Abnormal Psychology: Post Traumatic Stress Disorder

Post-traumatic stress disorder (PSTD) is a psychological condition that may develop after the individual is exposed (experiencing or seeing) to a catastrophic event outside the range of normal human experience.  These events may include a war incident, road traffic-accident, threat to oneself or near and dear ones, natural disaster, sexual assault, physical assault, hostage crisis, child abuse, combat, abductions, murders, etc.  The event should be felt as ‘traumatic’ by the individual and causes distress.  PSTD was previously known as ‘traumatic neurosis’.  The disorder may be acute (which lasts for 1 to 3 months) or chronic (which progresses beyond 3 months).  In Shakespearean literature, Henry IV may have fulfilled some of the criteria for PSTD.  References of the disorder were being mentioned to the Crimean war and the American Civil War[1].  However, PSTD was not being recognized at that time as a disorder.  It began to be recognized as a separate condition only after the introduction of the DSM-III criteria in 1980[2].  This was mainly following the American experience of the Vietnam War.  Studies conducted in individuals that had experienced the Vietnam War demonstrated that 31% (of the male segment) had suffered from PSTD, compared to 15% in the civilians that had similar traumatic experiences[3].  In women the rates were 27% (in Vietnam veterans) and 9% (in civilians with similar experiences)[4].  Studies show that about 9% of the population is affected with PSTD at any given point of time[5].

The chances of PSTD also depend hugely on the severity of the traumatic event[6].  Individuals affected with PSTD are also at a greater risk of developing other psychiatric disorders.  Hispanics were at a greater chance of developing PSTD than the general population[7].

PSTD can occur at any age, and is more often seen in women and adolescent girls than men and adolescent boys (the incidence is almost twice as high)[8].  Studies conducted demonstrate that around 13% of the female are affected with PSTD any time during their lifespan, and 3% are currently suffering from the disorder[9].  Individuals at a risk of developing PSTD include those with a shy personality, family history of depression or anxiety, those experiencing several life problems (such as family, social, interpersonal and marital problems), personality disorders and experiences of traumatic events very early during life (such as child abuse).  Research has been conducted to find out the role of genetic causes on PTSD.  However, it is not clear whether genetic or familial factors increase the chances of developing PTSD or increases the risk of the individual performing certain risky activities.  Studies have shown increased occurrence in twins[10] but not much of an environmental role in them[11].

PSTD cases are on the rise because of a huge increase in the events we perceive as ‘traumatic’ and to some extent because it can be a result of modern living.  A disaster (natural or man-made) in a particular area can often lead to several cases of PSTD in that particular region[12].

PSTD may develop due to improper processing of mental and cognitive data of a catastrophic life-event[13].  The individual is unable to digest the graphic details of the event, and has re-experiences of it in the form of dreams, nightmares, flashbacks, illusions, hallucinations, and real-life situations[14].  Incomplete processing of information of the traumatic life-event may lead to agitated and nervous states.  The individual may try to avoid stimuli that bring make memories of the event in order to get rid of the associated mental trauma.  The individual may avoid thoughts, feelings, conversations, activities, people and places they associate with the event.  The individual may also try to dissociate (separate) themselves from their thoughts and from the world.  They do not consider their future lives and are not interested in their jobs or families.

They may also develop several distressing symptoms such as inability to sleep, irritability, anger, inability to pay attention, nervousness, anxiety, depression, sadness, rapid heart beats (palpitations), headaches, phobias, guiltiness (when near and dear ones are unable to survive the event).  When interacted with, these individuals tend to get easily angry, startled or irritated.  They demonstrate agitation at their homes and offices (by showing an exaggerated reaction to otherwise normal interactions).  These problems seem to cause severe disturbance to the individual, affecting their ability to perform their functions normally, friendships, relationships, lifestyle and social respect.  The individual may also start drug abuse, alcohol abuse or tobacco use in order to forget memories of the traumatic event.

The symptoms of PSTD usually begin to appear 3 months after the traumatic event.  Substance abuse may frequently delay the appearance of the symptoms of PSTD, whereas anxiety may hasten appearance of the symptoms[15].  If the condition is left untreated, the symptoms can remain for life.  Normal mental development may stop in children affected with the disorder.  They tend to indulge in certain habits (such as thumb-sucking).  Previous problems may return and newly acquired skills may disappear.

