Post-traumatic stress disorder
In the aftermath of a life-threatening trauma, most people recover
with the support of family and friends. But some develop post-traumatic
stress disorder (PTSD), an anxiety disorder that may last a lifetime
if appropriate help is not available. Many unwelcome and unanticipated
life events, such as a spouse’s betrayal or the loss of a job,
can cause distressing emotional reactions, but most such events don’t
lead to Post Traumatic Stress Disorder (PTSD). Under the current official
definition, PTSD is diagnosed only if you have been exposed to actual
or threatened death or serious injury and responded with fear, helplessness,
However, the definition of PTSD is broadening, as mental health professionals
gain more experience with the disorder. Individual traits and circumstances
help determine how an event is perceived and how emotionally overwhelming
it is. In making a diagnosis of PTSD, a mental health professional considers
both the type of trauma and the individual’s reaction. The point
in a person’s life when a trauma occurs may also predict her likelihood
of developing the disorder.
First described in male war veterans, PTSD is now known to occur in
children and women as well, following a range of experiences. Motor vehicle
accidents are a leading cause of PTSD in both men and women. In women,
rape frequently results in PTSD, and some women develop PTSD after a
traumatic childbirth. Child abuse, including sexual abuse, can lead to
chronic PTSD even if force was not involved. PTSD may also occur following
a heart attack or diagnosis of cancer. Health care workers confronted
with the aftermath of violence or natural disaster can also develop PTSD.
What are the symptoms?
Mental health professionals divide the symptoms of PTSD into three types:
- Intrusion: Re-experiencing the trauma
in nightmares, daytime flashbacks, unwanted memories, thoughts, images,
or sensations. Cues resembling some aspect of the event can cause
intense emotional and physical distress, and the person may feel
and act as if the event is recurring.
- Avoidance: Avoiding thoughts, feelings,
activities, places, and people associated with the trauma. This may
result in social withdrawal and becoming numb to positive as well
as negative emotions.
- Arousal: Being constantly on guard, resulting
in insomnia, irritability, outbursts of anger, difficulty concentrating,
or being easily startled. Some people have panic attacks.
After a trauma, it’s normal to experience many of these symptoms
temporarily. Symptoms lasting more than three months are considered chronic
PTSD. Occasionally, someone develops “delayed PTSD” six months
later or more, following a reminder of the event.
Untreated PTSD takes a toll on the body as well as the mind. In the
June 28, 2004, Archives of Internal Medicine, researchers from
the Veterans Administration reported that women with PTSD have more medical
conditions and worse physical health than non-traumatized women, even
those with depression.
How PTSD occurs
The body responds to a traumatic event by releasing adrenaline, a stress
hormone that prepares the body to flee or fight. In the brain, adrenaline
and the brain chemical norepinephrine stimulate the amygdala, a deep
brain structure that spurs the formation of vivid, emotional memories
of the threat. In PTSD, memories and environmental cues provoke out-of-proportion
fear responses to ordinary situations, interfering with normal functioning.
“The amygdala appears to be overreactive in PTSD. We’re
currently examining whether it is already overreactive, making someone
more vulnerable to PTSD, or becomes that way in response to trauma,” says
Roger K. Pitman, M.D., professor of psychiatry at Harvard Medical School. “We’ve
also found that two areas of the brain which help keep the amygdala in
check, the hippocampus and the anterior cingulate cortex, appear not
to function as well in those with PTSD.”
Psychotherapy is the centerpiece of most PTSD treatment. The most specific
is a cognitive behavioral approach called exposure therapy,
which provides a safe environment for you to confront a situation that
you fear. People with PTSD often feel that the only way to reduce their
anxiety is to avoid anything that stirs their memories of the trauma.
But gradual and repeated exposure can reduce symptoms and help change
how you respond to the triggering situations.
The particulars of the trauma and personal history influence not only
the likelihood of developing PTSD but also the effectiveness of therapy.
Specialists from the University of Pennsylvania found that, even after
cognitive behavioral therapy, female assault victims had more severe
PTSD symptoms if they were physically injured during the attack or had
been subject to trauma during childhood. To plan treatment, a therapist
is likely to ask about any history of sexual or physical abuse.
If several weeks of psychotherapy don’t resolve symptoms (or if
additional help is needed), medications may be prescribed. Depending
on how well an individual tolerates the medication, and how long she’s
had PTSD symptoms, an approved drug may be prescribed for 6–24
months. The selective serotonin reuptake inhibitors (SSRIs) sertraline
(Zoloft) and paroxetine (Paxil) are FDA-approved for the treatment of
PTSD, although not all clinical trials have shown them to work better
than placebo. Although medication and psychotherapy have not been directly
compared, the combination seems to work better than medication alone.
Can PTSD be prevented?
Preventive medication is under consideration. Working on the understanding
that adrenaline acts to strengthen memories, Dr. Pitman and other researchers
at Massachusetts General Hospital are testing whether an adrenaline-reducing
medication, the hypertension drug propranolol, might help block abnormal
memory formation and prevent PTSD. In a 2002 pilot study, people who
received a 10-day course of propranolol, starting within hours of a trauma,
were less likely than those who received a placebo to develop PTSD symptoms.
April 2005 Update
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