Post-Traumatic Stress Disorder

What Is It?

In post-traumatic stress disorder (PTSD), distressing symptoms occur after one or more frightening incidents. For the most part, a person with this disorder must have experienced the event him or herself, or witnessed the event in person. The person may also have learned about violence to a close loved one. The event must have involved serious physical injury or the threat of serious injury or death.

Exposure to violence through media (news reports or electronic images) is usually not considered a traumatic incident for the purposes of this diagnosis, unless it is part of a person's work (for example, police officers or first responders to a violent event).

Some examples of traumas include:

• Military combat (PTSD was first diagnosed in soldiers and was known as shell shock or war neurosis)
• Serious motor vehicle accidents, plane crashes and boating accidents
• Industrial accidents
• Natural disasters (tornadoes, hurricanes, volcanic eruptions)
• Robberies, muggings and shootings
• Rape, incest and child abuse
• Hostage-taking and kidnappings
• Political torture
• Imprisonment in a concentration camp
• Refugee status

In the United States, physical assault and rape are the most common stressors causing PTSD in women, and military combat is the most common PTSD stressor in men.

Stress of this severity does not automatically cause PTSD. In fact, most people who are exposed to terrible trauma do not develop this particular illness. The severity of the stressor does not necessarily match the severity of symptoms. Responses to trauma vary widely. Many people develop mental disorders other than PTSD.

Acute Stress Disorder is the term used when symptoms develop within the first month after a traumatic event. The term PTSD with delayed onset (or delayed expression) is used when symptoms surface six months or more after the traumatic event.

It is not clear what makes some people more likely to develop PTSD. Certain people may have a higher risk of PTSD because of a genetic (inherited) predisposition toward a more intense reaction to stress. Another way to put this is that some people have greater inborn resilience in response to trauma. A person's personality or temperament may affect the outcome after a trauma. Lifetime experience of other traumas (especially in childhood) and current social support (having loving and concerned friends and relatives) also may influence whether or not a person develops symptoms of PTSD.

People with PTSD are more likely to have a personality disorder. They also are more likely to have depression and to abuse substances.

Up to 3% or so of all people in the United States have full-fledged PTSD in any given year. Up to 10% of women and 5% of men have PTSD at some point in their lifetime. Although PTSD can develop at any time in life, the disorder occurs more frequently in young adults than in any other group. This may be because young adults are more frequently exposed to the types of traumas that can cause PTSD. The risk of developing PTSD is also higher than average in people who are poor, unmarried or socially isolated, perhaps because they have fewer supports and resources helping them to cope.

Symptoms

The way PTSD is defined has evolved over the last 20 years or more. As research evolves, so does the description of the illness.

In most cases, a diagnosis of PTSD requires that you have been exposed to a severe trauma. The trauma must have happened directly to you, you must have witnessed the event in person, or — if you were not present for the trauma, it occurred to someone very, very close to you. The trauma must have involved death, or serious physical injury, or the threat of serious injury or death.

At some later time, you may begin to have the following symptoms:

• Experiencing intrusive mental images, thoughts or upsetting dreams related to the traumatic event
• Feeling as if the trauma is recurring
• Having marked anxiety and physical distress (shortness of breath, dizziness, palpitations, sweating)
• Avoiding all reminders (thoughts, people, conversations, activities) of the trauma
• Being unable to remember important details about the trauma
• Having markedly negative beliefs or expectations about oneself or others
• Persistently blaming oneself or others for the trauma
• Unrelenting negative emotion
• Losing interest in activities that were once enjoyable
• Feeling detached or disconnected from other people
• Feeling emotionally numb (unable to experience positive emotions, such as love)
• Believing that your life will be shorter than originally expected
• Being constantly on guard against danger and feeling easily startled
• Feeling stirred up (having trouble sleeping, being irritable, aggressive, reckless or self-destructive, lacking concentration)
• According to the definition, PTSD symptoms must last for at least one month and must seriously affect your ability to function normally at home, at work or in social situations.

