CENTER ON BEHAVIORAL MEDICINE

ADDITIONAL MATERIAL

RELATED PAPERS
Related Papers Menu

Post-Traumatic Stress Disorder
   
Permission graciously given by the author to reproduce this paper:   

Post-Traumatic Stress Disorder

 Elisabeth Courtenay

2004

I. Overview:

Ten years ago, one of my children began displaying certain behavioral problems that he had never displayed before. He was showing marked, diminished interest and participation in school and social events, he ruminated about death and dying, he had problems concentrating, was irritable, hypervigilant--to name a few. Only after taking him to medical doctors was he finally referred to a top therapist who diagnosed our son as suffering from Posttraumatic Stress Disorder--a disorder our family knew nothing about. The diagnosis came several months after my son and other family members had been injured in a car accident. Our child recovered quickly from physical injuries, but the emotional trauma stayed with him. I told the therapist that I thought the emotional trauma he suffered from this car accident was heightened by another trauma that had occurred a year earlier when friends of our family lost their 4-year-old son and 18-monthold daughter in a car crash. After this tragedy, the parents spent hours with our family, grieving and mourning. Our son was highly traumatized by the deaths of these children, and the parents' response to the loss. After our car accident, our son worried that family members would die, just as his friends had. In the months that followed our car accident, my son's behavior changed. He experienced nightmares, chest pains, and other physical and behavioral problems that could not explain. Even teachers at school contacted us about our son's behavior. Only after a trip to the emergency room for severe chest pains which made our son think he was having a heart attack) did we push doctors to help us find answers to our son's strange behavior. The doctors were not much help until one of them referred our son to a psychologist for evaluation. It took the help of the psychologist to put a "name" on the problem. When the psychologist presented the diagnosis of Posttraumatic Stress Disorder, I remember feeling a sense of relief that some answers were coming to us. We were fortunate. I learned later that many people who suffer from PTSD are often told their symptoms are "in their head", and they therefore never receive a proper diagnosis.

Psychological trauma on human functioning has presented puzzling and disturbing effects throughout the recorded history of mankind. Years ago when we lived in the state of Mississippi, where we visited Civil War museums, we learned that veterans of the Civil War complained of generalized weakness, chest pains, heart palpitations and other symptoms that were thought to be the result of physical stress from the war. The diagnosis given at the time was "soldier's heart". Today it would be recognized as Posttraumatic Stress Disorder. I remember visiting my Italian grandfather in Italy, who never talked about the bloody battles he experienced as a soldier during World War I. However, other relatives informed me that my grandfather came back from the war a "changed man", physically and emotionally. They said he often locked himself away in a room for hours on end, where he would cry and moan. He also suffered from depression the rest of his life. Today, I believe he would be diagnosed as suffering from PTSD. Many veterans of bloody battles have suffered from PTSD. However, a Vietnam veteran friend of mine was never accurately diagnosed with PTSD until 30 years after he fought in Vietnam. Post-traumatic stress was virtually ignored until veterans' groups and the feminist movement made psychological trauma an important issue. And even after many veterans were diagnosed by medical professionals as having PTSD, it took the U.S. government much longer to recognize the illness and grant disability benefits.

The above examples illustrate that before its inception in the DSM-III manual, PTSD was not recognized or accepted until researchers found connections between the psychological trauma and psychiatric morbidity. At first, it was believed that PTSD was a normal, expected response to trauma, with the degree of severity and chronicity tied directly to the nature of the trauma. It took more research to learn that the diagnostic criteria for PTSD involved several phenomena: 1) An initial and expectable response to trauma, 2) an initial pathological response, and 3) a more prolonged pathological state. It was found that the development of PTSD following a trauma is the exception, not the rule. In addition, it is now thought that individual vulnerabilities play a prominent role in the development of PTSD. Some researchers even suggest that trauma itself may not be the cause of PTSD but may the trigger of an endogenous psychiatric illness.

Acute and long-term responses to trauma are as varied and multi-determined as people themselves. Almost everyone is expected to experience some trauma or some form of disruption to mental functioning after a traumatic event. Many people are able to adapt to life following a traumatic event and return to their previous level of functioning, with or without certain chronic symptoms. When symptoms that follow the trauma impair functioning, however, they appear as syndromes--labeled in DSM-IV as Acute Stress Disorder and Posttraumatic Stress Disorder.

Trauma occurring in childhood and/or chronic exposure to trauma can produce long-lasting personality disturbances. When a person's response to trauma reaches the level of PTSD, there are usually a host of comorbid psychiatric conditions. I know a woman (I will call her "Linda") who experienced a series of trauma in her life. Some of the trauma included molestation during her childhood by a trusted male friend of the family, emotional and physical abuse at the hand of angry parents who beat her, marriage to a volatile man who cheated on her many times, and psychologically, emotionally, and physically abused her ("he hit me a few times", she says). Linda was recently diagnosed with PTSD. At what point in her tragic life did her response to trauma reach the level of PTSD is a difficult one to determine. Certainly every one of the traumatic events she experienced could have brought her to the level of PTSD; and certainly, the cumulative trauma brought her to the point that she suffers from chronic PTSD today, with a host of comorbid psychiatric conditions. And for those people whose exposure to trauma does not result in a psychiatric diagnosis, they may still suffer from chronic symptoms that have a significant impact upon their lives.

II. Diagnostic Criteria for Posttraumatic Stress Disorder

The DSM-IV manual defines PTSD and "trauma", and the three central groups of post-traumatic symptoms: intrusive/reexperiencing, avoidance/numbing, and hyperarousal. If these symptoms prove pervasive, prolonged and debilitating, they reach the threshold of a diagnosis for PTSD.

