Posttraumatic stress disorder (abbreviated
PTSD) is an
anxiety disorderAnxiety disorder is a blanket term covering several different forms of abnormal and pathological fears and anxieties which only came under the aegis of psychiatry at the very end of the 19th century. Current psychiatric diagnostic criteria recognize a wide variety of anxiety disorders...
that can develop after exposure to one or more traumatic events that threatened or caused great physical harm.
It is a severe and ongoing emotional reaction to an extreme
psychological traumaPsychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event. When that trauma leads to posttraumatic stress disorder, damage may involve physical changes inside the brain and to brain chemistry, which damage the person's ability to adequately cope with...
. This stressor may involve someone's actual death, a threat to the patient's or someone else's life, serious physical injury, an unwanted sexual act, or a threat to physical or psychological integrity, overwhelming
psychological defensesThe psychological definition of coping is the process of managing taxing circumstances, expending effort to solve personal and interpersonal problems, and seeking to master, minimize, reduce or tolerate stress or conflict....
.
PTSD is a more chronic and less frequent consequence of trauma than the normal
acute stress responseAcute stress over reaction is a psychological condition arising in response to a terrifying event...
.
PTSD has also been recognized in the past as
railway spineRailway 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 classic book, On Railway and Other Injuries of the Nervous System...
, stress syndrome,
shell shockShell Shock, also known as 82nd Marines Attack was a 1964 film by B-movie director John Hayes. The film takes place in Italy during World War II, and tells the story of a sergeant with his group of soldiers....
, battle fatigue, traumatic war neurosis, or post-traumatic stress syndrome.
Diagnostic symptoms include re-experiencing original trauma(s), by means of flashbacks or nightmares; avoidance of stimuli associated with the trauma; and increased arousal, such as difficulty falling or staying asleep, anger, and
hypervigilanceHypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Other symptoms include: abnormally increased arousal, a...
. Formal diagnostic criteria (both DSM-IV and ICD-9) require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and/or relationships).
Psychological trauma
PTSD is believed to be caused by either
physical traumaPhysical trauma refers to a physical injury, generally of a considerably severe degree. A trauma patient is someone who has suffered serious and life-threatening physical injury with the potential for secondary complications such as shock, respiratory failure and death.-Common causes:Comprehensive...
or
psychological traumaPsychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event. When that trauma leads to posttraumatic stress disorder, damage may involve physical changes inside the brain and to brain chemistry, which damage the person's ability to adequately cope with...
, or more frequently a combination of both. Possible sources of trauma include encountering or witnessing childhood or adult
physicalPhysical abuse is abuse involving contact intended to cause feelings of intimidation, pain, injury, or other physical suffering or bodily harm.-Forms of physical abuse:*Striking*Punching*Pushing, pulling*Slapping*Whipping*Striking with an object...
, emotional or
sexual abuseSexual abuse, also referred to as molestation, is the forcing of undesired sexual behavior by one person upon another, when that force falls short of being a sexual assault. The offender is referred to as a sexual abuser or molester...
. In addition, encountering or witnessing an event perceived as life-threatening such as physical
assaultAssault is a crime of violence against another person. In some jurisdictions, including Australia and New Zealand, assault refers to an act that causes another to apprehend immediate and personal violence, while in other jurisdictions, such as the United States, assault may refer only to the threat...
, adult experiences of
sexual assaultSexual assault is an assault of a sexual nature on another person. Although sexual assaults most frequently are by a man on a woman, it may be by a man on a man, woman on a man or woman on a woman. Approximately one in six American women will be a victim of a sexual assault in her lifetime...
, accidents,
drug addictionDrug addiction is a pathological condition which arises due to frequent drug use. The disorder of addiction involves the progression of acute drug use to the development of drug-seeking behavior, the vulnerability to relapse, and the decreased, slowed ability to respond to naturally rewarding stimuli...
,
illnessIllness can be defined as a state of poor health. Illness is sometimes considered a synonym for disease. Others maintain that fine distinctions exist...
es,
medical complicationsComplication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems...
, or employment in occupations exposed to
warWar is a reciprocated, armed conflict, between two or more non-congruous entities, aimed at reorganising a subjectively designed, geo-politically desired result...
(such as
soldierA soldier is a member of the land component of national armed forces; whereas a soldier hired for service in a foreign army would be termed a mercenary...
s) or disaster (such as
emergency serviceEmergency services are organizations which ensure public safety by addressing different emergencies. Some agencies exist solely for addressing certain types of emergencies whilst others deal with ad hoc emergencies as part of their normal responsibilities...
workers).
Traumatic events that may cause PTSD symptoms to develop include violent assault, kidnapping, sexual assault, torture, being a hostage, prisoner of war or concentration camp victim, experiencing a disaster, violent automobile accidents or getting a diagnosis of a life-threatening illness. Children may develop PTSD symptoms by experiencing bullying or sexually traumatic events like age-inappropriate sexual experiences.
Witnessing traumatic experiences or learning about these experiences may also cause the development of PTSD symptoms.
A preliminary study found that mutations in a stress-related gene interact with child abuse to increase the risk of PTSD in adults.
