Posttraumatic stress disorder
PTSD is a psychiatric disorder that can occur in people who have experienced (directly or indirectly) or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or other violent personal assault. PTSD is a real illness that causes real suffering.
PTSD has been known by many names in the past, such as “shell shock” during the years of World War I and “combat fatigue after World War II. But PTSD does not just happen to combat veterans. PTSD occurs in men and women, in people of any ethnicity, nationality, or culture, and at any age. PTSD affects approximately 3.5% of U.S. adults, and lifetime risk for PTSD is estimated at 8.7%.
Long after the traumatic event has ended, people with PTSD continue to have intense, disturbing thoughts and feelings related to their experience. They may relive the event through flashbacks or nightmares; they may suffer sadness, fear, or anger; and they may feel detached or estranged from other people. People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong negative reactions to something as ordinary as a loud noise or an accidental touch.
Exposure to an upsetting traumatic event is necessary for a diagnosis of PTSD. However, exposure could be indirect rather than first hand. For example, PTSD could occur in an individual who learns that a close family member or friend has died accidentally or violently.
According to DSM-5*, symptoms of PTSD fall into four categories. Individuals with PTSD may have all or just a few symptoms from each category, with different emphasis and severity.
1. Intrusive symptoms (1 symptom needed) such as repeated, involuntary memories, distressing dreams, or flashbacks of the traumatic event. Flashbacks may be so vivid that individuals feel they are re-living the traumatic experience or seeing it before their eyes.
2. Avoidance of reminders (1 symptom needed) of the traumatic event may include avoidance of people, places, activities, objects, and situations that bring on distressing memories. Individuals may try to avoid remembering or thinking about the traumatic event. For example, they may resist talking about what happened or how they feel about it.
3. Negative thoughts and feelings (2 symptoms needed) may include persistent and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); persistent fear, horror, anger, guilt, or shame; markedly diminished interest in activities; or feeling detached or estranged from others.
4. Arousal and reactivity symptoms may include irritable behavior and angry outbursts; reckless or self-destructive behavior; exaggerated startle response; problems with concentration; or sleep problems.
Many people who are exposed to a traumatic event experience symptoms like those described above in the days or weeks following the event. In PTSD, however, symptoms often persist for months and sometimes years. Many individuals develop symptoms within 3 months of the trauma, but other people’s symptoms appear later. A diagnosis of PTSD requires that symptoms cause significant distress or impaired functioning and last for more than a month. PTSD often occurs with—or may contribute to—other related disorders, such as depression, substance abuse, problems with memory, and other problems of physical and mental health.
Not everyone who experiences trauma develops PTSD, and not everyone who develops PTSD requires psychiatric treatment. For some people, symptoms of PTSD subside or disappear with time. Others get better with the help of family, friends, or clergy. But many people with PTSD need professional treatment to recover from psychological distress that can be intense and disabling. It is understandable that trauma may lead to severe distress; that distress is not the individual’s fault, and it is treatable.
Psychiatrists and other mental health professionals use various effective (research-proven) methods to help people recover from PTSD. Both psychotherapy and medication provide effective evidence-based treatments for PTSD.
Psychotherapy is very effective with the strongest evidence for cognitive behavioral therapies such as cognitive processing therapy, prolonged exposure therapy, and stress inoculation therapy.
Cognitive Processing Therapy focuses on modifying painful negative emotions (e.g. shame, guilt, etc.) and beliefs (e.g. “I have failed”; “the world is dangerous”) due to the trauma. Therapists confront such distressing memories and inappropriate emotions.
Prolonged Exposure therapy uses repeated, detailed imagining of the trauma or progressive exposures to symptom “triggers” in a safe, controlled way to help the patient face and gain control of fear and distress and learn to cope. For example, virtual reality programs have been used to help war veterans with PTSD re-experience the battlefield in a controlled, therapeutic way.
Other psychotherapies such as interpersonal, supportive, and psychodynamic therapies focus on the emotional and interpersonal aspects of PTSD and may benefit patients who would rather not initially expose themselves to reminders of their traumas.
Medication can help to control the symptoms of PTSD. There are a number of biological alterations in PTSD that are therapeutic targets for pharmacotherapy. In addition, the symptom relief that medication provides allows many patients to participate more effectively in psychotherapy
Some antidepressants (SSRIs and SNRIs, selective serotonin re-uptake inhibitors and selective serotonin-norepinephrine inhibitors) are first line medications for treating the core symptoms of PTSD either alone or in combination with psychotherapy or other treatment mentioned above. Other antidepressants, including tricyclic antidepressants, are also recommended as second-line treatments.
Other medications may lower anxiety and physical agitation, or treat the nightmares and sleep disturbances that trouble many individuals with PTSD. There are a number of other medications under investigation which also show promise
Stress Innoculation Therapy Involves a variety of anxiety management techniques such as education, muscle relaxation training and biofeedback. This may include social skills training, role-playing, distraction techniques, positive thinking and self-talk.
Family therapy may also help because the behavior of spouse and children may result from and affect the individual with PTSD. PTSD affects the entire family.
Group therapy encourages survivors of similar traumatic events to share their experiences and reactions to them. Group members help one another realize that many people would have done the same thing and felt the same emotions.
Also, the use of complementary and alternative medicine therapy to help people with PTSD is increasing. These approaches allow treatment outside the conventional mental health clinic and require less discussion and disclosure. They include acupuncture, animal-assisted therapy, virtual reality, stellate ganglion block technique, and others.
In addition to treatment, many people with PTSD find being able to share their experiences and feelings with others who have similar experiences, such as in peer support groups, very helpful.
*DSM-5 - Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Publishing, 2013