Typically, a posttraumatic response involves alternating symptoms of avoidance and reexperiencing, as the individual tries to come to terms with the trauma and its consequences. The typical problems faced in integrating the traumatic experience (or number of experiences, as in Linda's case) include: loss of a sense of invulnerability, fear of repetition of the trauma, feelings of personal failure, shame over helplessness, rage at the source of trauma and ensuing guilt, and guilt over survival while others perished.

Trauma is defined by the DSM-IV in a specific way; trauma involves physical threat to one's life or bodily integrity. Examples include violent assault, including rape and robbery, domestic violence, childhood physical and sexual abuse or neglect (as in the case of Linda), automobile accidents (as in the case of my son), exposure to military combat (as in the case of my Italian grandfather who fought in World War I and my Vietnam War veteran friend), natural disasters such as earthquakes, and sudden catastrophic medical illness.

Witnessing a traumatic event is also listed in the DSM-IV. My son, for example, was traumatized by witnessing the injury of others. Being told about a trauma experienced by a loved one is also specified in the DSM-IV for PTSD. This is what happened to my son when our friends (the parents of the children killed in the car crash) recounted in graphic detail the accident and deaths of the children. The parents also said to my son, "Sometimes God seems like Satan, and Satan seems like God, because He took our children away". I was very upset when I found out they said these things to my son. I had one relative who lost 3 children and she never exposed our young son to the trauma these parents did. I realize the parents were "out of their minds" with grief and anger and rage; they showed the classic symptoms of PTSD. However, their words and behavior traumatized my son to the extent that he fit the condition listed in DSM-IV that states being told of a trauma experienced by a loved one can induce trauma in the individual hearing about the trauma. This is exactly what he experienced.

A defining characteristic of a traumatic event, defined by DSM-IV, is a response that involves "intense fear, helplessness or horror". Since the feelings associated with 
a trauma are so intense, the perception of the traumatic event may be distorted. In other words, the person may experience fragments of sensations, time may be slowed or accelerated, feelings may be dissociated from events as they are occurring, or there may be varying degrees of amnesia for part of all of the traumatic event.

Another hallmark sign of PTSD is intrusive, reexperiencing symptoms. Since traumatic memories are usually disruptive, vivid, sensory experiences, they can intrude into a person's life unbidden. This is Linda's experience. She explains that she goes about her daily life when something will happen, or she unexpectedly hears a word in a conversation or she sees an object or person that triggers a flashback or memory of a trauma in her life. She has nightmares, too. Nightmares are a common experience to PTSD sufferers, and they are often repetitive, lifelike and very disruptive to sleep. Patients often dread going to sleep; they may fight sleep to avoid the frightening recurrence of the nightmare. Intense emotional distress and physical reactions such as heart palpitations, tightening of the chest, shortness of breath, and excessive sweating will occur in response to the external and internal reminders of the trauma.

Avoidance of reminders of the trauma and psychological numbing can be the most disabling symptoms that follow a trauma. The person may avoid everything and anything that is a reminder of the trauma. This includes activities, thoughts, feelings, places or people associated with the trauma. The person may also experience amnesia for the trauma itself. Linda could not remember a particular episode in her marriage that was violent because she had blocked it from memory; only later, when a female friend brought the episode up, did it return to memory. Linda has also struggled with numbing symptoms and an overall sense of detachment, a diminished range of emotions and withdrawal from many important activities. Family and friends have a challenge getting Linda to participate in activities.

Hyperarousal symptoms are another hallmark sign of PTSD. These include irritability and anger outbursts, difficulty with concentration, marked sleep difficulty, hypervigilance and an exaggerated startle response.

DSM-IV Diagnostic criteria is as follows:
A. The individual has been exposed to a traumatic event in which both of the following are present,

(1) The individual witnessed, experienced, 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 other

 (2) The individual's response involved intense fear, helplessness or horror

B. The traumatic event is consistently reexperienced in one, or more, of the following ways:

(1) Recurrent distressing dreams of the event

(2)    Intrusive and recurrent, distressing recollections of the event, including thoughts, perceptions, and images

(3)    Feeling or acting as if the traumatic event were recurring. This can include a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur when intoxicated or upon awakening

(4)    Intense psychological distress upon exposure to external or internal cues that symbolize or resemble an aspect of the traumatic event

(5)    Physiological reactions upon exposure to external or internal cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (that were not present before the trauma), as indicated by three or more of the following:

(1)    Efforts to avoid feelings, thoughts, or conversations associated with the trauma

(2)    Efforts to avoid people, places, or activities that arouse memories and recollections of the trauma

(3)    Inability to recall an important aspect of the trauma

(4)    Marked diminished interest or participation in significant activities

(5)    Feelings of detachment or estrangement from others

(6)    Restricted range of affect, such as the inability to have loving feelings

(7)    Sense of a foreshortened future; does not expect a normal life span, marriage, career, children, etc.

D. Persistent symptoms of increased arousal that were not present before the trauma, as indicated by two or more of the following:

(1)    Irritability or outbursts of anger

(2)    Difficulty falling or staying asleep

(3)    Exaggerated startle response

(4)    Difficulty concentrating

(5)    Hypervigilance

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is longer than 1 month

F. The disturbance causes clinically significant distress or impairment in social, occupational or other important area of functioning. Specify if:

Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more

With Delayed Onset: if onset of symptoms is at least 6 months after the stressor Linda has demonstrated the symptoms listed above, except for "sense of a foreshortened future".