Neuroendocrinology
PTSD displays
biochemicalBiochemistry is the study of the chemical processes in living organisms. It deals with the structure and function of cellular components such as proteins, carbohydrates, lipids, nucleic acids and other biomolecules....
changes in the brain and body that differ from other psychiatric disorders such as major depression. Individuals diagnosed with PTSD respond more strongly to a
dexamethasone suppression testThe dexamethasone suppression test is designed to diagnose and differentiate among the various types of Cushing's syndrome and other hypercortisol states.It has also been used in the research of depression.-Physiology:...
than individuals diagnosed with
clinical depressionMajor depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and loss of interest or pleasure in normally enjoyable activities...
.
In addition, most people with PTSD also show a low secretion of
cortisolCortisol is a corticosteroid hormone or glucocorticoid produced by the adrenal cortex, that is part of the adrenal gland . It is usually referred to as the "stress hormone" as it is involved in response to stress and anxiety, controlled by CRH...
and high secretion of
catecholamineCatecholamines are sympathomimetic "fight-or-flight" hormones that are released by the adrenal glands in response to stress. They are part of the sympathetic nervous system....
s in
urineUrine is a liquid waste product of the body secreted by the kidneys by a process of filtration from blood called urination and excreted through the urethra. Cellular metabolism generates numerous waste compounds, many rich in nitrogen, that require elimination from the bloodstream...
, with a
norepinephrineNoradrenaline or norepinephrine is a catecholamine with dual roles as a hormone and a neurotransmitter....
/cortisol ratio consequently higher than comparable non-diagnosed individuals. This is in contrast to the normative
fight-or-flight responseThe "fight-or-flight response", also called the "fight-or-flight-or-freeze response", the "fright, fight or flight response", "hyperarousal" or the "acute stress response", was first described by Walter Cannon in 1929....
, in which both catecholamine and cortisol levels are elevated after exposure to a stressor.
Brain catecholamine levels are low, and corticotropin-releasing factor (CRF) concentrations are high. Together, these findings suggest abnormality in the
hypothalamic-pituitary-adrenal (HPA) axisThe hypothalamic-pituitary-adrenal axis , also known as thelimbic-hypothalamic-pituitary-adrenal axis , is a complex set of direct influences and feedback interactions among the hypothalamus , the pituitary gland , and the adrenal glands...
.
Given the strong cortisol suppression to
dexamethasoneDexamethasone is a potent synthetic member of the glucocorticoid class of steroid hormones. It acts as an anti-inflammatory and immunosuppressant...
in PTSD, HPA axis abnormalities are likely predicated on strong negative feedback inhibition of cortisol, itself likely due to an increased sensitivity of
glucocorticoid receptorThe glucocorticoid receptor also known as NR3C1 is the receptor that cortisol and other glucocorticoids bind to....
s. Some researchers have associated the response to stress in PTSD with long-term exposure to high levels of
norepinephrineNoradrenaline or norepinephrine is a catecholamine with dual roles as a hormone and a neurotransmitter....
and low levels of cortisol, a pattern associated with improved
learningLearning is acquiring new knowledge, behaviors, skills, values, preferences or understanding, and may involve synthesizing different types of information. The ability to learn is possessed by humans, animals and some machines. Progress over time tends to follow learning curves.Human learning may...
in animals.
Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response through a hypersensitive, hyperreactive and hyperresponsive HPA axis.
Low cortisol levels may predispose individuals to PTSD: Following war trauma,
SwedishSweden , officially the Kingdom of Sweden , is a Nordic country on the Scandinavian Peninsula in Northern Europe...
soldiers serving in
Bosnia and HerzegovinaBosnia and Herzegovina Bosnia and Herzegovina Bosnia and Herzegovina ( or (Bosnian, Croatian, Serbian Latin: Bosna i Hercegovina; Serbian Cyrillic: Босна и Херцеговина) is a country in Southeast Europe, on the Balkan Peninsula...
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. Because cortisol is normally important in restoring
homeostasisHomeostasis is the property of a system, either open or closed, that regulates its internal environment and tends to maintain a stable, constant condition...
after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD.
However, there is considerable controversy within the medical community regarding the neurobiology of PTSD. A review of existing studies on this subject showed no clear relationship between cortisol levels and PTSD. Only a slight majority have found a decrease in cortisol levels while others have found no effect or even an increase.
Neuroanatomy
In addition to biochemical changes, PTSD also involves changes in brain morphology. In a study by Gurvits et al., Combat veterans of the Vietnam war with PTSD showed a 20% reduction in the volume of their
hippocampusThe hippocampus is a major component of the brains of humans and other mammals. It belongs to the limbic system and plays important roles in long-term memory and spatial navigation. Like the cerebral cortex, with which it is closely associated, it is a paired structure, with mirror-image halves in...
compared with veterans who suffered no such symptoms.
In human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories.
NeuroimagingNeuroimaging includes the use of various techniques to either directly or indirectly image the structure, function/pharmacology of the brain...
