Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a term for the psychological consequences of exposure to or confrontation with stressful experiences, which involve actual or threatened death, serious physical injury or a threat to physical integrity and which the person found highly traumatic. Symptoms can include reexperiencing phenomena such as nightmares and flashbacks, avoidance of reminders and emotional detachment, and hyperarousal with sleep abnormalities, extreme distress resulting from personal "triggers", irritability and excessive startle. There is also the possibility of simultaneous suffering of other psychiatric disorders. Experiences likely to induce the condition include rape, combat exposure, natural catastrophes, violent attacks, childbirth and perhaps its accompanying exhaustion, and childhood physical/emotional abuse. PTSD often becomes a chronic condition but can improve with treatment or even spontaneously.
PTSD is primarily an anxiety disorder and should not be confused with normal grief and adjustment after traumatic events. For most people, the emotional effects of traumatic events will tend to subside after several months. If they last longer than that then consideration should be given to diagnosing a psychiatric disorder. Most people who experience traumatic events will not develop PTSD. PTSD may have a delayed onset of years or even decades and may be triggered by a life event such as the death of someone close or the diagnosis of a serious medical condition. Once PTSD reaches the criteria for diagnosis the untreated course is generally for some worsening and then stability of the level of symptomatology over many years.
Psychological distress after trauma was reported in 1900 BC by an Egyptian physician who described hysterical reactions to trauma (Veith 1965). Hysteria was also related to traumatic reminiscences a century ago (Janet 1901). At that time Freuds pupil Kardiner was the first to describe what later became posttraumatic stress disorder symptoms (Lamprecht & Sack 2002). Hippocrates utilized a homeostasis theory to explain illness, and stress is often defined as the reaction to a situation that threatens the balance or homeostasis of a system (Antonovsky 1981).
The situation causing the stress reaction is defined as the stressor, but the stress reaction, and not the stressor is what jeopardizes the homeostasis (Aardal-Eriksson 2002). Posttraumatic stress is thus an imbalance according to stress theory. PTSD is a rather recent diagnosis in psychiatric nosology appearing in the Diagnostic and Statistical Manual of Mental Disorders (DSM) for the first time in 1980. It is claimed that the development of the PTSD concept partly has socio-economic and political implications (Mezey & Robbins 2001). War veterans were to a great deal incapacitated by psychiatric illness, including posttraumatic stress in the aftermath of the Vietnam war. They had however difficulties receiving economic compensation since there was no psychiatric diagnosis available by which they could claim indemnity. This situation has changed and PTSD is now the only psychiatric diagnosis for which a person can receive compensation such as a war veteran indemnity pension in the USA (Mezey & Robbins 2001). PTSD like symptoms were thus recognized in combat veterans following many historical conflicts however the modern understanding of the condition dates to the 1980s.
The diagnostic criteria for PTSD according to Diagnostic and Statistical Manual of Mental Disorders -IV (DSM-IV) go from A to F. It is noticeable that the stressor criterion A is divided into two parts. The first part A1 requires that the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The second part A2 requires that the persons response involved intense fear, helplessness, or horror. The DSM-IV A criterion differs substantially from the previous DSM-III-R stressor criterion which specified that the traumatic event should be of a type that would cause significant symptoms of distress in almost anyone, and that the event was outside the range of usual human experience. Therefore since the introduction of DSM-IV the number of possible PTSD-traumas has increased, and one study suggests that the increase is around 50% (Breslau & Kessler 2001).
Symptoms and their possible explanations
Symptoms can include general restlessness, insomnia, aggressiveness, depression, dissociation with reality, emotional detachment, or nightmares. Amplification of other underlying psychological conditions may also occur. Young children suffering from PTSD will often enact aspects of the trauma through their play, and may often have nightmares that lack any recognizable content.
One patho-psychological way of explaining PTSD is characterized by viewing the condition as secondary to deficient emotional or cognitive processing of a trauma (Cordova 2001). This view also helps to explain the three symptom clusters of the disorder (Shalev 2001).
Since the person cannot process the difficult emotions in a normal way she is plagued by recurrent nightmares, or daytime flashbacks, while she realistically reexperiences the trauma. These reexperiences are characterized by high anxiety levels, and make up one part of the PTSD symptom cluster triad called intrusive symptoms.
PTSD is also characterized by a state of nervousness with the organism being prepared for fight or flight. The typical hyperactive startle reaction characterized by jumpiness in connection with high sounds or fast motions is typical for another part of the PTSD cluster called hyperarousal symptoms, and could also be secondary to an incomplete processing.
The hyperarousal and the intrusive symptoms are eventually so distressing that the individual strives to avoid contact with everything, and everyone, even her own thoughts, that can arouse memories of the trauma and thus cause the intrusive and hyperarousal states to go on. She isolates herself, being detached in her feelings with a restricted range of emotional response, and can experience so-called emotional numbing. This avoiding behavior is the third and most important part of the symptom triad that makes up the PTSD criteria. The avoidance behavior could also be explained by a feeling of being different due to both the exclusiveness of the trauma and the strange and painful symptoms of intrusion and hyperarousal causing depersonalization.