III. Epidemiology

The prevalence of PTSD in the general population shows results ranging from 1% to 4%. The Epidemiological Catchment Area Study showed lifetime PTSD rates to be around 1.3% at two sites. More subjects who reported sub-clinical symptoms following a trauma put the figure around 15%.  A survey of 1,007 young adults in an HMO in Detroit showed that out of the 39% exposed to a traumatic event 23.6% developed PTSD. And out of this 23.6%, the PTSD lead to a lifetime prevalence of 9.2%--with 11.3% for females and 6.0% for males.

The prevalence of PTSD following specific traumas show that the rates for natural disasters vary. For example, a dam break and subsequent flood at Buffalo Creek showed a 59% lifetime prevalence of PTSD--with 25% still meeting the criteria 14 years later. And following the volcano eruption at Mt. St. Helens, a population sample showed a lifetime prevalence of PTSD at 3.6%, compared to 2.6% in controls.

For war veterans, the rates for PTSD vary as well, depending upon the level of traumatic exposure. The overall lifetime PTSD rates for Vietnam veterans is 15%. However, those exposed to median levels of combat showed a rate of 28% compared to 65% for those exposed to the highest levels of combat. For torture victims the rate can be as high as 90%. Political prisoners and prisoners of war range from 30% to more than 70%.

For individuals who suffer a violent assault, there is a 20% rate of PTSD. Rape victims have been found to have rates near 50% in some studies (which surprises me; I thought the rates would be higher). The likelihood of women developing PTSD is two times higher than that of males due to the fact that females are more vulnerable to assaultive violence.

Witnessing the serious injury or killing of another person shows a risk of 7%. And for those in a traffic accident, 10% to 30% still show PTSD 6 to 18 months after the accident. For those who experienced the sudden, unexpected death of a relative or close friend, 14% developed PTSD. My son experienced all three listed in this paragraph.

IV.    Longitudinal Course of PTSD

PTSD can be a chronic illness. 50% of World War II prisoners of war had PTSD 40 years after the trauma. And out of the number of Vietnam veterans who developed PTSD after the war, 50% of males and 32% of females still suffered from PTSD in 1988. PTSD can be acute if symptoms last less than 3 months. It is chronic if symptoms last for more than three months. It is delayed if there is an onset of symptoms at least 6 months after the stressor. The symptoms of PTSD can be intermittent and residual. It is also common for PTSD to be reactivated years after it had been apparently resolved. If the trauma involves interpersonal violence, victims are at a much greater risk for chronic PTSD.

V.    Risk Factors for Developing PTSD

The most important risk factor for developing PTSD is the nature of the traumatic stressor. However, not everyone develops PTSD after undergoing exposure to a traumatic event, even a serious one. By contrast, some people develop PTSD from "mild" trauma. Some studies propose that preexisting personality factors impact the development of posttraumatic stress disorder. In one study (Mikulincer & Solomon, 1988) of Israeli soldiers who showed combat stress reaction during the 1982 war in Lebanon, those who were prone to brooding about their feelings were more likely to develop PTSD. The National Vietnam Veterans Readjustment Study conducted by the U.S. government showed four factors that increased the likelihood of developing PTSD in soldier subject to combat stress. The four factors were: having a history of 
childhood behavior problems, having a history of affective disorders, having a history of drug abuse or dependency, and being raised in a household with financial problems (Kulka et aL, 1990). Twin studies indicate that since heredity plays a crucial role in the development of personality traits, heredity might also play a role in determining a person's susceptibility to developing PTSD (True et al., 1993).

Personal vulnerability is an important risk factor--especially in cases of less severe trauma. These risk factors include: 1) Previous psychiatric history (including anxiety disorders, major depression, conduct disorder, neurotic personality, antisocial and narcissistic personality disorder); 2) a history of previous trauma, including childhood sexual abuse; 3) low intelligence; 4) limited social support; 5) divorce of parents during early childhood, or childhood separation from parents; 6) and a family history of major depression or anxiety disorders (which suggests the heredity component to PTSD). Dissociative symptoms experienced during or shortly after a traumatic event appear to predict the later development of PTSD. The presence of severe symptoms early on appear to predict more severe symptoms later on.

VI. Associated Syndromes and Co-Morbidity

Children who are exposed to sexual or physical abuse (as Linda experienced in childhood) or adults who are exposed to prolonged and repeated trauma (as Linda has experienced throughout her adult life) may develop long-standing, chronic problems in interpersonal and psychological functioning. The younger the individual, the more vulnerable he or she is to long-term difficulties. Although it is not yet accepted as a distinct diagnosis in the DSM, this syndrome is known in literature as Complex PTSD or Disorders of Extreme Stress Not Otherwise Specified. This syndrome has a range of debilitating symptoms such as: Difficulty with affect regulation (including problems with anger management, self-destructive behavior, risk-taking behavior, and impulsive behavior); somatization; dissociative symptoms and amnesia; and a range of characterological problems--including chronic guilt and shame, damaged sense of self, feelings of ineffectiveness, idealization of the perpetrator, difficulty in forming and maintaining trusting relationships, a chronic sense of despair and hopelessness, and a tendency to be revictimized or victimize others.

Though studies show that PTSD is a distinct syndrome, comorbidity is frequently the rule rather than the exception. Typical comorbid conditions include substance abuse, major depression and other anxiety disorders.