The differential diagnoses of PTSD include panic attacks, major depression, phobias, head injuries (with brain damage), hyper-vigilance, hallucinations, schizophrenia, etc[16].

In PSTD, a history of a catastrophic life-event exists, and the individual develops intense fear and distress following the event.  Three types of symptoms mainly develop, namely re-experiences of the event, avoiding circumstances (such as people, places, thoughts, etc) that bring back memories of the event and psychiatric symptoms (such as distress, worry, agitation, and depression).

In adjustment disorder, the stressful event is usually less severe, and the individual maladapts to the situation[17]. Besides, certain problems (such as re-experiences and avoidance of certain situations) are usually absent in adjustment disorders.

Often the disorder resembles phobias (due to the avoidance symptoms).  However, the avoidance may only be to stop memories of the event.

            Symptoms of PTSD may often be similar to panic attacks.  However, in PTSD, panic attacks are not a major concern for the individual.

            The symptoms of PTSD may be similar to major depression.  However, major depression may be associated with PTSD and may even coexist, which needs to be detected and treated appropriately.

            Often certain symptoms of brain damage such as amnesia and inattentiveness may resemble PSTD[18].  Hyper-vigilance (also a symptom of obsessive-compulsive disorder) may also appear in PSTD.  However, this symptom exists to avoid the memories associated with the event and not as a ritual or compulsion.

The exact cause (etiology) of PSTD is still not understood clearly.  Several theories such as the psychodynamic theory, biological theory and behavior models have been put forth[19].

Psychodynamic theories consider that the stressful event may bring back hidden conflicts in the individual that originate from childhood[20].  However, newer versions of the theory suggest that the individual is not able to process data of the incident.  These conflicts are demonstrated through various symptoms such as agitation and avoidance.

Individuals suffering from PSTD showed that autonomic nervous system responses to reminders of the traumatic event existed[21].  PTSD may be associated with increased synthesis of nor-epinephrine from a group of neurons present in the brain (locus coeruleus)[22].  An agent that opposes the action of alpha-2 adrenergic (yohimbine) was produced during arousal and re-experience situations.  Besides, the heart rate and biochemical activity also elevated which are apparently similar to panic attacks[23].

The learning pattern of PTSD can be of 2 types, namely classical conditioning and instrumental learning.  Classical conditioning is a situation in which seemingly normal stimuli are paired with the trauma.  Instrumental learning is a condition in which new behaviors (such as avoidance) are acquired to reduce the anxiety associated with the instrumental learning.

The history, symptoms, mental evaluation and physical examination, helps in the diagnosis of PTSD.  Several psychological assessment tools such as questionnaire may be required.  However, the reliability and validity of such tools have to be determined before using them clinically[24].  Besides, several diagnostic tests such as sleep studies may be required to know more details of the symptoms.  The process of differential diagnosis is necessary to rule out mental disorders that have similar symptoms

A diagnostic criteria known as ‘Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision’ (DSM-IV-TR), has been accepted to confirm the presence of PTSD[25].  6 points need to be fulfilled in PTSD (namely criteria A, B, C, D, E and F).  The symptoms more often develop within 6 months after the event (as per the DSM-IV-TR criteria).

Criteria A involve exposure to a traumatizing event that is beyond the limits of normal human experience.  The individual may have experienced the event or merely witnessed it.  Besides, the individual should react to the event with horror, agitation (especially in children) helplessness or fear.

Criteria B involve re-experiencing the traumatic event in the form of dreams, nightmares, thoughts, feelings, real-life incidents, illusions, hallucinations, flashbacks, etc.  The individual exhibits intense emotions following exposure to the re-experiences.  Children may re-enact the details of the trauma.

Criteria C involve intention of the individual to avoid any stimulus that is associated with the traumatic event.  The individual may avoid thoughts, conservations, people, activities, places, etc they associate with the event.  They may be incapable of recalling details of the event.  They may remain detached from others and may avoid normal day to day activities.  The symptoms of avoidance affect their functioning at home, workplace and in social settings.  Besides, relationships and friendships may be lost.  The individual may not bother about the future, friends or family members.

