfully positive activity-based intervention for individuals with PTSD can be the use of a service dog. Particularly toward the completion of more conventional treatments, service dogs have been found to be effective in improving PTSD suffers' sense of safety, responsibility, optimism, and self-awareness.

Families of PTSD individuals, as well as the sufferer, may benefit from family counseling, couples counseling, parenting classes, and conflict-resolution education. Family members may also be able to provide relevant history about their loved one (for example, about emotions and behaviors, drug abuse, sleeping habits, and socialization) that people with the illness are unable or unwilling to share.

Directly addressing the sleep problems that can be part of PTSD not only helps alleviate those problems but thereby helps decrease the symptoms of PTSD in general. Specifically, rehearsing adaptive ways of coping with nightmares (imagery rehearsal therapy), training in relaxation techniques, positive self-talk, and screening for other sleep problems can be helpful in decreasing the sleep problems associated with PTSD.

Medications that help PTSD sufferers include serotonergic antidepressants (SSRIs) and medicines that help decrease the physical symptoms associated with illness, like propranolol and other medications. Individuals with PTSD are much less likely to experience a relapse of their illness if the person continues antidepressant treatment for at least a year. SSRIs tend to help PTSD sufferers modify information that is taken in from the environment (stimuli) and to decrease fear. Research also shows that this group of medicines tends to decrease anxiety, depression, and panic. SSRIs may also help reduce aggression, impulsivity, and suicidal thoughts that can be associated with this disorder. 

Other less directly effective but nevertheless potentially helpful medications for managing PTSD include mood stabilizers and antipsychotics. 

Benzodiazepines have unfortunately been associated with a number of problems, including withdrawal symptoms, and risks of overdose and addiction, and have not been found to be significantly effective for helping individuals with PTSD.

While disaster-preparedness training is a good idea in terms of improving the immediate physical safety and logistical issues involved with a traumatic event, such training may also provide important preventive factors against developing PTSD. That is as evidenced by the fact that those with more professional-level training and experience (for example, police, firefighters, mental health professionals, paramedics, and other medical professionals) tend to develop PTSD less often when coping with disaster than those without the benefit of such training or experience. People who have experienced trauma but are not members of those professions have been found to be less likely to develop PTSD if they receive imaging exposure and therapeutic processing by trained professionals within a day of the trauma and weekly sessions for at least two weeks thereafter.

There are medications that help prevent the development of PTSD. Some medicines that treat depression, decrease the heart rate, or increase the action of other body chemicals are effective tools in the prevention of PTSD when given in the days immediately after an individual experiences a traumatic event.

A number of factors improve the prognosis (outlook) for people with PTSD. They include personal attributes like above-average cognitive abilities, high self-esteem and optimism, interpersonal abilities like good social skills, problem solving, and impulse control, and external factors like secure attachment, sense of safety, and environmental stability.

Some suggested ways for PTSD patients to cope with this illness include

• learning more about the disorder as well as talking to friends, family, professionals, and PTSD survivors for support;
• joining a support group;
• reducing stress by using relaxation techniques (for example, breathing exercises, positive imagery); 
• actively participating in treatment as recommended by professionals; 
• increasing positive lifestyle practices (for example, exercise, healthy eating, distracting oneself through keeping a healthy work schedule if employed; 
• volunteering whether employed or not); and
• minimizing negative lifestyle practices like substance abuse, social isolation, working to excess, and self-destructive or suicidal behaviors.

Air Force Palace HART
Phone: 800-774-1361
Email: [email protected]

American Love and Appreciation Fund (for veterans)
305-673-2856

Army Wounded Warrior Program
Phone: 800-237-1336 or 800-833-6622

DHSD Deployment Helpline
Phone: 800-497-6261

Marine for Life
Phone: 866-645-8762
Email: [email protected]

Military One Source
Phone: 800-342-9647
http://www.militaryonesource.com/

Military Severely Injured Center
Phone: 800-774-1361
Email: [email protected]

National Center for PTSD
http://www.ptsd.va.gov
802-296-6300

National Coalition Against Sexual Assault
Phone: 717-728-9764

National Alliance for Mentally Ill
Phone: 800-950-6264

National Institute of Mental Health
http://www.nimh.nih.gov
Email: [email protected]
866-615-6464

National Mental Health Association
Phone: 800-969-6642

Navy Safe Harbor
Phone: 800-774-1361
Email: [email protected]

Operation Comfort (for veterans and their families)
Phone: 866-632-7868 (1-866-NEAR TO U)

PTSD Alliance
888-436-6306
http://www.ptsdalliance.org

PTSD Information Hotline
Phone: 802-296-6300

PTSD Sanctuary
Phone: 800-THERAPIST

Rape, Abuse and Incest National Network
Phone: 800-656-HOPE
http://www.rainn.org

U.S. Department of Veterans Affairs
Crisis Line: 800-273-8255
http://www.mentalhealth.va.gov