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Post-traumatic stress disorder
ICD-10 F43.1
ICD-9 309.81
OMIM {{{OMIM}}}
DiseasesDB {{{DiseasesDB}}}
MedlinePlus {{{MedlinePlus}}}
eMedicine {{{eMedicineSubj}}}/{{{eMedicineTopic}}}
MeSH {{{MeshNumber}}}

Post-traumatic stress disorder (PTSD) is a term for certain psychological consequences of exposure to, or confrontation with, stressful experiences that the person experiences as highly traumatic. [1] The experience must involve actual or threatened death, serious physical injury, or a threat to physical and/or psychological integrity. It is occasionally called post-traumatic stress reaction to emphasize that it is a routine result of traumatic experience rather than a manifestation of a pre-existing psychological weakness on the part of the patient.

It is possible for individuals to experience traumatic stress without manifesting Post-Traumatic Stress Disorder, as indicated in the Diagnostic and Statistical Manual of Mental Disorders.

Symptoms of PTSD can include the following: nightmares, flashbacks, emotional detachment or numbing of feelings (emotional self-mortification or dissociation), insomnia, avoidance of reminders and extreme distress when exposed to the reminders ("triggers"), irritability, hypervigilance, memory loss, and excessive startle response, clinical depression and anxiety, loss of appetite.


For most people, the emotional effects of traumatic events will tend to subside after several months; if they last longer, then a psychiatric disorder may be diagnosed. Most people who experience traumatic events will not develop PTSD - PTSD is thought to be primarily an anxiety disorder and should not be confused with normal grief and adjustment after traumatic events. It is also possible to suffer (comorbidity) of other psychiatric disorders; these disorders often include clinical depression, general anxiety disorder and a variety of addictions. PTSD may have a delayed onset of months, years or even decades and may be triggered by an external factor or factors.

Experiences likely to induce the condition include:

  • childhood physical/emotional or sexual abuse; also, witnessing such abuse inflicted on another child or adult
  • violent physical assaults (at any age)
  • adult experiences of rape or warfare
  • witnessing and/or surviving a terrorist attack
  • experiencing or witnessing physical or psychological torture
  • occupational experiences, such as through police work or combat exposure (combat stress reaction)
  • living through a natural disaster, such as a tornado, tsunami, or severe earthquake
  • witnessing the sudden death of a loved one
  • having or witnessing a serious automobile accident
  • experiencing a vicious attack by a dog, shark, mountain lion, etc.
  • having a close brush with death as a result of nearly [drowning, electric shock, life-threatening medical complications, falling from great height, etc.
  • having a "bad trip" after taking hallucinogenic drugs
  • being subjected to psychological or physical abuse as a member of — or separation from — a cult, religious sect etc
  • serious exploitation, such as through prostitution or enslavement

Main ArticlesEdit

Main article: PTSD: History of the disorder.
Main article: PTSD - Biological factors
Main article: PTSD: Neuroscience of memory perspective
Main article: PTSD:Theoretical approaches.
Main article: PTSD:Epidemiology.
Main article: PTSD:Risk factors.
Main article: PTSD:Etiology.

Main article: PTSD:Diagnosis & evaluation.
Main article: PTSD:Comorbidity.
Main article: PTSD:Treatment.
Main article: PTSD:Prognosis.
Main article: PTSD:Service user page.
Main article: PTSD:Carer page.

BackgroundEdit

The first case of psychological distress was reported in 1900 BCE, Egypt by an Egyptian physician who described "hysterical" reaction to trauma (Veith 1965). Hysteria was also related to "traumatic reminiscences" a century ago (Janet 1901). At that time, Sigmund Freud's pupil, Kardiner, was the first to describe what later became known as symptoms of post-traumatic stress disorder (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). Post-traumatic stress can thus be seen as a chemical imbalance of neurotransmitters, according to stress theory.

Railway spine was a nineteenth-century diagnosis for the post-traumatic symptoms of passengers involved in railroad accidents.

The first full length medical study of the condition was John Eric Erichsen's On Railway and Other Injuries of the Nervous System, published in 1864. For this reason, railway spine is often known as "Erichsen's disease".

Many physicians thought that the symptoms were due to the "excessive speeds" (about 30 mph) of the trains, and that the human body could not cope with speeds that fast. It was later found to be purely psychological in origin, and no longer exists as a valid disorder.

However, PTSD in and of itself is a relatively recent diagnosis in psychiatric nosology, first appearing in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. It has been said that development of the PTSD concept has, in part, socio-economic and political implications (Mezey & Robbins 2001). War veterans are the most publicly-recognised victims of PTSD; long-term psychiatric illness was formally observed in World War I veterans but did not appear to enter the public consciousness until the aftermath of the Vietnam War - however, victims had difficulties receiving economic compensation since there was no psychiatric diagnosis available by which veterans could claim indemnity. This situation has changed during the last two decades and PTSD is now one of several psychiatric diagnoses for which a veteran can receive compensation, such as a war veteran indemnity pension, in the U.S. (see below: Mezey & Robbins 2001)

Diagnostic criteriaEdit

The diagnostic criteria for PTSD, according to Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), are stressors listed from A to F. The current diagnostic criteria for the PTSD published in the Diagnostic and Statistical Manual of Mental Disorders may be found DSM-IV-TR here.