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 cortexThe prefrontal cortex is the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas.This brain region has been implicated in planning complex cognitive behaviors, personality expression, decision making and moderating correct social behavior...
and the
hippocampusThe hippocampus is a major component of the brains of humans and other mammals. It belongs to the limbic system and plays important roles in long-term memory and spatial navigation. Like the cerebral cortex, with which it is closely associated, it is a paired structure, with mirror-image halves in...
. Further animal and clinical research into the amygdala and
fear conditioningFear conditioning is the method by which organisms learn to fear new stimuli. It is a form of learning in which fear is associated with a particular neutral context or neutral stimulus . This can be done by pairing the neutral stimulus with an aversive stimulus...
may suggest additional treatments for the condition.
Genetics
There is evidence that susceptibility to PTSD is hereditary. For twin pairs exposed to combat in Vietnam, having a monozygotic (identical) twin with PTSD was associated with an increased risk of the co-twin having PTSD compared to twins that were dizygotic (non-identical twins).
Recently, it has been found that several single nucleotide polymorphisms (SNPs) in
FK506 binding protein 5FK506 binding protein 5, also known as FKBP5, is a protein which in humans is encoded by the FKBP5 gene.- Function :The protein encoded by this gene is a member of the immunophilin protein family, which play a role in immunoregulation and basic cellular processes involving protein folding and...
(FKBP5) interact with childhood trauma to predict severity of adult PTSD. These findings suggest that individuals with these SNPs who are abused as children are more susceptible to PTSD as adults.
This is particularly interesting given that FKBP5 SNPs have previously been associated with peritraumatic dissociation (that is, dissociation at the time of the trauma), which has itself been shown to be predictive of PTSD. Furthermore, FKBP5 may be less
expressedGene expression is the process by which information from a gene is used in the synthesis of a functional gene product. These products are often proteins, but in non-protein coding genes such as rRNA genes or tRNA genes, the product is a functional RNA...
in those with current PTSD.
Risk and protective factors for PTSD development
Although most people (50-90%) encounter trauma over a lifetime, only about 8% develop full PTSD. Vulnerability to PTSD presumably stems from an interaction of biological diathesis, early childhood developmental experiences, and trauma severity.
Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood. This effect of childhood trauma, which is not well understood, may be a marker for both traumatic experiences and attachment problems.
Proximity to, duration of, and severity of the trauma also make an impact; and interpersonal traumas cause more problems than impersonal ones.
Schnurr, Lunney, and Sengupta identified risk factors for the development of PTSD in
Vietnam veteransThe Vietnam Veterans were a six-person French psychedelic group that released six records in the 1980s. The band was praised by many alternative music publications....
. Among those are:
- Hispanic ethnicity, coming from an unstable family, being punished severely during childhood, childhood asocial behavior and depression as pre-military factors
- war-zone exposure, peritraumatic dissociation, depression as military factors
- recent stressful life events, post-Vietnam
The Vietnam War or the Second Indochina War was a Cold War military conflict that occurred in Vietnam, Laos, and Cambodia from 1959 to 30 April 1975...
trauma and depression as post-military factors
They also identified certain protective factors, such as:
- Japanese-American ethnicity, high school degree or college education, older age at entry to war, higher socioeconomic status and a more positive paternal relationship as pre-military protective factors
- Social support at homecoming and current social support as post-military factors. Other research also indicates the protective effects of social support in averting and recovery from PTSD.
There may also be an attitudinal component; for example, a soldier who believes that they will not sustain injuries may be more likely to develop symptoms of PTSD than one who anticipates the possibility, should either be wounded. Likewise, the later incidence of suicide among those injured in home fires above those injured in fires in the workplace suggests this possibility.
Diagnosis
The diagnostic criteria for PTSD, per the
Diagnostic and Statistical Manual of Mental DisordersThe Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides diagnostic criteria for mental disorders...
IV (Text Revision) (DSM-IV-TR), may be summarized as:
- A. Exposure to a traumatic event
- B. Persistent reexperience (e.g. flashbacks
A flashback is a psychological phenomenon in which an individual has a sudden, usually powerful, re-experiencing of a past experience or elements of a past experience...
, nightmares)
- C. Persistent avoidance of stimuli associated with the trauma (e.g. avoidance of experiences that they fear will trigger flashbacks and reexperiencing of symptoms fear of losing control)
- D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep, anger and hypervigilance
Hypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Other symptoms include: abnormally increased arousal, a...
)
- E. Duration of symptoms for more than 1 month
- F. Significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and relationships.)
Notably, criterion A2 requires that "the person’s response involved intense fear, helplessness, or horror." The DSM-IV-TR 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%.
Various scales exist to measure the severity and frequency of PTSD symptoms.
Psychotherapy
Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling for PTSD includes education about the condition and provision of safety and support.
Cognitive therapyCognitive behavioral therapy is a psychotherapeutic approach that aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure...
shows good results, and group therapy may be helpful in reducing isolation and
social stigmaSocial stigma is severe social disapproval of personal characteristics or beliefs that are perceived to be against cultural norms. Stigma is often based on ignorance, irrational or unfounded fears, mass hysteria, lack of education, or a lack of information pertaining to a particular person or group...