Exposure to trauma that does not develop into PTSD can create long-standing symptoms, such as damage to the victim's sense of self, and depressed and anxious mood. In the absence of PTSD, however, exposure to trauma itself does not appear to be a risk factor for specific psychiatric diagnoses.

If a person does develop PTSD following a traumatic event, he or she is at much greater risk for developing other psychiatric disorders--such as major depression, substance abuse or other anxiety disorders--as compared to the person who is exposed to trauma but does not develop PTSD.

PTSD is a risk factor for major depressive disorder and major depressive disorder is a risk factor for PTSD. Oftentimes they can develop at the same time.

Epidemiological Area Catchment Studies showed 60-80% lifetime co-morbidity with PTSD cases compared to 15% in controls. In one study on Vietnam veterans, 50% of Veterans with current PTSD met criteria for another DSM-III diagnosis 6 months before an assessment, versus 11.5% of veterans without PTSD. Another study found that lifetime comorbidity in Vietnam veterans with PTSD is around 99% (including depression, substance abuse, anxiety disorders and anti-social personality disorder).

VII. Neurobiology of PTSD

The neurobiology of PTSD is still an evolving and rapidly advancing field of study. Though there is no single model to fully explain the pathophysiology of PTSD, data shows PTSD to be a discrete illness with biological correlates. When one considers the neurobiology of the normal stress response, the following happens: Norepinephrine plays a part in orienting to new stimuli, selective attention and autonomic arousal; in the pons, the locus caeruleus holds a large number of the brain's noradrenergic cell bodies that project throughout the brain; cortisol stimulates the metabolic processes that prepare the body for fight or flight and modulates the stress-response by counter-acting catecholamines and restoring homeostasis, providing negative feedback for the stress response; endogenous opiates increase the pain threshold; neurotransmitters link together in a web of feedback loops--so during stress, for example, the corticotropin releasing factor (CRF) increases the turnover of norepinephrine (NE), and NE increases concentrations of CRF in the locus caeruleus; and serotonin appears to play a role in regulating the stress response. In a theoretical scenario proposed by Rauch (2002), the limbic system and cerebral cortex process a stressful event. The thalamus sends information about the threat to the prefrontal cortex and amygdala (the limbic structure involved in threat assessment, fear conditioning, and emotional learning). The amygdala attaches emotional significance to incoming stimuli and facilitates the flight or fight response. The amygdala sends information to the hippocampus, paralimbic system, sensory processing systems and other structures. The hippocampus (a limbic structure involved in learning and memory--notably verbal information, facts, places and events) processes contextual information and provides feedback to the amygdala regarding past experience and current context. The anterior cingulate cortex (part of the paralimbic system) may set priorities between emotional and cognitive processes and may play a role in regulating the amygdala. One hypothesis is that abnormalities in the sympathetic branch of the autonomic nervous system play a role in the symptoms of intrusion and arousal. Animal models have demonstrated that severe stress can cause disruption to the locus caeruleus, resulting in hypersensitivity to external stimuli. Combat veterans with PTSD have shown exaggerated heart rate responses during exposure to combat-related stimuli (as compared to combat veterans without PTSD and veterans with other anxiety disorders). Some studies suggest that urinary excretion of norepinephrine is higher in patients with PTSD, as compared with controls.

Another principle finding in PTSD is abnormalities of the hypothalamic- pituitaryadrenal (HPA) axis, especially in regard to cortisol. In PTSD, cortisol levels are chronically lowered, there is increased glucocorticoid receptor sensitivity, stronger negative feedback and sensitization of the HPA system. By strong contrast, with major depression, and acute and chronic stress, cortisol levels show an increase, there is decreased glucocorticoid receptor responsiveness, a decrease in negative feedback, and desensitization of the HPA system (Yehuda, 2002). Patients with PTSD can have lower cortisol levels up to 50 years following the first trauma. Lower cortisol levels that immediately follow a trauma can be a risk factor for developing PTSD at a later date. Studies have found that following a rape, low cortisol was associated with prior rape or assault--which, in turn, was the strongest predictor of subsequent PTSD. Some animal studies showed high levels of cortisol to be damaging to the hippocampus. The hippocampus tends to be smaller in subjects with PTSD. MRI measurements of hippocampal volume in PTSD patients have been done in only a few, small studies, and these findings suggest slightly smaller hippocampal volumes, correlated with severity of traumatic exposure, cognitive deficits and PTSD symptoms. (However, the significance of these findings is unclear; these lower volumes may represent a premorbid factor, a result of exogenous toxins, or be the result of elevated cortisol).

Studies using functional neuro-imaging suggest a typical pattern of brain activation with traumatic stimuli in PTSD patients. Only a small number of subjects have been stimulated with traumatic stimuli in studies using functional neuro-imaging, but the findings suggest that PTSD is associated with exaggerated activation of the amygdala and deactivation of Broca's area. One study (Rauch, 2002) suggests that PTSD may involve a primary hypersensitivity of the amygdala, or an inadequate inhibition of the amygdala by the hippocampus or anterior cingulate. Another study (Van der Kolk, 1999) suggests that traumatic memories are laid down in the hippocampus under stress, and in such a way these traumatic memories remain as sensory fragments without an organized narrative. Other biological models for PTSD include fear conditioning, stress sensitization and learned helplessness.

XIII. Evaluation and Treatment Immediately Following a Traumatic Event

Unfortunately, many survivors rarely come to the attention of psychiatrists and psychologists right after a traumatic event--especially in the case of a natural disaster--because they are trying to find food and shelter and reconnect to family and support services. Then there are those who adapt to traumatic events without professional help and may decline an offer of such help. Then there are those like Linda--who slip through the cracks as children and never receive help for the trauma they underwent as children--until they become adults and seek help. 