Notably, the stressor criterion A is divided into two parts. The first (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 (A2) requires that "the person’s response involved intense fear, helplessness, or horror." The DSM-IV A criterion differs substantially from the previous DSM-III-R stressor criterion, which specified 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." 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 explanationsEdit

Symptoms can include general restlessness, insomnia, aggressiveness, depression, dissociation, emotional detachment and nightmares. A potential symptom is memory loss about an aspect of the traumatic event. Amplification of other underlying psychological conditions may also occur. Young children suffering from PTSD will often re-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 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):

Intrusion: Since the sufferer is unable to process the extreme emotions brought about by the trauma, they are plagued by recurrent nightmares or daytime flashbacks, during which they graphically re-experience the trauma. These re-experiences are characterized by high anxiety levels and make up one part of the PTSD symptom cluster triad called intrusive symptoms.

Hyperarousal: PTSD is also characterized by a state of nervousness with the patient 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.

Avoidance: The hyperarousal and the intrusive symptoms are eventually so distressing that the individual strives to avoid contact with everything and everyone, even their own thoughts, which may arouse memories of the trauma and thus provoke the intrusive and hyperarousal states. The sufferer isolates themselves, becoming detached in their feelings with a restricted range of emotional response and can experience so-called emotional detachment ("numbing"). This avoidance behavior is the third part of the symptom triad that makes up the PTSD criteria.

Dissociation: Dissociation is another "defense" that includes a variety of symptoms including feelings of depersonalization and derealization, disconnection between memory and affect so that the person is "in another world," and, in extreme forms can involve apparent multiple personalities and acting without any memory ("losing time").

Biology of PTSDEdit

NeurochemistryEdit

PTSD displays biochemical changes in the brain and body, which are 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 axis (HPA) , 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 United Nations 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.[How to reference and link to summary or text]

It is important to note that you may find seemingly contradictory information concerning physiological processes of PTSD as there is considerable controversy within the medical community regarding the biology of PTSD. For example, only a slight majority of studies have found a decrease in cortisol levels; many others have found no effect or even an increase.

NeuroanatomyEdit

In animal research as well as human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. Neuroimaging studies in humans have revealed both morphological and functional aspects of PTSD. The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex and the hippocampus. Further animal and clinical research into the amygdala and fear conditioning may suggest additional treatments for the condition.

PrevalenceEdit

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% and 80% will develop PTSD depending on the severity of the trauma and personal vulnerability.

The National Comorbidity Survey Report provided the following information about PTSD in the general adult population: The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.[1]

In recent history, the 2004 Indian Ocean Tsunami Disaster, which took place December 26, 2004 and took hundreds of thousands of lives, as well as the September 11, 2001 attacks on the World Trade Center in New York City and WS The Pentagon in Washington DC, may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as International Red Cross and Red Crescent Movement and the Salvation Army provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder.

Other agencies, such as the National Meditation Center for World Peace [2], have created similar special programs. The NMC trains agencies such as crisis centers NGOs and works with international agencies to prevent trauma to children.

Other information concerning prevalence of PTSD is that females have a higher rate of PTSD than do males, and Hispanics have higher rates of PTSD than do other ethnicities.

Veterans and PTSD politicsEdit

The practice of providing compensation for veterans with PTSD is under review in the United States. In 2005, the US Department of Veterans Affairs Veterans Benefits Administration began a review of claims after it noted a reported 30% increase in PTSD claims in recent years. Because of the negative effect on the budget and the apparent inconsistency in the rate of rewards by different rating offices of the Department, they undertook this review. There was broad political backlash from veterans rights groups and some highly publicized suicides by veterans who feared loss of their benefits, which in some cases served as their only source of income. In response to these events, on November 10, 2005, the Secretary of the US Department of Veterans affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for post-traumatic stress disorder..."

However the feeling of reprieve experienced by some veterans and veteran advocates was short-lived. Soon thereafter, the Department of Veterans Affairs announced that it had contracted with the Institute of Medicine (IOM) to conduct a study on PTSD. The committee will review and comment on the objective measures used in the diagnosis of PTSD and known risk factors for the development of PTSD. It will also "review the utility and objectiveness of the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and will comment on the validity of current screening instruments and their predictive capacity for accurate diagnoses." The committee will also "review the literature on various treatment modalities (including pharmacotherapy and psychotherapy) and treatment goals for individuals with PTSD [and] ... comment on the prognosis of individuals diagnosed with PTSD and existing comorbidities." Some veteran advocates expressed concern that this was merely a backdoor method of reducing benefits to veterans who have served and currently serve in Iraq and the Persian Gulf. On the other hand, conservative groups such as psychiatrist Sally Satel, who is affiliated with the conservative American Enterprise Institute, say "an underground network advises veterans where to go for the best chance of being declared disabled." The institute organized a recent meeting to discuss PTSD among veterans.