. The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral programs, variants of
exposure therapyExposure therapy is a cognitive behavioral therapy technique for reducing fear and anxiety responses, especially phobia, based on the principles of habituation and cognitive dissonance. It is similar to systematic desensitization, though it works more quickly and produces more robust results...
, stress inoculation training (SIT), variants of cognitive therapy (CT),
eye movement desensitization and reprocessingEye movement desensitization and reprocessing is a form of psychotherapy that was developed to resolve symptoms resulting from disturbing and unresolved life experiences. It uses a structured approach to address past, present, and future aspects of disturbing memories...
(EMDR), and many combinations of these procedures. Psychodynamic psychotherapy, while widely employed, has not been well tested as a treatment for PTSD.
Cognitive Behavioral Therapy (CBT) is a psychotherapeutic approach that aims to change the patterns of thinking or behavior that are responsible for a patient’s negative emotions and, in doing so, change the way they feel. CBT has been proven to be an effective treatment for PTSD, and is currently considered the standard of care for PTSD by the
Department of DefenseThe United States Department of Defense is the federal department charged with coordinating and supervising all agencies and functions of the government relating directly to national security and the military...
. In CBT, patients learn to identify thoughts that make them feel afraid or upset, and replace them with less distressing thoughts. The goal is to understand how certain thoughts about trauma cause stress and make symptoms worse.
Exposure involves assisting trauma survivors to therapeutically confront distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders.
Indeed, the success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD. Some organizations have endorsed the need for exposure. Yet other approaches, particularly involving social supports, may also be important.
An open trial of interpersonal psychotherapy reported high rates of remission from PTSD symptoms without using exposure.
A current, NIMH-funded trial in New York City is now comparing interpersonal psychotherapy,
prolonged exposure therapyProlonged exposure therapy is a form of behavior therapy and cognitive behavioral therapy designed to treat posttraumatic stress disorder.-About Prolonged Exposure Therapy:...
, and relaxation therapy
.
Critical incident stress management
Early intervention after a traumatic incident, known as
critical incident stress managementCritical incident stress management is an adaptive short term helping process that focuses solely on an immediate and identifiable problem. It spans pre-incident preparedness to acute crisis to post-crisis follow up...
(CISM) is used to attempt to reduce traumatic effects of an incident, and potentially prevent a full-blown occurrence of PTSD. However, recent studies regarding CISM seem to indicate
iatrogenicThe terms iatrogenesis and iatrogenic artifact refer to adverse effects or complications caused by or resulting from medical treatment or advice. In addition to harmful consequences of actions by physicians, iatrogenesis can also refer to actions by other healthcare professionals, such as...
effects.
Six studies have formally looked at the effect of CISM, four finding no benefit for preventing PTSD, and the other two studies indicating that CISM actually made things worse. Hence this is not a recommended treatment.
Some benefit was found from being connected early to cognitive behavioral therapy, or for some medications such as
propranololPropranolol is a non-selective beta blocker mainly used in the treatment of hypertension. It was the first successful beta blocker developed. It is the only drug proven effective for the prophylaxis of migraines in children...
. Effects of all these prevention strategies was modest.
Eye movement desensitization and reprocessing
Eye Movement Desensitization and ReprocessingEye movement desensitization and reprocessing is a form of psychotherapy that was developed to resolve symptoms resulting from disturbing and unresolved life experiences. It uses a structured approach to address past, present, and future aspects of disturbing memories...
(EMDR) is specifically targeted as a treatment for PTSD.
Based on the evidence of controlled research, the
American Psychiatric AssociationThe American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
and the U.S.
Department of Veterans AffairsDepartment of Veterans Affairs may refer to:*Department of Veterans' Affairs*United States Department of Veterans Affairs*Veterans Affairs Canada*Ministry of Patriots' and Veterans' Affairs...
and
Department of DefenseThe United States Department of Defense is the federal department charged with coordinating and supervising all agencies and functions of the government relating directly to national security and the military...
, have
placed EMDR in the highest category of effectiveness and research support in the treatment of trauma. Several international bodies have made similar recommendations.
A
meta-analyticIn statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. This is normally done by identification of a common measure of effect size, which is modelled using a form of meta-regression...
comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in terms of effectiveness in treating PTSD. The
British Journal of PsychiatryThe British Journal of Psychiatry is a British peer reviewed scientific journal published monthly by The Royal College of Psychiatrists containing original research, systematic reviews etc. relating to the area of psychiatry. According to the journal's editor, the primary audience is psychiatrists,...
has recommended EMDR or trauma-specific cognitive behavioral therapy as first-line treatments for trauma patients.
Medication
Medications have shown benefit in reducing PTSD symptoms, but "there is no clear drug treatment for PTSD".
Standard medication therapy useful in treating PTSD includes
SSRIs Selective serotonin reuptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders...
(selective serotonin reuptake inhibitors) and
TCAsTricyclic antidepressants are a class of psychoactive drugs used primarily as antidepressants, which were first discovered in the early 1950s, and subsequently introduced later in the decade...
(tricyclic antidepressants). Positive symptoms (re-experiencing, hypervigilance, increased arousal) generally respond better to medication than negative symptoms (avoidance, withdrawal).