There has been a great deal of interest trying to determine whether or not acute psychological intervention has an impact on the subsequent development of post-traumatic symptoms. Different debriefing strategies have been developed, but the research findings have been mixed. Some propose that well-trained clinicians working in teams can use a highly-structured, debriefing process in a group setting (i.e., flood victims, earthquake victims) that would diminish the development of PTSD symptoms.

Others suggest that such interventions could worsen the problem because of all the overwhelming feelings involved. Current research is looking at whether these types of debriefings should be offered only to those at high risk or to all survivors.

An evaluation and treatment plan should be guided by certain important principles. First and foremost, the goal of any intervention plan following a traumatic event should be to help the individual regain a sense of mastery and control. Communication should include a sense of hope and expectation of recovery. Second, the use of existing support services should be encouraged; those at high risk should be referred for psychological treatment, though the option of follow-up should be made to everyone. Attention must be paid to the practical and immediate concerns brought about by the trauma Victims should be given any and all information available (i.e., medical support, transportation support, etc.). The patient's mental status should be assessed to determine if she or he is capable of managing safely with the current support available; this is important because dissociation can be very pronounced (and can be a high risk factor for the subsequent development of PTSD). The patient should be gently encouraged to review the trauma and surrounding events. The aspect of the trauma most distressing to the patient should be identified, if possible. However, the patient's ability to tolerate a retelling of the event must be taken into consideration because, if it is not necessary nor helpful, it can be harmful and overwhelming for the patient to recount the event. The need to see the reality of the event has to be balanced with the "denial" because the patient needs to be able to process the event in a tolerable way. Appreciation and respect should be shown for the patient's coping style.

The patient should be assessed for the risk factors for PTSD. Those at highest risk will likely need ongoing treatment. Victims of rape and domestic violence, for example, need specialized follow-up. They need a medical work-up that evaluates their physical condition and provides documents needed for legal proceedings. Most of all, they need a sense of safety. They need referral to specialized psychological services (such as rape-crisis centers and domestic violence shelters) that can give support and treatment, and help with legal issues. Patients need an assessment process to see if they are at risk for ongoing trauma (which is usually the case with victims of child abuse and spousal abuse). Children especially are in need of immediate protection, with the help of social service agencies. Victims of domestic violence come from all socioeconomic groups and are often reluctant to acknowledge the extent of their danger; they need encouragement to seek help. For those who face persistent threat, they should be encouraged to write out a safety plan that details definitive steps they can take to avoid future trauma. The plan may include the help of local law enforcement authorities. Even though the clinician or therapist encourages the patient to take steps for self-preservation and protection, it is the patient who must make the ultimate decision (unless it involves children).

The clinician should be tolerant of the patient's feelings and help the patient put them into context. The clinician can be gently reassuring to the patient that feelings of helplessness, fear, shame, guilt and anger are expected responses to a traumatic event.

The clinician can educate the patient about common responses to trauma such as insomnia, irritability, nightmares, and intrusive memories during the first few months after the trauma, and that the symptoms will begin to subside. Such education can help the patient feel more in control of his or her experiences. The patient should also be educated about possible maladaptive responses to trauma (alcohol abuse is common in patients trying to manage hyper-arousal and intrusive symptoms).

Medication should be used sparingly because there is no long-term benefit from sedating someone heavily following a trauma. Sometimes insomnia, agitation and severe anxiety are treated with low-dose benzodiazepines. Supplies of medication are not typically given for more than several days and are contraindicated in patients with alcohol or substance abuse.

IX. Evaluation of Patients with PTSD

Patients with PTSD can be evaluated in a variety of settings. Evaluation may come as a result of a general psychiatric evaluation, or it may be part of a course of treatment specifically for PTSD. Linda was evaluated with PTSD after she sought counseling for marriage problems. In a general psychiatric evaluation, a therapist can screen for exposure to traumatic occurrences throughout the person's life cycle by asking questions about specific trauma, rather than trauma in general, and this can be done in a normalizing and non judgmental manner. For example, Linda's female therapist broached one specific area by saying, "It is not uncommon for people to have been touched in ways they did not want to be touched when they were children. Did you ever have the experience of being touched in a harsh or sexual manner during your childhood?" This question prompted Linda to recount episodes of discipline when she was slapped in the face or hit with a belt by her father, or "whipped" with a switch or wooden spoon by her mother. The question also prompted Linda to talk about the sexual molestation by a "grandfatherly" family friend.

The therapist has to be aware of how the interview is affecting the patient. Straight-forward questions can bring an eruption of overwhelming and powerful feelings. The therapist has to work with the patient to establish a tolerable level of stress that is appropriate for the circumstances. For example, Linda's therapist said, "Some of the questions I ask may bring up some rather strong feelings, so please let me know if something is too difficult to talk about". This approach helped Linda and she was able to talk about the specific traumas in her life. Other patients, however, may not be able to talk about the trauma itself. The clinician may have to shift the focus from the traumatic event to the effects of the trauma on various parts of the person's life.