Diagnosis

In addition to asking about the traumatic events that triggered your symptoms, your doctor will ask about your life history and will ask you to describe both positive experiences and negative or traumatic ones. Your current circumstances are very important.

Your doctor will evaluate the possibility that a different disorder might be at the root of your distress. You may have an anxiety disorder (for example, panic disorder). Or perhaps you have a mood disorder, such as depression or bipolar disorder. People with PTSD often turn to alcohol or drugs for relief, so don't be surprised by detailed questions about such use. If you have a problem with substances, treatment is essential.

Here are sample questions your doctor may ask:

• What experiences have been traumatic and what was your reaction?
• Do you have nightmares or frightening recollections of the trauma that intrude on your everyday life?
• Do situations, conversations, people or things remind you of the trauma? How do you react to these reminders?
• What is your current emotional state?
• Do you feel irritable or edgy? Do you startle easily?
• Is your sleep disturbed?
• Do you have difficulty concentrating?
• Has your interest in everyday or pleasurable activities fallen off?
• Is anything making your anxiety worse, such as medical problems or stress?
• Do you drink too much coffee or alcohol, smoke cigarettes or use drugs? (Drug or alcohol dependency and withdrawal sometimes can cause symptoms that mimic those of PTSD.)
• Can you describe your important relationships?
• Do you get support from family or friends?
• How do you feel about the future?

Expected Duration

By definition, symptoms of PTSD must last for at least one month. Untreated PTSD can be long-lasting. Symptoms may come and go over many years. For example, according to one study of World War II prisoners of war, 29% of those who developed PTSD still had symptoms more than 40 years after the conflict ended.

Prevention

Some trauma cannot be prevented, but it can be a great source of relief to receive counseling and supportive therapy immediately afterward. Don't let others push you to describe all the details of the trauma because such conversations may re-expose you to the trauma as you relive it in your mind. (A technique called "critical incident stress debriefing," has not been shown to reduce risk. In fact, controlled studies indicate that this technique may actually increase risk of developing PTSD. The term, debriefing, refers to a process of asking detailed questions about a traumatic experience.)

Not all victims of a trauma want treatment, and that should be respected because most victims recover on their own with the support of family and friends. Treatment, however, should be made available to those who want it. In the aftermath of a traumatic event, health professionals should attend to a victim's basic physical and emotional needs first, providing reassurance and emphasizing coping.

Treatment

Treatment can take a long time, which may explain the high dropout rate. Some researchers have found that three-quarters of people with PTSD stop treatment. However, treatment (usually a combination of psychotherapy and medications) can be helpful if you stick with it.

Psychotherapy

The aim of psychotherapy is to help a person cope with painful memories and manage emotional and physical reactions to stress. A variety of techniques can be helpful. Regardless of the technique used, education about human responses to trauma is valuable. Psychotherapy and education can help family members understand the disorder and cope with its effects.

If you have had a frightening experience, it can change your view of the world. Dealing with the stress of a traumatic event can be more difficult if you see yourself as a victim and your self-image centers on your experience of being a victim. If psychotherapy reinforces this belief, it can be counterproductive. In psychotherapy, you can recognize that tragedy, violence and evil are human experiences, that the desire for revenge or compensation is normal, but that many parts of your life remain in your control. The goal is to help you live the best life you can despite the frightening experience.

Some people with PTSD do better with more structured psychotherapy. Others may need a place to explore the connection between traumatic experiences and one's personal development.

Two of the techniques that can be helpful and it is quite common in practice to combine elements of both:

Cognitive behavioral therapy (CBT) is a therapy that aims to change negative thinking. CBT techniques teach a person to recognize the origin of the symptoms and modify the painful psychological and physical reactions that occur when a person is reminded of a trauma. Here are two examples:

Exposure therapy. This technique gradually re-exposes a person to traumatic images and ideas in a safe, controlled setting. The patient practices techniques designed to make feelings more manageable.

