Post-traumatic stress disorder doesn't single out combat
veterans. It can also afflict those battling heart disease.
As soldiers return from Iraq and Afghanistan, post-traumatic
stress disorder is in the news again. Much has been learned about
this condition since its current name was coined during the
Vietnam War (see "What's in a name?"). One thing we've come to
realize is that post-traumatic stress disorder (PTSD) isn't
limited to soldiers, victims of a terrorist attack, or witnesses
of a horrifying event. It can also appear after heart trouble,
major surgery, or diagnosis of a serious illness such as cancer
What's in a name?
Although the term post-traumatic stress disorder has only
been around since the 1970s, the reality of it has been
with us since before the beginning of civilization. Early
humans attacked by animals or brutalized by their own
kind probably developed it. Achilles, the Greek warrior
at the center of Homer's Iliad, may have had it. During
the Civil War it was called "nostalgia" or "soldier's
heart"; in World War I, it was "shell shock." "Combat
neurosis" and "battle fatigue" were the preferred terms
during World War II and the Korean War. By the late 1970s
it had evolved into post-traumatic stress disorder. Today
it is disorder 309.81 in the Diagnostic and
Statistical Manual of Mental Disorders IV, the bible
of psychiatric diagnoses.
Imagine collapsing in the mall because your heart suddenly stops
beating. The next thing you know, you're jolted back to life by a
shock from a defibrillator and rushed to a hospital.
That's traumatic. So is a stroke, a
searing-pain-in-the-chest kind of heart attack, or open-heart
surgery. The more out of the blue the event, the more traumatic
it can be.
A small but growing body of research shows that the consequences
of heart disease or procedures for treating it can trigger
post-traumatic stress disorder. Not only does it cause emotional
and psychological distress, but it may slow recovery from a heart
attack, stroke, or surgery, and hasten the progression of heart
What is PTSD?
In a nutshell, post-traumatic stress disorder is a lasting and
exaggerated reaction to a terrifying or life-threatening event.
It makes you feel like you are living through the event over and
over again. PTSD shows itself in three main ways:
Re-experiencing. People with PTSD mentally relive
the triggering trauma in daytime flashbacks, nightmares, or
inescapable thoughts about the event. Sights, sounds, smells,
or other stimuli can bring the event to life.
Avoidance. People with PTSD tend to avoid people,
places, thoughts, feelings, and activities that remind them
of the trauma. They get less enjoyment out of family,
friends, work, and play, and they often become numb to both
positive and negative feelings.
Arousal. People with PTSD are constantly on guard
against danger. They have trouble falling asleep or staying
asleep. They tend to be irritable and have trouble
concentrating. And they startle easily.
These symptoms arise from the brain's circuits for instantly
responding to potentially life-threatening situations.
Traumatic events, such as engaging in hand-to-hand combat,
witnessing a bombing, or having a heart attack, set off the same
immediate responses in the brain. Danger warnings from the senses
streak into the brain and are shunted into two circuits. One
feeds straight into the amygdala, an almond-shaped structure deep
in the brain that coordinates the fear response. The amygdala is
responsible for immediately marshaling all the body's systems to
fight or to flee. It also activates the hippocampus, which helps
the brain form vivid, emotional memories. Creating memories like
this is actually a good survival strategy. It might, for example,
have put a hunter or gatherer on high alert without much
conscious thought when nearing an area where he or she saw a
fellow traveler attacked.
The second circuit is routed to the cortex, the part of the brain
that handles data processing and analysis. The cortex confirms
the danger, figures out what is causing it, and determines how
best to respond. Once the danger has passed, the cortex sends an
all-clear message even as it continues to process the event and
its aftermath. The anterior cingulate cortex seems to be involved
in responding to fear.
People with PTSD create memories of a traumatic event that are
stronger, more vivid, and more easily recalled than normal. An
overreactive amygdala may be partly to blame. Malfunctions in the
hippocampus and the anterior cingulate cortex, both of which help
keep the amygdala in check, may also contribute to PTSD.
PTSD and the brain
Three areas of the brain — the amygdala, hippocampus, and
the anterior cingulate cortex — appear to play key roles
in the development of PTSD.