Linda's therapist offered the opportunity to recount a traumatic event. The therapist paid close attention to Linda's ability to tell the story. Linda turned out to be the type of patient who found it helpful to talk about the event--as compared to those who become so overwhelmed that they think or speak of nothing else, or they are not able to speak of the trauma at all. The therapist has to review the symptoms of PTSD and make an assessment of the frequency and intensity of the patient's symptoms. Patients often report intrusive and hyper-arousal symptoms, but rarely the numbing and avoidance symptoms that can be very disabling. The therapist should ask the patient how he or she copes with the symptoms. The therapist needs to evaluate the patient's overall psychological, social, and occupational functioning such as: Is there an increase in social isolation, is the patient able to resume normal activities, is the patient able to relate to family and friends, etc.? Premorbid functioning should be assessed: Has the trauma changed the patient's self-esteem, ability to trust, take risks, tolerate loss, manage dependency, autonomy and intimacy? The therapist should formulate a differential diagnosis because several psychiatric illnesses share characteristics of PTSD; for example, bipolar disorder and PTSD can both present with anger outbursts, impulsive risk-taking behavior, marked sleep disturbance, and irritable and labile mood--however, PTSD does not involve expansive moods or prolonged euphoria. The patient should be screened often for frequently-occurring co-morbid conditions that complicate the process of treatment and recovery, such as alcohol and other substance abuse, somatoform disorders, major depressive disorder, dissociative disorders, and other anxiety disorders. The therapist should evaluate the patient's strengths and take notice of the patient's efforts to adapt successfully to trauma. The patient may present for treatment due to a precipitating factor that disrupts previously successful adaptations to trauma. The therapist must also assess the patient's safety and risk for ongoing trauma. X. Treatment of PTSD:

Patients vary in the severity of PTSD and the timeline to recovery. Some use treatment to overcome trauma, while others make little progress. The passage of time and life events help some patients to recover, while others are unable to move forward. Linda is having a very difficult time moving forward. The symptoms of PTSD have created a cycle that traps her within a world of traumatic memories which threaten to overwhelm her. She tries to cope with these powerful and disorganized memories; however, the threat from within is that intense feelings may trigger a traumatic memory, and the threat from without is the stimuli associated with the trauma. This is what happens to Linda. Intense feelings will trigger a traumatic memory. She may see, hear, or experience a stimulus in her environment she associates with the trauma. People like Linda may withdraw into dissociative states or use alcohol to subdue intrusive memories and hyper-arousal.

People suffering from PTSD feel helpless in coping with the past and helpless in managing the present. Their loss of control in the present stimulates the traumatic memories and keeps the cycle going. Treatment, therefore, must address this cycle and be guided by the following general guidelines and principles:

A).    Treatment should generally involve an integration of several therapeutic approaches, including cognitive-behavioral and psychodynamic. Medication may also play an adjunctive role.

B).    Treatment should be phase-oriented. The first goal should focus on stabilizing the patient and address acute symptoms. The second phase of the plan should revolve around working through the trauma. The third phase should focus on reestablishing social relationships. 

C)   Stabilization may take a long time and actually be a very prolonged phase. Sometimes it can entail the entire treatment. The cornerstone of therapy is to educate the patient about post-traumatic experiences. If the patient can anticipate an expectant response, he or she will feel less helpless. Being able to identify feelings and put bodily experiences into words will help the patient begin to organize the chaotic, emotional state. As the patient learns how symptoms come and go, he or she will learn to exercise more control over emotions. Connection to the therapist with treatment that establishes clear and predictable boundaries will facilitate safety. Stabilization also involves addressing maladaptive behaviors, such as substance abuse and self-destructive behavior. Ongoing exposure to trauma will undermine growth and improvement, so the patient needs to learn to distinguish between safe and unsafe behavior.

D.    Treat co-morbid disorders.

E.    Work through the trauma. This can be done in several different ways. The patient can learn to tolerate environmental triggers and traumatic memories and become desensitized, thus diminishing avoidance. The patient can also create a narrative of the traumatic event and gain understanding of its personal meaning. The reality of the trauma and its impact will become integrated into the survivor's sense of self.

F.    Facilitating social relationships is a crucial part of recovery from trauma. The patient must ultimately learn to return to daily life in the community.

G.    The therapist can experience emotional strain treating the patient with PTSD because hearing about the trauma and witnessing the patient's distress can be 
traumatic for the therapist as well. Therefore, it can be challenging for the therapist to maintain the needed balance between seeing the patient as the helpless victim and as the survivor who can take responsibility for his or her life.

H.    The therapist has to balance the need for the patient to review the trauma with the danger that the patient will be traumatized by retelling the trauma.

I.    Patients who have a history of childhood sexual abuse (as in Linda's case) or patients with complex PTSD are often very challenging to treat. These patients often suffer from problems with affect regulation and trust; therefore, it may take years for the patient to develop a trusting relationship with the therapist strong enough to manage the exploration of the trauma. Learning basic positive self regard, impulse control, affect regulation and boundary management are prerequisites for the exploration of the trauma itself.

XI. Psycho-Social Treatment Modalities for PTSD

A. Psychodynamic approaches are characterized by:

1)    Emphasizing the exploration of the personal meaning of the traumatic event.

2)    Exploring the impact of the trauma on the patient's self-concept, as feelings of grief, helplessness, and shame emerge. Through the course of treatment, feelings of anger and guilt, accompanied by fantasies of having omnipotent control, are often encountered.

3)    Unresolved conflict (i.e., child abuse) from an earlier stage in life may be heightened by the trauma and should, therefore, be dealt with in treatment.

4)    Taking special note of the patient's style of coping and defense mechanisms. The patient who experiences flooding of affects is helped by organizing himself or herself. And the patient who is over-controlled and detached is helped by gaining access to feelings. The patient may need to explore the fear of losing control as treatment begins.