Tricyclics tend to be associated with greater side effects and lesser improvement of the three PTSD symptom clusters than SSRIs. SSRIs for which there are data to support use include:
citalopramCitalopram is an antidepressant drug used to treat major depression associated with mood disorders. It is also used on occasion in the treatment of body dysmorphic disorder and anxiety....
,
escitalopramEscitalopram is an antidepressant of the selective serotonin reuptake inhibitor class. It is approved by the U.S...
,
fluvoxamineFluvoxamine is an antidepressant which functions as a selective serotonin reuptake inhibitor and is predominantly used to treat obsessive–compulsive disorder.-History:...
,
paroxetineParoxetine is a selective serotonin reuptake inhibitor antidepressant. Marketing of the drug began in 1992 by the pharmaceutical company SmithKline Beecham, now GlaxoSmithKline...
and
sertralineSertraline hydrochloride is an antidepressant of the selective serotonin reuptake inhibitor class. It was introduced to the market by Pfizer in 1991. Sertraline is primarily used to treat major depression in adult outpatients as well as obsessive–compulsive, panic, and social anxiety disorders in...
.
There are data to support the use of "autonomic medicines" such as
propranololPropranolol is a non-selective beta blocker mainly used in the treatment of hypertension. It was the first successful beta blocker developed. It is the only drug proven effective for the prophylaxis of migraines in children...
(
beta blockerBeta blockers is a class of drugs used for various indications, but particularly for the management of cardiac arrhythmias, cardioprotection after myocardial infarction , and hypertension. Propranolol was the first clinically useful beta adrenergic receptor antagonist. Invented by Sir James W...
) and
clonidineClonidine is a medication used to treat several medical conditions. It is a direct-acting α2 adrenergic agonist.-Uses:It has been prescribed historically as an antihypertensive agent...
(
alpha-adrenergic agonistAn adrenergic alpha-agonist is a drug that selectively stimulates alpha adrenergic receptors. The alpha-adrenergic receptor has two subclasses α1 and α2.-Classes:...
) if there are significant symptoms of "over-arousal". These may inhibit the formation of traumatic memories by blocking adrenaline's effects on the
amygdalaThe ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans...
, has been used in an attempt to reduce the impact of traumatic events, or they may simply demonstrate to the patient that the symptoms can be controlled thereby assisting with "self efficacy" and helping the patient remain calmer.
There are also data to support the use of mood-stabilizers such
lithium carbonateLithium pharmacology refers to use of the lithium ion, Li
+, as a drug. A number of chemical salts of lithium are used medically as a mood stabilizing drug, primarily in the treatment of bipolar disorder, where they have a role in the treatment of depression and particularly of mania,...
and
carbamazepineCarbamazepine is an anticonvulsant and mood stabilizing drug used primarily in the treatment of epilepsy and bipolar disorder, as well as trigeminal neuralgia...
if there is significant uncontrolled mood or aggression.
RisperidoneRisperidone is an atypical antipsychotic used to treat schizophrenia , the mixed and manic states associated with bipolar disorder, and irritability in children with autism...
is used to help with dissociation, mood and aggression, and benzodiazepines are used for short-term anxiety relief.
Recently the
anticonvulsantThe anticonvulsants are a diverse group of pharmaceuticals used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used in the treatment of bipolar disorder, since many seem to act as mood stabilizers. The goal of an anticonvulsant is to suppress the rapid and...
lamotrigineLamotrigine is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder...
has been reported to be useful in treating some people with PTSD.
There is some evidence suggesting that administering
glucocorticoidGlucocorticoids are a class of steroid hormones that bind to the glucocorticoid receptor , which is present in almost every vertebrate animal cell...
s immediately after a traumatic experience may help prevent PTSD. Several studies have shown that patients who receive high doses of hydrocortisone for treatment of
septic shockSeptic shock is a serious medical condition caused by decreased tissue perfusion and oxygen delivery as a result of infection and sepsis, though the microbe may be systemic or localized to a particular site. It can cause multiple organ dysfunction syndrome and death...
or following surgery have a lower incidence and fewer symptoms of PTSD. Additionally, post-stress high dose
corticosteroneCorticosterone is a 21 carbon steroid hormone of the corticosteroid type produced in the cortex of the adrenal glands.-Roles:In many species, including amphibians, reptiles, rodents and birds, corticosterone is a main glucocorticoid, involved in regulation of fuel, immune reactions, and stress...
administration was recently found to reduce 'PTSD-like' behaviors in a rat model of PTSD. In this study, corticosterone impaired memory performance, suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories. The neurodegenerative effects of the glucocorticoids, however, may prove this treatment counterproductive.
Combination therapies
PTSD is commonly treated using a combination of
psychotherapyPsychotherapy or personal counseling with a psychotherapist, is an intentional interpersonal relationship used by trained psychotherapists to aid a client or patient in problems of living.It aims to increase the individual's sense of their own well-being...
and medications.