Cognitive restructuring. This technique helps people deal with feelings like guilt or shame that may be wrongly associated with traumatic experiences. Another aim is to learn how to cope with one's thoughts more realistically.

Psychodynamic psychotherapy is less structured than CBT. It focuses on how the trauma has impaired your ability to manage emotions or soothe yourself in times of stress. The psychotherapy takes into account your unique experiences in life. People often become overwhelmed by a detailed remembering of traumatic events, so it is not a good idea to devote too much attention to the trauma itself, especially in the early phases of psychotherapy. In later phases, when you feel more secure, you can confront ideas and situations that get in the way of putting your self-concept back together. Reconstructing traumatic events should not be a goal in itself.

Medications

People respond to severe stress in many different ways. Your doctor may recommend medications for prominent symptoms. Controlled studies have not yet provided clear guidance about which medications are most helpful. Several classes of medications are commonly prescribed to treat PTSD. Antidepressants have been used most and can provide some relief. Some of the most commonly used drug classes are described below:

Antidepressants — Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and several new antidepressants are used to treat chronic problems with anxiety, depression and irritability. SSRIs include sertraline (Zoloft) and paroxetine (Paxil), which have been approved by the U.S. Food and Drug Administration (FDA) for treating adults with PTSD. Other SSRIs — fluoxetine (Prozac), paroxetine (Paxil) and citalopram (Celexa) — may also be prescribed. If an SSRI does not work, or you can't tolerate the side effects, your doctor may suggest one of the relatively new antidepressants, such as venlafaxine (Effexor), or one of the older tricyclic antidepressants, such as imipramine (Tofranil) and amitriptyline (Elavil).

Antianxiety drugs — Benzodiazepines are a family of medicines that can be helpful for the short-term work well in the treatment of anxiety, including the symptoms of PTSD. They include diazepam (Valium), clonazepam (Klonopin), and lorazepam (Ativan).

The FDA requires all benzodiazepines to carry the strongest warning regarding the risks of dependency, addiction, or withdrawal symptoms. The FDA also emphasized the importance of not combining a benzodiazepine drug with an opioid because it can stop a person’s breathing.

As an alternative, doctors may prescribe the antianxiety drug buspirone (BuSpar). Buspirone takes longer to work than do benzodiazepines, but it may be safer for long-term use in certain patients.

Adrenergic inhibitors — These fall into two groups, the alpha-adrenergic agonists (for example, prazosin and clonidine) and beta-blockers (like propranolol and metoprolol). These medications alter nerve pathways that bring about the physical symptoms of anxiety, such as tremor or rapid heartbeat. Although theoretically such drugs may block symptoms of PTSD, controlled studies have not yet proven them to be effective at preventing the disorder.

Mood stabilizers — These medications also are used to treat mood symptoms. They are sometimes used alone and sometimes used in combination with antidepressants or antianxiety medications. Examples are valproic acid (Depakote) and lithium (sold under several brand names).

Antipsychotic medications — These medications are sometimes used to boost the effect of antidepressants and may be offered after other combinations of medications have been tried.

When To Call a Professional

If you have been exposed to one of the traumatic stressors that can trigger PTSD or if you already have PTSD symptoms, consult your doctor. He or she can direct you to a qualified therapist who will help you to identify your reactions to the trauma and deal with them.

Prognosis

The long-term outlook for PTSD varies widely and depends on many factors, such as your ability to cope with stress, your personality or temperament, a history of depression, the use of substances, the nature of social support, your level of ongoing stress and your ability to stay in treatment. Overall, about 30% of people eventually recover completely with proper treatment, and another 40% get better, even though less-intense symptoms may remain. Treatment with psychotherapy and/or medications, such as SSRIs, has been very helpful. Even without formal treatment, many people receive the support they need to make a successful adjustment as time puts distance between them and the traumatic event.

Additional Info

American Psychiatric Association
https://www.psychiatry.org/

National Institute of Mental Health
https://www.nimh.nih.gov/

National Center for PTSD
www.ptsd.va.gov/