5)    The patient's relationship with the therapist is an integral part of the treatment plan. Such a connection helps contain affects and process transference reactions. 

B. Cognitive-behavioral approaches are characterized by:

1)    The goal of treatment to disrupt the connection between the trauma-related cues and the strong anxiety responses and avoidance that is typical for PTSD. The patient is taught to distinguish traumatic memories and trauma-related emotions from the current reality, thereby learning to feel more in control of his or her world.

2)    The technique often stimulates the experience of a traumatic memory, and this is needed in order to modify the response to that particular memory.

3)    Educating the patient about the nature of the symptoms of PTSD, thereby establishing a focus of treatment.

4)    Helping the patient identify underlying, distorted, "all-or-nothing" beliefs held about the world (i.e., "I'm at fault for everything", "the world is a bad place", etc.). The patient learns to address and alter these distorted thoughts.

5)    The patient is taught methods of relaxation and guided imagery to help him or her manage PTSD symptoms. 

6) The patient is exposed to traumatic material and is taught to respond in new ways by learning how to distinguish between real and imagined threat and diminish physiological reactivity.
Cognitive behavioral techniques have been the most studied methods of treatment for PTSD and have shown themselves to be very helpful in the treatment of PTSD.

C.    Group treatment can be a helpful component of the overall treatment plan because it provides information and support to the patient. Some patients are helped by a group setting because it can allow for a diffusion of the strong transference reactions that can impede the healing process.

D.    Eye-Movement Desensitization and Reprocessing (EMDR). (Linda underwent EMDR with one therapist for a short period of time, but stopped going before results could be observed).

1) Shapiro (2002) found negative responses to disturbing memories and thoughts to be attenuated with rapid eye movements, so she developed a plan of treatment for PTSD based on the following: An affect-laden image of the trauma is constructed, along with a summary statement, and the subjective distress is rated. An alternate, positive statement is formulated. The patient initiates eye movements following an object across a visual field while holding the traumatic image in mind. Then, after 12-24 repetitions, the patients takes note of his or her subjective distress. The cycle is repeated 3-15 times until there is a significant reduction in distress.

2) EMDR treatment is prescribed as an adjunct to other modalities, and it has been 
suggested that several sessions can make a significant reduction in PTSD symptoms.

3) There is much dispute between the psychiatric community and scientific literature in regard to this technique. The critics say that EMDR, at its best, is a non-intrusive exposure technique and its benefits are non-specific. Proponents say that, even though the method of action is unclear, it shows impressive benefits. Also, even though the technique is controversial and still looked at as being experimental, it is being used more and more in clinical practice.

XII. Pharmacotherapy of PTSD

A. Medication is often used as an adjunctive treatment for PTSD, tailored to specific symptoms and stage of illness. However, medication may mask some of the anxiety the patient needs to make use of psychological treatment. Linda, in fact, refuses to take medication because she says it makes her feel "dull-headed" and "takes away the feeling or need for therapy". She tried psychiatric treatment, but was very disappointed by psychiatrists "who only prescribe medications for the problem instead of helping me find healthier ways to cope".

For those who prescribe medications for PTSD, the first line of treatment usually uses selective serotonin reuptake inhibitors and anti-adrenergic agents. Fluoxetine

has been used for intrusive hyperarousal and numbing symptoms in civilian populations, as well as other SSRI's that are thought to be effective. Clonidine and propranolol have been used for intrusive symptoms--particularly flashbacks and nightmares--and for hyperarousal symptoms in open studies. Nefazodone has been used in recent studies and has shown some promise in the treatment of war veterans. Tricyclic antidepressants have had mixed results in controlled studies. Monoamine oxidase inhibitors have been found to be effective in intrusive symptoms, but are rarely used because of drug interactions and dietary problems. Benzodiazepines have been used sparingly and cautiously for hyperarousal symptoms; they may exacerbate dissociative symptoms, and abuse and dependence are significant risks. Trazodone, mirtazapine and doxepin have been used for sleep problems. Mood stabilizers such as lithium, carbamazepine and valproate have been used in small, open studies and used empirically for anger outbursts and mood lability. Anti-psychotic medications are reserved for only the most disorganized and psychotic individuals, yet the newer, atypical antipsychotics are being studied as a treatment for PTSD.

As mentioned previously, Linda refuses to see a psychiatrist or take medication, as she did previously, because she experienced too many adverse side effects from medication and found psychiatrists "too quick" to prescribe. Linda is now undergoing treatment with a psychologist who integrates several therapeutic approaches, including psychodynamic and cognitive-behavioral. She finds these approaches to be more helpfuL She also says she practices yoga and other relaxation techniques (i.e., "listening to beautiful music" and "taking long walks") help her. She also says the psychotherapy plays a tremendous role--along with a healthy exercise program, nutritious diet, rest and relaxation techniques--to help her with PT SD.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (4th ed.) Washington, D.C.: American Psychiatric Association, 1994.

Bremner, J. D., Licinio, J., Darnell, A., Krystal, J. H., Owens, M., Southwick, S. M., Nemerofi C. B., Charney, D. S., (1997): Elevated CSF corticotropin-releasing factor concentrations in posttraumatic stress disorder. American Journal of Psychiatry 154:624-629.

Bremner, J. D., Douglas, J., and Marmar, C. (eds.) (1998). Trauma, Memory and Dissociation, Washington, D.C.: American Psychiatric Press.