Clinical trialClinical trials are conducted to allow safety and efficacy data to be collected for new drugs or devices. These trials can only take place once satisfactory information has been gathered on the quality of the product and its non-clinical safety, and Health Authority/Ethics Committee approval is...
s evaluating
methylenedioxymethamphetamineMDMA is a psychoactive amphetamine drug with entactogenic, psychedelic, and stimulant effects....
(MDMA, "Ecstasy") in conjunction with psychotherapy are being conducted in Switzerland and Israel. A clinical trial is also examining the efficacy of hydrocortisone in conjunction with exposure therapy for PTSD symptoms.
Comorbid substance dependence
Recovery from post traumatic stress disorder or other anxiety disorders may be hindered or even worsened by alcohol or
benzodiazepine dependenceBenzodiazepine dependence or benzodiazepine addiction is the condition when a person is dependent on benzodiazepine drugs. Dependence can either be a psychological dependence or a physical dependence or a combination of the two...
. Treating comorbid substance dependences particularly alcohol or benzodiazepine dependence can bring about a marked improvement in the patients mental health status and anxiety levels. Recovery from benzodiazepines tends to take a lot longer than recovery from alcohol but people can regain their previous good health. Symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.
Epidemiology
PTSD may be experienced following any traumatic experience, or series of experiences that satisfy the criteria and that do not allow the victim to readily recuperate from the detrimental effects of stress. 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.
The
National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5% of female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was 30.9 for males and 26.9 for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans suffered from PTSD-symptoms. Four out of five reported recent symptoms when interviewed 20–25 years after Vietnam.
In recent history, catastrophes (by human means or not) such as the
Indian Ocean Tsunami DisasterThe 2004 Indian Ocean earthquake was an undersea megathrust earthquake that occurred at 00:58:53 UTC on December 26, 2004, with an epicentre off the west coast of Sumatra, Indonesia. The quake itself is known by the scientific community as the Sumatra-Andaman earthquake...
may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as the
Red CrossThe International Red Cross and Red Crescent Movement is an international humanitarian movement with approximately 97 million volunteers worldwide which started to protect human life and health, to ensure respect for the human being, and to prevent and alleviate human suffering, without any...
and the
Salvation ArmyThe Salvation Army, an international movement, describes itself as an armed evangelical movement part of the Christian Church. It has a quasi-military structure and was founded in 1865 in the United Kingdom as the East London Christian Liberation Mission by William and Catherine Booth. It is well...
provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder.
There is debate over the rates of PTSD found in populations, but despite changes in diagnosis and the criteria used to define PTSD between 1997 and 2007,
epidemiologicalEpidemiology is the study of factors affecting the health and illness of populations, and serves as the foundation and logic of interventions made in the interest of public health and preventive medicine...
rates have not changed significantly.
Earliest reports
Reports of battle-associated stress appear as early as the 6th century BCE. One of the first descriptions of PTSD was made by the Greek historian
HerodotusHerodotus of Halicarnassus was a Greek historian who lived in the 5th century BC and is regarded as the "Father of History" in Western culture. He was the first historian known to collect his materials systematically, test their accuracy to a certain extent and arrange them in a...
. In 490 BCE he described, during the
Battle of MarathonThe Battle of Marathon took place in 490 BC during the first Persian invasion of Greece. It was fought between the citizens of Athens, aided by Plataea, and a Persian force commanded by Datis and Artaphernes. It was the culmination of the first attempt by Persia, under King Darius I, to subjugate...
, an Athenian soldier who suffered no injury from war but became permanently blind after witnessing the death of a fellow soldier.
In the early 1800's military medical doctors started diagnosing soldiers with "exhaustion" after the stress of battle. This "exhaustion" was characterized by mental shutdown due to individual or group trauma. Similar to present time, soldiers during the 1800's were not supposed to be scared or show any fear in the midst of battle. The only treatment for this "exhaustion" was to bring the afflicted to the back for a bit then send them back into battle. During the intense and frequently repeated stress, the soldiers became fatigued as a part of their body's natural shock reaction.
One-tenth of mobilised American men were hospitalised for mental disturbances between 1942 and 1945, and after thirty-five days of uninterrupted combat, 98% of them manifested psychiatric disturbances in varying degrees.
Although PTSD-like symptoms have also been recognized in combat veterans of many military conflicts since, the modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by US military veterans of the war in Vietnam.
Terminology
The term
post-traumatic stress disorder or
PTSD was coined in the mid 1970s. Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders. The term was formally recognized in 1980. (In the authoritative DSM-IV, the spelling "posttraumatic stress disorder" is used. Elsewhere, "posttraumatic" is often rendered as two words — "post-traumatic stress disorder" or "post traumatic stress disorder" — especially in less formal writing on the subject.)
In the United States
The diagnosis was removed from the DSM-II, which resulted in the inability of Vietnam veterans to receive benefits for this condition. In part through the efforts of anti Vietnam war activists and the anti war group
Vietnam Veterans Against the WarVietnam Veterans Against the War is a tax-exempt non-profit organization and corporation, originally created to oppose the Vietnam War. VVAW describes itself as a national veterans' organization that campaigns for peace, justice, and the rights of all United States military veterans...
and
Chaim F. ShatanChaim F. Shatan was a Canadian psychiatrist born in Włocławek, Poland.Shatan's parents moved to Canada when he was two. He received his MDCM degree from McGill University in Montreal, Canada...
