What is Post Traumatic Stress Disorder
PTSD is a reaction to exposure to a traumatic event - or consolidation of traumatic events - which interferes with daily functioning, and shows a marked change in behaviour from before the traumatic event.
In DSM-5 PTSD is now categorised under Trauma-and Stress-or-Related Disorders, rather than anxiety disorders, previously in DSM-IV-TR.
The diagnostic criteria for DSM-5 identify the trigger to PTSD as exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:
• directly experiences the traumatic event;
• witnesses the traumatic event in person;
• learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or
• experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).
The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individual’s social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol.
Symptoms:
DSM-5 pays more attention to the behavioural symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. They are described as re-experiencing, avoidance, negative cognitions and mood (new), and arousal.
Re-experiencing covers spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress.
Avoidance refers to distressing memories, thoughts, feelings or external reminders of the event.
Negative cognitions and mood represents myriad feelings, from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.
Finally, arousal is marked by aggressive, reckless or self-destructive behaviour, sleep disturbances, hyper-vigilance or related problems. DSM-IV emphasizes the “flight” aspect associated with PTSD; the criteria of DSM-5 also account for the “fight” reaction often seen.
Not everyone exposed to a traumatic event develops PTSD. Here are some statistics: 3% among civilians who have been exposed to a physical attack, 20% among people wounded in Vietnam, 50% victims of rape or POW world war II or Korea, Most frequent trauma that precipitates PTSD in a loss of a loved one: ⅓ of all cases. Women twice as likely to develop PTSD.
(SOURCE: Abnormal Psychology, 8th edition, 2001, NY, pp. 151-158)
Contributing factors for developing PTSD:
Sensitivity, accumulation of other traumatic events, low stress threshold, lack of preparation for stressful situations, damaged fight or fight responses, belief system, lack of internal resources and support, poor attachments.
How the brain and the nervous system react to PTSD:
The amygdala structure (part of the limbic system) plays a key role in a fear network, storing memories of emotionally-charged experiences. The prefrontal cortex normally keeps the amygdala operating normally. But if it loses control, emotional memories and reactions can get out of hand. Probably the best-documented findings in PTSD show under-activity in the prefrontal cortex. Normal emergency reactions lead to a release of adrenaline and noradrenaline, chemicals that help increase heart rate and open tiny bronchioles that bring air into the lung. These reactions can help the body deal with emergencies by enhancing the oxygen supply to the muscles. Within the brain, adrenaline and noradrenaline can activate structures on the surface of nerve cells called adrenergic receptors. The type known as beta-adrenergic receptors seem to enhance the amygdala's ability to store memories of frightening events. During evolution, the ability to store memories of dangerous situations and react accordingly could be life-saving. But these reactions can become excessive and cause suffering for years after the emergency has passed.
When the limbic system perceives danger, it sends messages to the hypothalamus, which in turn activates the Autonomic Nervous System (ANS) by the release of appropriate of hormones. (A major symptom of PTSD is hyper-arousal in the ANS). The ANS plays a role in regulating the muscles, heart, pupils, kidneys, circulation, lungs, intestines, bladder, bowel. The ANS has two parts, being: SNS (sympathetic nervous system) is activated with effort & stress, by the release of adrenaline and noradrenaline, which gets the body primed for action. PNS (parasympathetic nervous system) is activated in states of rest & relaxation by the release of cortisol. SNS & PNS function in balance; generally, when one is activated, the other is suppressed. This, incidentally, bypasses the logical part of your brain, the prefrontal cortex. In the cases of PTSD the PNS is not successfully activated – a deficiency in cortisol production has been observed - and the body remains in a state of alertness. The SNS system is activated for fight or flight responses, but if the threat it too great (death is perceived as imminent, or there is not enough strength for fight or flight) then the SNS and the PNS are activated simultaneously causing a freeze response (tonic immobility), where the victim enters in a state of altered reality, of dissociation: time slows down, pain is not feared, nor experienced as intensly.