Bremner, J. D., and Narayan, M. (1998). The effects of stress on memory and the hippocampus throughout the life cycle: implications for childhood development and aging. Developmental Psychopathology 10:871-886.

Bremner, J. D., Randall, P. R., Scott, T. M., Bronen, R. A., Delaney, R. C., Seibyl,
J. P., Southwick, S. M., McCarthy, G., Charney, D. S., and Innis, R. B. (1995): MRI-based measurement of hippocampal volume in posttraumatic stress disorder. American Journal of Psychiatry 152:973-981.

Bremner, J. D., Randall, P., Vermetten, E., Staib, L., Bronen, R. A., Mazure, C. M., Capelli, S., McCarthy, G., Innis, R. B., Charney, D. S. (1997): MRI-based measurement of hippocampal volume in posttraumatic stress disorder related to childhood physical and sexual abuse: A preliminary report. Biological Psychiatry 41:23-32.

Bremner, J. D., Scott, T. M., Delaney, R. C., Southwick, S. M., Mason, J. W., Johnson, D. R., Innis, R. B., McCarthy, G., and Charney, D. S. (1993): Deficits in short-term memory in post-traumatic stress disorder. American Journal of Psychiatry 150:1015-1019.

Bremner, J. D., Southwick, S. M., Charney, D. S. (1999): The neurobiology of posttraumatic stress disorder: An integration of animal and human research. In: Saigh, P., and Bremner, J. D. (Eds.): Posttraumatic Stress Disorder: A Comprehensive Text. New York: Allyn and Bacon, pp. 103-143. 

Bremner, J. D., Staib, L., Kaloupek, D., Southwick, S. M., Soufer, R., Charney, D. S. (1999): Positron emission tomographic (PET) based measurement of cerebral blood flow correlates of traumatic reminders in Vietnam combat veterans with and without posttraumatic stress disorder. Biological Psychiatry 45: 806-816.

Breslau, N. Epidemiology of Trauma and Posttraumatic Stress Disorder. In Yehuda, It, ed., Psychological Trauma. Washington, DC: American Psychiatric Press, 2002.
Carlson, Neil, R. Physiology of Behavior, 7th edition. Massachusetts: Allyn and Bacon, 2001.

Foa, E. and Meadows, E. Psychosocial Treatments for Posttraumatic Stress Disorder, in: Yehuda, R, ed: Psychological Trauma. Washington, DC: American Psychiatric Press, 2002.

Freidman, Matthew. Current and Future Drug Treatment for Posttraumatic Stress Disorder Patients. Psychiatric Annals 2002; 28 (8): 461-467.

Gurvits, T. V., Shenton, M. E., Hokama, H., Ohta, H., Lasko, N.B., Gilbertson, M. W., Orr, S. P., Kikinis, R., Jolesz, F. A., McCarley, R. W., and Pittman, R. K. (1996): Magnetic resonance imaging study of hippocampal volume in chronic, combat-related posttraumatic stress disorder. Biological Psychiatry 40: 192-199.

Herman, J. L. Sequelae of prolonged and repeated trauma: evidence for a complex Posttraumatic syndrome (DESNOS). In: Davidson JRT, Foa EB, eds. Posttraumatic Stress Disorder: DSM-IV and Beyond. Washington, D.C.: American Psychiatric Press, 1993; 213-228.

Horowitz, M. J. Stress Response Syndromes. Northvale, NJ: Jason Aronson, 1986.

Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., Nelson, C. B. (1995). Posttraumatic Stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52: 1048-1060.

Marmar, C. R., Foy, D., and Kagan, B, et al. An integrated approach for treating post-Traumatic stress. In: Oldham, J. M., Riba, M.B., and Tasman, A., eds. Review of Psychiatry, Vol. 12. Washington, DC: American Psychiatric Press, 1993: 293-273.

Meichenbaum, D. A Clinical Handbook/Practical Therapist Manual for Assessing and Treating Posttraumatic Stress Disorder. Waterloo, Ontario: Institute Press, 1994.

Ornstein, R. Approach to the Patient Following a Traumatic Event. In: Stern, T., Herman, J., and Slavin, P., eds: The MGH Guide to Psychiatry in Primary Care. New York: McGraw Hill, 2002.

Rauch, S., Shin L., and Pitman, S. Evaluating the Effects of Psychological Trauma Using Neuroimaging Techniques. In: Yehuda, R., ed: Psychological Trauma. Washington, DC: American Psychiatric Press, 2002.

Saigh, P. A., Mroweh, M., Bremner, J. D. (1997). Scholastic impairments among traumatized adolescents. Behavior Research and Therapy 35:429-436.

Schiraldi, G. R. The Post-Traumatic Stress Disorder Sourcebook. Lincolnwood, Illinois: Lowell House, 2000.

Shapiro, F. Eye Movement Desensitization and Reprocessing. New York: Guilford Press, 1995.

Stein, M. B., Koverola, C., Hanna, C., Torchia, M. G., McClarty, B. (1997): Hippocampal volume in women victimized by childhood sexual abuse. Psychol Medicine 27:951-959.

Tomb, D.A., and Allen, S.N. Phenomenology of Posttraumatic Stress Disorder, Psychiatric Clinic North America, 1994; 17(2): 237-250.

Van der Kolk, B., McFarlane, A.C., and Weisaeth, L., eds: Traumatic Stress. New York: Guilford Press, 2002.

Yehuda, R. Neuroendocrinology of Trauma and Posttraumatic Stress Disorder. In Yehuda, K., ed: Psychological Trauma. Washington, DC: American Psychiatric Press, 2002.