, who worked with them and coined the term
post-Vietnam Syndrome, the condition was added to the DSM-III as posttraumatic stress disorder. The
United States Department of Veterans AffairsThe United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is responsible for administering programs of veterans’ benefits for veterans, their families, and survivors....
estimates that 830,000 Vietnam veterans suffered symptoms of PTSD.
A review of the provision of compensation to veterans for PTSD by the
United States Department of Veterans AffairsThe United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is responsible for administering programs of veterans’ benefits for veterans, their families, and survivors....
began in 2005 after the VA had noted a 30% increase in PTSD claims in recent years. This led to a backlash from veterans'-rights groups, and to some highly-publicized suicides by veterans who feared losing their benefits, which in some cases constituted their only income. In response, on November 10, 2005, the Secretary 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..."
The diagnosis of PTSD has been a subject of some controversy due to uncertainties in objectively diagnosing PTSD in those who may have been exposed to
traumaPsychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event. When that trauma leads to posttraumatic stress disorder, damage may involve physical changes inside the brain and to brain chemistry, which damage the person's ability to adequately cope with...
, and due to this diagnosis' association with some
incidenceIncidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...
of compensation-seeking behavior.
Many veterans of the wars in
IraqThe Iraq War, also known as the Occupation of Iraq or Operation Iraqi Freedom, is an ongoing military campaign which began on March 20, 2003 with the invasion of Iraq by a multinational force led by troops from the United States and the United Kingdom.Prior to the war, the governments of the United...
and
AfghanistanThe War in Afghanistan is an ongoing coalition conflict which began on October 7, 2001, as the British military participated in the US military's Operation Enduring Freedom that was launched in response to the September 11 attacks...
returning home have faced significant physical, emotional and relational disruptions. In response the
United States Marine CorpsThe United States Marine Corps is a branch of the United States armed forces responsible for providing force projection from the sea, using the mobility of the United States Navy to rapidly deliver combined-arms task forces. It is one of seven uniformed services of the United States...
has instituted programs to assist them in re-adjusting to civilian life - especially in their relationships with spouses and loved ones - to help them communicate better and understand what the other has gone through. Similarly,
Walter Reed Army Institute of ResearchThis article is about the U.S. Army medical research institute . Otherwise, see Walter Reed .The Walter Reed Army Institute of Research is the largest biomedical research facility administered by the U.S. Department of Defense...
(WRAIR) developed the
BattlemindBattlemind is both the mental orientation developed during a combat zone deployment and a program developed at Walter Reed Army Institute of Research intended to reduce its impact post-deployment.-Mental Orientation:...
program to assist service members avoid or ameliorate PTSD and related problems. In the UK there has been some controversy that National Health Service is dumping veterans on service charities like
Combat StressCombat Stress is a UK charity offering residential treatment to ex-servicemen and women suffering from Post Traumatic Stress Disorder and other mental health issues....
.
Canadian veterans
Veterans Affairs CanadaThe Department of Veterans Affairs , also referred to as Veterans Affairs Canada , is the department within the government of Canada with responsibility for pensions/benefits and services for war veterans, retired personnel of the Canadian Forces and Royal Canadian Mounted Police, their families,...
offers a new program that includes rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support.
Cultural references
In recent decades, with the concept of trauma and PTSD in particular becoming just as much a cultural phenomenon as a medical or legal one, artists have engaged the issue in their work. Many movies, such as
the Bourne filmsThe Bourne films are a series of spy films based on the character Jason Bourne, a former CIA assassin suffering from psychogenic amnesia, created by author Robert Ludlum. All three of Ludlum's novels were adapted for the screen, featuring Matt Damon as the titular character in each...
,
First Blood,
BirdyBirdy is a 1984 film directed by Alan Parker and starring Matthew Modine and Nicolas Cage. It is based on the novel of the same name by William Wharton. The story is about two friends, Birdy and Al , who become friends at school and serve in Vietnam...
,
Born on the Fourth of JulyBorn on the Fourth of July is a 1989 film adaptation of the best selling autobiography of the same name by Vietnam War veteran Ron Kovic. Tom Cruise plays Kovic, in a performance that earned him his first Academy Award nomination. Oliver Stone co-wrote the screenplay with Kovic, and also produced...
,
Brothers,
Coming HomeComing Home is a 1978 drama film which tells the story of an injured Vietnam War veteran's difficulty in re-entering civilian life after his return from the war. It stars Jane Fonda, Jon Voight, Bruce Dern, Penelope Milford, Robert Carradine and Robert Ginty.The movie, which was adapted from the...
,
The Deer HunterThe Deer Hunter is a war drama film co-written and directed by Michael Cimino about a trio of Russian American steel worker friends and their infantry service in the Vietnam War...
,
Heaven & Earth,
In the Valley of ElahIn the Valley of Elah is a 2007 Academy Award-nominated film written and directed by Paul Haggis, starring Tommy Lee Jones, Charlize Theron, and Susan Sarandon...