Treatment:
Psychotherapy
The therapist will help the client explore thoughts and feelings about the trauma. To work through feelings of guilt, self-blame, and mistrust. Working with coping with and controlling intrusive memories. Addressing problems PTSD has caused in the client's life and relationships. Trauma therapy can be quite challenging work for the therapist, so good knowledge of trauma and safeguards – both for client and therapist – are advisable to be put in place.
CBT
The therapist helps the client to understand his/her current thought patterns. In particular, to identify any harmful, unhelpful and false ideas or thoughts. The aim is then to change the ways of thinking in order to avoid these ideas. Also, to help the thought patterns to be more realistic and helpful. It may help especially to counter recurring distressing thoughts and avoidance behaviour.
EMDR
Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapy approach that is used for a number of mental health issues but most significantly for trauma or Post Traumatic Stress Disorder (PTSD). EMDR is also used for other mental health issues such as Social Phobia, Panic Disorder, prolonged grief due to guilt, body dysmorphia (negative body image), chronic pain and chemical dependencies.Treatment consists of 8 different phases that focus on the traumatic memory or image. In the early phases, the client is provided with coping skills, if needed, to enhance emotional stability. After treatment, clients often find that they no longer experience emotional distress when remembering or discussing their traumatic event.
SOURCE: www.ithoucounseling.com/emdr
Pharmacological
In 1944 a technique called narcosynthesis was used on soldiers. An intravenous injection of sodium Pentothal was administered, and under extreme drowsiness the therapist worked with the traumatic through to the waking state in order to relegate the event to past, and no longer a threat. In this fashion a synthesis, or coming together, of the past horror with the patient’s presentation life, was sought.
(SOURCE: Abnormal Psychology, 8th edition, 2001, NY, pp. 151-158)
Since propranolol blocks beta-adrenergic receptors - it's a beta blocker - researchers predicted that it might prevent traumatic memories from solidifying. When emotionally-charged memories are reactivated, they are in a more fluid state, neuroscience models suggested. Propranolol given within a specific time-window can interfere with their ability to solidify again. In more scientific terms, it can block the re-consolidation of threatening memories.
Antidepressants such as paroxetine, mirtazapine, amitriptyline or phenelzine are sometimes used to treat PTSD in adults. They have been found to help reduce the main symptoms of PTSD by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing symptoms. Of these medications, paroxetine is the only one licensed specifically for the treatment of PTSD. However, mirtazapine, amitriptyline and phenelzine have also been found to be effective and are often recommended as well. All of these medications have side effects and withdrawal symptoms and the sufferer must be aware of these. Benzodiazepines such as diazepam are sometimes prescribed for a short time (2-3 weeks) to ease symptoms of anxiety, poor sleep and irritability, but they are addictive and can lose their effect if used for longer.
(SOURCE: www.nhs.uk/Conditions/Post-traumatic-stress-disorder/Pages/Treatment.aspx & www.patient.co.uk/health/post-traumatic-stress-disorder-leaflet)
Anxiolytic (minor tranquillizers, anti-anxiety)drugs are also prescribed sometimes, but do cause a dependency.
(SOURCE: Abnormal Psychology, 8th edition, 2001, NY, pp. 151-158)
Further information:
Herman, J.L. (1992). Trauma and Recovery. New York: Basic
Knoller, F. (2005). Living with the Enemy. London: Metro Publishing
Rothchild, B. (2000). The Body Remembers. New York: W. W. Norton & Company
Schore, A. (1994) Affect Regulation and Disorders of the Self, New York : Norton
Zulueta, de F. (2006) b. The treatment of PTSD from an attachment perspective. Journal of Family Therapy, 28, 334-351.
Zulueta, de (2009) Post traumatic stress disorder and attachment: possible links with borderline personality disorder, In Advances in Psychiatry vol. 15; Issue 3, pp172-180.
EMDR: www.emdr-europe.org
Stress, Trauma and the Body: www.youtube.com/watch?v=q6M1FumqeyM