PTSD and the heart
After a heart attack, sudden cardiac arrest, or stroke, almost
everyone has some post-traumatic stress. "These are big shocks to
the system and the psyche that often require a massive
readjustment to who you are and what you have been doing," says
Leonard Doerfler, a psychologist who has been studying the links
between heart disease and PTSD since the mid-1980s.
Most people recover and readjust, drawing on a combination of
inner strength, faith, and family or other support. Indeed, for
some people a heart attack or stroke sounds a wake-up call to
take stock and make positive changes in their relationships and
for their health. Others slide toward depression. Somewhere
between 5% and 10% of heart attack survivors develop symptoms of
PTSD. It has also been seen in people after a stroke, a heart
transplant or other major heart surgery, and implantation or
firing of a cardioverter/defibrillator.
One of the special problems of heart-related PTSD is that the
trauma comes from within. "The knowledge that your body betrayed
you once, and could very well do it again, has some heart attack
survivors walking on eggshells," says Doerfler, a professor of
psychology at Assumption College in Worcester, Mass. These people
are constantly on the alert for a racing heart, shortness of
breath, sweating, or other signs that preceded their heart
attacks. The trouble is, these are also normal responses to
physical activity, a traffic jam, or even a hot, humid day.
Interestingly, the severity of PTSD isn't related to the severity
of the heart attack or other traumatic event. Even a minor stroke
can kick off major PTSD.
People with heart-related PTSD may go to great lengths to avoid
reminders. Some stop climbing stairs, making love, gardening, or
doing other activities that make the heart beat faster. Some stop
taking aspirin and other medications because doing this reminds
them of their heart attack.
PTSD takes a toll on the body as well as the mind and
relationships. Cutting back on physical activity and not taking
important medications can set the stage for another heart attack
or stroke. Chronic activation of the fight-or-flight response may
increase blood pressure or cause potentially deadly heart
rhythms. It may also spur atherosclerosis, the process that leads
to cholesterol-clogged arteries and often culminates in a heart
attack or stroke.
Coping with PTSD
It's perfectly normal to feel anxious or down in the dumps for a
while after a heart attack, stroke, or open-heart surgery. So how
would you know if you or a loved one had PTSD? Think about these
Do you find yourself thinking about the traumatic event even
when you don't want to, or have nightmares about it?
Do you go out of your way to avoid situations, thoughts, or
feelings that remind you of it?
Do you feel constantly on alert, or find yourself getting
Are you feeling detached from family, friends, or other loved
ones, or avoiding people or activities that used to give you
Answering yes to three or four of these should prompt a talk with
a doctor or counselor about being evaluated for PTSD or
Treating PTSD usually starts with something called cognitive
behavioral therapy. This type of talk therapy aims to help a
person come to terms with a traumatic event by conjuring up
memories of it in a safe situation. While stressful at first,
this reimagining can gradually show that the memory itself isn't
harmful. It also helps tie together the traumatic memory and the
emotions it spawned. This makes it easier to file away the memory
as something that happened in the past, and not something that is
Reconnecting with people, interests, and activities is another
goal of therapy. This improves mental and physical activity as
well as social connections, all of which are good for the mind
and the heart.
In addition to talk therapy, some people benefit from taking an
antidepressant in the selective serotonin reuptake inhibitor
family. Two of these — paroxetine (Paxil, generics) and
sertraline (Zoloft, generics) — have been specifically approved
for treating PTSD. It's likely that the others in this group —
fluvoxamine (Luvox, generics), fluoxetine (Prozac, generics), and
citalopram (Celexa, Lexapro, generics) — also work.
One of the cruel ironies of heart-related PTSD is that the
symptoms often appear when recovery is well under way.
Recognizing the signs of PTSD (and depression), realizing they
aren't just "in your mind," and getting help will be good for
your heart, your health, and your life.
More information and further reading
The booklet "Post-Traumatic Stress Disorder, A Real
Illness" is available from the National Institute of
Mental Health by calling 866-615-6464 (toll free) or
The Anxiety Disorders Association of America offers
information and support for people with PTSD as well as
family and friends: 240-485-1001 or www.adaa.org.
Two books by Boston psychiatrist Jonathan Shay —
Achilles in Vietnam: Combat Trauma and the Undoing of
Character (Scribner, 1995) and Odysseus in
America: Combat Trauma and the Trials of Homecoming
(Scribner, 2003) — draw striking parallels between the
experiences of American soldiers and warriors from