PTSD

(Post-Traumatic Stress Disorder)

The Facts

Post-traumatic stress disorder, or PTSD, is a new name for a very old condition. In the earlier 1900s, it was known as "shell shock" or "battle fatigue." Before then, it had no name. In PTSD, a witness or victim of a terrible event or tragedy is so haunted by memories of the event that personal health and personality is affected. Events likely to lead to PTSD are those that cause the victim to feel fear, horror, or helplessness. Many people start to have symptoms within three months of the trauma, but symptoms may occur later. PTSD often occurs together with other conditions such as depression, anxiety, or substance abuse.

Research suggests that approximately 6% to 9% of the Canadian population will be affected at one time in their life with PTSD. Women are twice as likely to be affected as men. The specific type of trauma is important in the gender distribution. For example, women exposed to a physical attack or threatened with a weapon are more likely to develop PTSD than men who are exposed to the same trauma. Rates of PTSD are similar in men and women after accidents, natural disasters, and unexpected death of loved ones.

The Causes

The kinds of events that can trigger PTSD were traditionally limited to the most violent and frightening situations, such as being involved in a plane crash, a shooting, or the collapse of a building after an earthquake or bomb. The main source of such trauma is war, and in North America the largest category of PTSD sufferers are war veterans. Much of what we know about this syndrome comes from studies involving former soldiers.

More recently, the definition has broadened. People who suffer rape or physical or sexual abuse may react in much the same way as those who have witnessed carnage or been threatened by violent death. Particular risk factors such as early age trauma, a history of childhood abuse, previous exposure to trauma, personality or psychiatric disorders, or a family history of psychosis, may make certain individuals more likely to develop post-traumatic stress disorder. PTSD among children has become a major focus because they are particularly likely to develop the symptoms associated with this condition.

Symptoms And Complications

The most noticeable signs in a person suffering from PTSD are introversion and joylessness. This condition is characterized by frequent, undesired memories which replay the triggering event. People with this syndrome are unable to take pleasure from things they might have enjoyed in the past. They avoid the company of others and become generally more passive than before. They wish to avoid anything that will trigger memories of the traumatic event. A person with PTSD might drift out of a conversation and appear distant and withdrawn. This is known among soldiers as a "thousand-yard stare." This is a sign that unpleasant memories have returned to haunt them.

Having trouble sleeping is almost inevitable in this syndrome. Nightmares are common, and even when someone with PTSD is not thinking about the event, sleep is often disturbed. A common symptom among veterans is nocturnal myoclonus, a sudden spasm of the whole body while sleeping or drifting off into sleep. It lasts for about a fraction of a second, but may occur several times in a single night. Often people with PTSD will sleep through such a spasm, but their partner may not. Children with PTSD may have many nightmares, yet those dreams may not contain anything that's obviously related to the original trauma.

Psychiatrists speak of 4 main symptoms that define PTSD – intrusion, avoidance, negative symptoms, and hyperarousal. Intrusion is the inability to keep memories of the event from returning. Avoidance is an attempt to avoid stimuli and triggers that may bring back those memories*. Negative symptoms* are ongoing negative feelings about oneself or others, and may include anger, guilt and shame, or a decreased ability to experience positive emotions. Hyperarousal is similar to jumpiness. It may include insomnia (trouble sleeping), a tendency to be easily startled, a constant feeling that danger or disaster is nearby, an inability to concentrate, extreme irritability, or even violent behaviour.

Depression is very likely to go hand in hand with PTSD, and in severe cases, suicide is a real danger. People with this syndrome, as with any psychiatric illness, are more likely than average to abuse alcohol or drugs. Psychiatrists see this as an attempt to self-medicate the condition, but naturally the drugs involved are very unlikely to improve the situation. People with PTSD are at an increased risk of suffering from depression, anxiety, or substance abuse.

Making A Diagnosis

The diagnosis of PTSD is based on 4 specific features that must be present for at least one month and cause significant distress or impact on a person's daily life and functioning that is not caused by another medical condition, medication, or substance (e.g., alcohol):

intrusion symptoms – re-experiencing symptoms after the trauma, such as intrusive thoughts or recollections, recurrent dreams of the trauma, flashbacks of the trauma
avoidance symptoms – avoiding thinking about the trauma, avoiding people or places that remind you of the trauma
negative symptoms – inability to remember specifics about the trauma, detachment, diminished interest in activities, detachment from others, inability to experience positive kinds of emotions, negative feelings about oneself or the world
hyperarousal symptoms – insomnia, irritability, decreased concentration, hypervigilance, or exaggerated startle response

These symptoms must also cause significant distress or interfere with a person's daily life and functioning.

Treatment And Prevention

Treatment can be effective for PTSD and involves psychological intervention as well as medications.

The main psychological treatment for treating PTSD is trauma-focused psychotherapy, which includes cognitive-behavioural therapy and exposure-based therapies. Cognitive-behavioural therapy means examining the thought processes associated with the trauma, the way memories return, and how people react to them. PTSD often fades over time, even without treatment, and the goal of therapy is to accelerate that natural healing process.

Because the horror may fade over time, being confronted with memories of the trauma when in a safe situation may help a person over time to become less frightened or depressed by those memories. This is a form of exposure-based therapy called prolonged exposure therapy, which is often combined with cognitive behavioural therapy. Psychological treatments are particularly helpful for the "re-experiencing symptoms" and any social or vocational impairment caused by PTSD. Eye movement desensitization and reprocessing (EMDR) is also a recognized treatment for PTSD.

Medications that may be used in treatment are serotonin reuptake inhibitors (SSRI’s; e.g., fluoxetine, paroxetine, sertraline). Another class of medications called serotonin-norepinephrine reuptake inhibitors (SNRI’s; e.g. venlafaxine) is sometimes used as well. Most people with PTSD will benefit from taking antidepressant medications, whether or not they have clinical depression accompanying their PTSD. SSRIs are usually started at low doses and increased slowly. It may take 2 to 3 months to determine the full effectiveness of the medication, although some people may continue treatment with the medication for 6 months up to a year or longer. Prazosin, which is used to treat high blood pressure, may not treat PTSD itself, but has been shown to help with PTSD associated nightmares. Other medications (e.g., those that help balance mood and reduce mood swings, or antipsychotics) may also help to relieve symptoms.