Biology of PTSD
PTSD displays biochemical changes in the brain and body different from other psychiatric disorders such as major depression. In PTSD patients the dexamethasone cortisol suppression is strong while it is weak in patients with major depression. In most PTSD patients the urine secretion of cortisol is low, at the same time as the catecholamine secretion is high, and the norepinephrine/cortisol ratio is increased. Brain catecholamine levels are low, and corticotropin-releasing factor (CRF) concentrations are high. There is also an increased sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis with a strong negative feedback of cortisol due to a generally increased sensitivity of cortisol receptors (Yehuda, 2001). The response to stress in PTSD is abnormal with long-term high levels of norepinephrine, at the same time as cortisol levels are low, a pattern associated with facilitated learning in animals. Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response (Yehuda 2002). With this deduction follows that the clinical picture of hyperreactivity and hyperresponsiveness in PTSD is consistent with the sensitive HPA-axis. Swedish UN soldiers serving in Bosnia with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms following war trauma than soldiers with normal pre-service levels (Aardal-Eriksson 2001). Another possible factor in PTSD is that a persistence of depressive symptoms may be caused by an underlying biochemical disorder associated with insulin resistance (dysglycemia) that can be treated by a hypoglycemic diet. In animal research, a part of the brain called the amygdala has been shown to be needed to form fear memories. From brain imaging studies, the amygdala has also been shown to be active in human fear. Dysfunction of the amygdala may be involved in PTSD. Further animal and clinical research into the amygdala and fear conditioning may provide additional treatments for the condition.
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% (life threatening disease such as cancer) and 80% (rape) will develop PTSD depending on the severity of the trauma and personal vulnerability.
In peacetime, 30% of those that suffer will go on to develop a chronic condition; in wartime, the levels of disorder are believed to be higher.
In recent history the Indian Ocean Tsunami Disaster, which took place December 26, 2004 and took hundreds of thousands of lives and the September 11, 2001 attacks on the World Trade Center and the Pentagon may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as The Red Cross and the Salvation Army provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder.
Cancer as PTSD-trauma
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 in 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 5 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. Cancer trauma, like combat, is often characterized by extended duration with a potential for recurrence, and a varying immediacy of life-threat (Smith 1999).
PTSD is usually treated by a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and drug therapy (antidepressant or atypical antipsychotics, e. g. brand names such as Prozac(fluoxetine), Effexor (venlafaxin), Zoloft (sertraline), Remeron (mirtazapine), Zyprexa (olanzapine), or Seroquel (quetiapine)). 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. The US FDA recently approved a clinical protocol that combines the drug MDMA ("Ecstasy") with talk therapy sessions (this doesn't mean that Ecstasy has proven efficiency for treating PTSD). Basic counseling 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).
Dr. Jan Bastiaans of the Netherlands has developed a form of psychedelic psychotherapy involving LSD, with which he has successfully treated concentration camp survivors who suffer from PTSD.
PTSD is often comorbid with other psychiatric disorders with depression and substance abuse being the most common.
There have been scores of other treatments suggested for the treatment of PTSD. Two of these controversial techniques are Eye Movement Desensitisation and Reprocessing (EMDR) and Traumatic Incident Reduction (TIR).
EMDR is a technique developed by Dr. Francine Shapiro (Shapiro 1989), in which the therapist induces eye movements in the client which is meant to access the traumatic event and allow the integration of emotions and sensations that occurred during the traumatic event. Critics claim that EMDR is no more effective than CBT and that it derives its benefits from the therapist client interaction and not the eye movements. EMDR may increase our understanding of the mechanisms behind PTSD. The link is the rapid eye-movements (REM) sleep. During REM sleep the individual is presumably processing what she has experienced during the day. In PTSD the realistic nightmares of reexperiencing the trauma could be seen as unsuccessful processing of the trauma during REM sleep. EMDR then supposedly mimicks the brains activities during REM sleep. The eye movements per se may not be as important as the repetitive redirecting of attention in EMDR, which induces a neurobiological state, similar to that of REM sleep (Stickgold, 2002).
TIR is a less well known technique for reducing and eliminating the effects of a traumatic event. TIR is more of a graduated exposure technique that is controlled by the client. In TIR the client retells the trauma and releases the emotions held in check. In addition the client remembers the event and allows the conscious mind to process any decisions, intentions and cognitive distortions that might have occurred during or after the trauma. Practitioners who have been trained in both EMDR and TIR report that TIR is safer because it is focused on a single event and EMDR can occasionally trigger several events and multiple emotions. Interviews with these practitioners have suggested that, while they continue to use both techniques, TIR is the preferred intervention for known traumatic events where the client wants insight and understanding about the event and the aftereffects of the trauma. Both TIR and EMDR have been described as unscientific. TIR is derived from Scientology and has no controlled outcome studies to back any of their claims. It is not an empirically supported treatment and, under no circumstances, should this be a first-line treatment.
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