While PTSD-like symptoms were recognized in combat veterans following many historical conflicts, the modern understanding of the condition dates to the 1980s. Reported OEF/OIF cases of combat-PTSD incidents are currently being compiled in ePluribus Media's PTSD Timeline

Cancer as PTSD-traumaEdit

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 among 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 five 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, and like combat, is often characterized by extended duration with a potential for recurrence and a varying immediacy of life-threat (Smith 1999).

TreatmentEdit

Early intervention after a traumatic incident, known as Critical Incident Stress Management (CISM) is often used to reduce traumatic effects of an incident, and potentially prevent a full-blown occurrence of PTSD. However recent studies regarding CISM seem to indicate iatrogenic effects (Carlier, Lamberts, van Uchelen & Gersons 1998) (Mayou, Ehlers & Hobbs 2000).

There have been scores of treatments suggested for the treatment of PTSD. The most researched (non-medical) psychotherapeutic method, specifically targeted at the disorder PTSD, is Eye Movement Desensitization and Reprocessing (EMDR) (Devilly & Spence, 1999] "The relative efficacy and treatment distress of EMDR and a cognitive behavioral trauma treatment protocol in the amelioration of post traumatic stress disorder". Journal of Anxiety Disorders, 13, 131–157.</ref>. Traumatic Incident Reduction is another, more controversial targeted method of treatment.

Relationship based treatments are also often used. Johnson, S., (2002). Emotionally Focused Couples Therapy with Trauma Survivors. NY: Guilford, is one example. These, and other approaches, such as Dyadic Developmental Psychotherapy [2] [3] use attachment theory and an attachment model of treatment. The treatment of complex trauma often requires a multi-modal approach

PTSD is commonly treated using a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and psychotropic 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)). According to some studies, the most effective psychotherapeutic treatment for PTSD is Eye Movement Desensitization and Reprocessing (EMDR) q.v. (see http://www.emdr.com/efficacy.htm). 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) [4] 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 Food and Drug Administration (FDA) recently approved a clinical protocol that combines the drug MDMA ("Ecstasy") with talk therapy sessions.[3]

Basic counseling for PTSD 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.[4]

PTSD is often co-morbid with other psychiatric disorders such as depression and substance abuse. Currently under scrutiny is the inclusion of Complex Post Traumatic Stress in the 2006 revision of the DSM-IV-TR. This is a variant of PTSD that includes the breakthrough of Borderline Personality traits.

James McGaugh is a pioneer in the neurobiology of learning and memory. He directs the Center for Neurobiology of Learning and Memory at the University of California at Irvine.

For several decades, he has performed numerous animal and human experiments to understand the processes involved in memory consolidation. He believes strongly in the work being done to help people suffering from PTSD.

An event becomes a strong memory, a traumatic memory, when emotions are high, he explains. Those emotions trigger a release of stress hormones like adrenaline, which act on a region of the brain called the amygdala -- and the memory is stored or "consolidated," explains McGaugh.

Current studies have focused on a drug called propranolol, which is commonly prescribed for heart disease because it helps the heart relax, relieves high blood pressure, and prevents heart attacks. "Hundreds of thousands, millions of people take this drug now for heart disease," he tells WebMD. "We're not talking about some exotic substance."

Studies have shown that "if we give a drug that blocks the action of one stress hormone, adrenaline, the memory of trauma is blunted," he says.

The drug cannot make someone forget an event, McGaugh says. "The drug does not remove the memory -- it just makes the memory more normal. It prevents the excessively strong memory from developing, the memory that keeps you awake at night. The drug does something that our hormonal system does all the time -- regulating memory through the actions of hormones. We're removing the excess hormones." [5]

See alsoEdit

BibliographyEdit

Key Texts – BooksEdit

Additional material – BooksEdit

  1. David Satcher etal. (1999). "Chapter 4.2" Mental Health: A Report of the Surgeon General.
  2. Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity For Attachment, Wood 'N' Barnes, OK. ISBN 1-885473-72-9
  3. Becker-Weidman, A., (2006). Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. Vol. 13 #1, April 2006.
  4. Forbes, D. et al. (2001) "Brief report: treatment of combat-related nightmares using imagery rehearsal: a pilot study", Journal of Traumatic Stress 14 (2): 433-442

Key Texts – PapersEdit

Additional material - PapersEdit

  • Vermetten, E., & Bremner, J. D. (2003). Olfaction as a traumatic reminder in posttraumatic stress disorder: Case reports and review. Journal of Clinical Psychiatry, 64, 202-207.

External links Edit

PTSD: Academic support materials

  • PTSD: Lecture slides
  • PTSD: Lecture notes
  • PTSD: Lecture handouts
  • PTSD: Multimedia materials
  • PTSD: Other academic support materials
  • PTSD: Anonymous fictional case studies for training


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