,
The War at HomeThe War at Home is a 1996 motion picture starring Emilio Estevez, Kathy Bates, and Martin Sheen. Estevez also directed the film and also served as co-producer....
, and
Gran TorinoGran Torino is a American drama film directed and produced by Clint Eastwood, who also stars in the film. The film marks Eastwood's return to a lead acting role after four years, his last leading role having been in Million Dollar Baby. The film features a predominantly Hmong cast, as well as...
deal with PTSD. It is an especially popular subject amongst "war veteran" films, often portraying Vietnam war veterans suffering from extreme PTSD and having difficulties adjusting to civilian life. Military-themed videogames have also begun touching on the subject;
Metal Gear Solid 4: Guns of the PatriotsMetal Gear Solid 4: Guns of the Patriots, commonly abbreviated to MGS4, is a stealth action video game developed by Kojima Productions for the PlayStation 3. Guns of the Patriots is the latest addition to the Metal Gear series and was directed by Hideo Kojima...
presents the idea of a quick-fix technology that stops soldiers from experiencing an emotional reaction to combat, thus negating PTSD, and the ensuing trauma soldiers under this system suddenly find themselves with when the technology fails and leaves them without any built-up tolerance. Several characters in the game are revealed to have experienced extreme trauma at a young age, and PTSD over these events influences them into their adult lives.
In more recent work, an example is that of
Krzysztof WodiczkoKrzysztof Wodiczko is an artist currently living in Boston and teaching at MIT. The son of Polish conductor of an orchestra Bohdan Wodiczko, he was born in 1943 in Warsaw, and graduated from the Academy of Fine Arts, Warsaw in 1968 with a degree in industrial design, and taught at the Warsaw...
who teaches at MIT and who is known for interviewing people and then projecting these interviews onto large public buildings. Wodiczko aims to bring trauma not merely into public discourse but to have it contest the presumed stability of cherished urban monuments. His work has brought to life issues such as homelessness, rape, and violence. Other artists who engage the issue of trauma are Everlyn Nicodemus of
TanzaniaThe United Republic of Tanzania is a country in central East Africa bordered by Kenya and Uganda to the north, Rwanda, Burundi and the Democratic Republic of the Congo to the west, and Zambia, Malawi and Mozambique to the south. The country's eastern borders lie on the Indian Ocean.The United...
and Milica Tomic of
SerbiaSerbia , officially the Republic of Serbia , is a country located in both Central and Southeastern Europe. Its territory covers the southern part of the Pannonian Plain and central part of the Balkans...
.
General
Romeo DallaireLieutenant-General Roméo Antonius Dallaire, OC, CMM, GOQ, MSC, CD is a Canadian senator, humanitarian, author and retired general...
mentions his PTSD in his book, Shake hands with the Devil, which was adapted into a film.
Targets: Reporters in Iraq is a film made by
Maziar BahariMaziar Bahari is a Canadian-Iranian journalist, playwright and film maker. He is a reporter for Newsweek. Bahari was imprisoned by the Iranian government in June 2009, but was released on October 20, 2009.-Career:...
that deals with journalists suffering PTSD in Iraq.
Posttraumatic stress disorder is the central subject of the Israeli film
Waltz with BashirWaltz with Bashir is a 2008 Israeli animated documentary film written and directed by Ari Folman. It depicts Folman in search of his lost memories from the 1982 Lebanon War....
, in which a former soldier struggles to cope with his traumatic memories of the 1982 Lebanon War twenty years later. The narrative of the film itself becomes structured entirely around the nature of PTSD recollection. In one scene, a specialist on post-traumatic stress disorder directly addresses his trauma.
See also
- Acute stress reaction
Acute stress over reaction is a psychological condition arising in response to a terrifying event...
- Complex post-traumatic stress disorder
Complex post-traumatic stress disorder is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma with lack or loss of control, disempowerment, and in the context of either captivity or entrapment, i.e. the lack of a viable escape route for the...
- Emotional dysregulation
Emotional dysregulation is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response...
- Media violence research
Media and violence research attempts to determine whether a link between consuming media violence and subsequent aggressive and violent behavior exists...
- Post-traumatic embitterment disorder
Post-traumatic embitterment disorder is a proposed disorder modeled after post-traumatic stress disorder. Some psychiatrists are proposing this as a mental disorder because they believe there are people who have become so bitter they can barely function....
- Psychogenic amnesia
Psychogenic amnesia, also known as functional or dissociative amnesia, is a disorder characterized by abnormal memory functioning in the absence of structural brain damage or a known neurobiological cause; severe cases are very rare...
- Psychoneuroimmunology
Psychoneuroimmunology is the study of the interaction between psychological processes and the nervous and immune systems of the human body...
- Survivor syndrome
- Thousand-yard stare
The thousand-yard stare or two-thousand-yard stare is a phrase originally coined to describe the limp, unfocused gaze of a battle-weary soldier...
- Trauma model of mental disorders
Trauma models of mental disorder emphasise the effects of psychological trauma, particularly in early development, as the key causal factor in the development of some or many psychiatric disorders .Trauma models are typically founded on the view that traumatic experiences...