Criteria D involve persistent symptoms of agitation such as irritability, nervousness, confusion, anger, problems during interaction with others (demonstration of impatience), inability to concentrate, hyper-vigilance, sleeplessness, exaggerated startle reaction, etc.

            Criteria E include the duration of symptoms from criteria A, B, C and D which exist for more than a month.

            According to criteria F, the disorder should cause considerable amount of distress or impair the functioning of the individuals at the home, workplace or social settings.

            The disorder should also be distinguished from the acute form (in which the symptoms are for less than 3 months) and the chronic form (in which the symptoms are for more than 3 months)[26].  Sometimes a delayed version of the disorder may develop, when the symptoms begin to appear at least 6 months after the event[27].

            PSTD should be assessed and treated promptly in order to prevent complications and further disability to develop.  It is usually treated using psychotherapy and pharmacotherapy (for short periods)[28].  Sometimes, associated problems (such as substance abuse and major depression) may also be present and are given immediate attention.

            Pharmacotherapy may be required for a short period of time in order to control the symptoms (such as depression, anxiety and anger).  Certain groups of drugs such as antidepressants, sedatives, ant-anxiety agents, anti-histamines and anti-epileptics may be required.  Studies have shown that antidepressants help to reduce the symptoms of anxiety, re-experiences and avoidance[29].  However, following administration of medications, the symptoms reduce very slowly, but do not totally disappear.  Studies are being conducted on several newer drugs to determine their efficacy and safety in treating individuals with PTSD[30].

            Cognitive-behavior therapy (a psychotherapy technique) has proven to be very useful in treating PSTD, and helps to overcome re-experiences and avoidance[31].  Treatment is usually provided in three stages, which may take several months.  In the first stage, safety measures are taken to prevent further complications from developing and enable the individual to return back to normal (this is a part of general management).  The most vital problem (re-experiences or intrusions) is reduced by talk-therapy or counseling.  Group therapy is one of the means of helping the individual to share experiences with others and also understand that such experiences are a part of life.  In the second phase, the emotions to the catastrophic life-incident are dealt with by discussing it with the individual.  The therapist should obtain information about incident from the individual or other sources.  Behavior modification techniques (such as desensitization, controlled exposure, memory reactivation, flooding and restructuring) may be required if the individual finds it difficult to speak about it.  The therapist can try several ways to help cope up with the stress.  In future, the individual should be able to accept the incident as a part of life (try to look at the incident not from a negative viewpoint).  In the third phase, the individual is shown mental techniques of reducing bad memories of the event.  A belief system that better suites reality is followed.

            The outcome of PTSD depends on 2 factors: – the extent to which the symptoms interfere with normal functioning and the early management.  Untreated conditions may result in long-standing PSTD.

References:

1. American Psychiatric Association (2006). DSM-IV and DSM-IV-TR – Posttraumatic Stress Disorder (PTSD).
2. Braunwald, E., Fauci, A., Kasper, D., Hauser, S., Longo, D., & Jameson, J. (2004). Harrison’s Principles of Internal Medicine, (16th Ed), New York: McGraw-Hill.
3. Cusack, K., Falsetti, S., & De Arellano, M. (1998). Gender Considerations in the Pscyhometric Assessment of PTSD. In: Kimbling, R., Ouimette, P., & Wolfe, J. (Eds), Gender and PTSD, Guilford Press, New York.
4. Davidson, J. R. T., & March, J. S. (1997). Traumatic Stress Disorders. In: Tasman, A., Kay, J., & Lieberman, J. A. (Eds). Psychiatry (Vol. 2), Philadelphia: W.B. Saunders Company.
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17. American Psychiatric Association (2006). DSM-IV and DSM-IV-TR – Posttraumatic Stress Disorder (PTSD).
18. American Psychiatric Association (2006). DSM-IV and DSM-IV-TR – Posttraumatic Stress Disorder (PTSD).
19. Braunwald, E., Fauci, A., Kasper, D., Hauser, S., Longo, D., & Jameson, J. (2004). Harrison’s Principles of Internal Medicine, (16th Ed), New York: McGraw-Hill.
20. Nagy, L. M., Riggs, M. R., Krystal, J. H., & Charney, D. S. (1998). Anxiety Disorders. In: Stoudemier, A. (Eds). Clinical Psychiatry for Medical Students, (3rd Ed), Philadelphia: Lipponcott Raven.
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