Post Traumatic Stress Disorder [PTSD]

Post-traumatic stress disorder is a psychiatric disorder that was not recognized as a distinct nosological entity until the 1900s, but has been present since the dawn of our civilization. It is a disorder that typically develops after a particularly traumatic event, an event that has threatened the health and physical or psychological integrity of the subject. It is characterized by particularly debilitating symptoms, such as very intense and frequent anxiety, a drop in mood, intrusive thoughts, images, or memories of the traumatic event, and often a very intense emotional experience, as if one were reliving the traumatic episode (Yehuda et al., 2015).

However, not all traumatic life events lead to the development of posttraumatic stress disorder. In fact, it is common for traumatic events to naturally cause some form of temporary psychological distress, which in most cases (approximately 70-80% of cases) resolves spontaneously without the need for professional intervention (ibid.).

Situations that cause post-traumatic stress disorder and acute stress disorder are usually events involving death or threat of death, or serious injury or threat to one’s own or others’ physical integrity, and include serious accidents (motor vehicle, work), assaults, kidnappings, natural disasters, war, and diagnosis of serious illness. Sometimes the trauma may affect other people, and the person who becomes ill may simply be a bystander to the incident (death or serious injury or illness, especially if borne by family members or friends). It should be noted, however, that the severity of the event is always very subjective, as some people may develop symptoms in the face of an event that is not particularly significant in itself.

The prevalence of post-traumatic stress disorder is about 2 percent, but if you include all the forms that do not come to the attention of doctors, the prevalence rises to 10 percent. Most affected are young adults.

It is characterized by a set of symptoms that develop after the individual has experienced an extremely traumatic event. He or she reacts to the experience with fear and a sense of helplessness and tries not to remember it, but the event is relived over and over again. The consequence of the trauma is to relive the event through intrusive memories that include images, thoughts, or perceptions, or through unpleasant dreams, or to feel or act as if the event itself is happening again (this includes feelings of reliving the experience, delusions, hallucinations, flashbacks), or even to react to or experience psychological distress when one comes into contact with factors that in some way reproduce some aspects of the event.

All of this leads to avoidance behaviors toward stimuli related to the trauma: efforts to avoid thoughts, feelings, or conversations related to the trauma, or to avoid places, people, or activities that evoke memories of the trauma; inability to remember some important aspect of the trauma (dissociative amnesia); marked reduction in interest or participation in meaningful activities; feelings of detachment and alienation from others; inability to experience feelings of love; diminished future prospects (expectation of not having a career, marriage or children, or a normal life span). Also found are increased excitability (causing difficulty falling or staying asleep, irritability or angry outbursts, difficulty concentrating, hypervigilance, exaggerated alarm responses) and significant distress or impairment in the person’s functioning.

To be defined as such, PTSD must occur days, weeks, or months after the trauma and last at least one month. There are three types: acute PTSD, which lasts less than 3 months; chronic PTSD, which lasts longer than 3 months; and delayed-onset PTSD, which occurs at least 6 months after the stressful event.

Acute stress disorder (ASD) is similar to posttraumatic stress disorder but differs in a temporal criterion: it occurs within 1 month of the stressful event and lasts from at least 2 days to less than 1 month. Individuals with DAS experience the same symptoms as those with PTSD, only more intense and disabling.

It is not uncommon for the onset of symptoms to occur years after the original traumatic event.

The course of the disease can be acute or chronic; only slightly less than 1/3 of patients go into complete remission. Children and the elderly have a less favorable course.

Epidemiology

One of the most important epidemiological studies of PTSD was conducted among American soldiers involved in the Vietnam War, which showed that 19% of veterans developed PTSD after returning home (Dohrenwend et al., 2006). In the general population, which on average has not been exposed to such highly traumatic events, the prevalence of post-traumatic stress disorder is about 1 percent (Karam et al., 2014).

Posttraumatic stress disorder is often comorbid with other psychiatric disorders, particularly major depression and substance abuse (Kessler et al., 2005). In addition, the disorder is twice as common in women as in men (Resnick et al., 1993). This finding is explained in part by a woman’s greater risk of experiencing trauma such as violence or sexual abuse, and in part by a greater genetic susceptibility to the disorder (Yehuda et al., 2015).

Symptoms of post traumatic stress disorder

Post-traumatic stress disorder can manifest in a variety of ways, but the main feature is the development of a range of anxiety-depressive symptoms following a traumatic event. In some patients, symptoms related to fear, avoidance, and anxiety predominate; in others, there is a decline in mood and anhedonia; and still others may show dissociative symptoms, although a combination of these symptoms is often observed in PTSD patients.

We can divide the symptoms of PTSD into four categories: intrusive symptoms, avoidance strategies, mood and thought changes, and increased psychomotor activation state. These four categories represent 4 of the criteria defined by the DSM-5 for the diagnosis of PTSD (DSM-5, APA., 2013).

Intrusive symptoms in PTSD

Intrusive symptoms primarily involve memories related to the traumatic event. These memories are called intrusive because the individual feels out of control and powerless; they enter the individual’s consciousness in a disturbing and involuntary manner (Koenigs et al., 2009). They may be present during the day or even at night, in the form of dreams or nightmares. Symptoms of distress may also occur in the presence of a stimulus (such as an image or sound) that is reminiscent of the traumatic episode.

Avoidance strategies

Another symptom of post-traumatic stress disorder is the use of experiential avoidance strategies to avoid exposure to stimuli that remind them of the trauma. Individuals tend to avoid places, situations, or people that remind them of the traumatic event (Cominski et al., 2014). This avoidance mode can lead to a significant reduction in the subject’s life domain, as he or she typically begins to avoid places that are particularly important to him or her (e.g., places that remind him or her of the traumatic event), progressively reducing his or her quality of life (Pohar et al., 2017).

Changes in thinking or mood

Cognitive and emotional symptoms can also occur in the face of a traumatic event. Specifically, patients with PTSD may not remember the traumatic event (posttraumatic amnesia) (Bernsten et al., 2015), or they may develop negative ideas about themselves, others, and the world. Finally, patients with posttraumatic stress disorder may present with decreased mood as a symptom, feel emotionally distant from everyone, or be unable to experience positive emotions.

Changes in reactivity and increased arousal

Patients with PTSD may eventually exhibit symptoms of hyperarousal and increased reactivity. These individuals may be particularly angry and irritable, even to the point of violent and destructive behavior. Patients may also show a constant state of anxiety, sleep problems, and changes in attention and memory (Gupta, 2013).

All of these symptoms can be particularly distressing and can significantly reduce the quality of life for individuals. Therefore, it is important to address the traumatic event in a psychotherapeutic setting.

DSM-5 diagnosis of post traumatic stress disorder

To make a diagnosis of post-traumatic stress disorder, DSM-5, the Diagnostic and Statistical Manual of Mental Disorders (source: Diagnostic and Statistical Manual of Mental Disorders, V edition), suggests certain criteria to guide the clinician in making the diagnosis. The DSM-5 criteria for PTSD apply to adults as well as adolescents and children over the age of 6. Below the age of 6, the diagnostic criteria change.

The DSM-5 criteria for PTSD are:

  1. Exposure to a life-threatening traumatic event, serious injury, or sexual abuse.
  2. The presence of one or more intrusive symptoms, such as intrusive memories of the event, flashbacks, or strong psychomotor activation to trauma-related stimuli.
  3. Persistent avoidance of stimuli associated with the traumatic events. Such avoidance must be initiated after the traumatic event and may include an attempt to avoid memories, thoughts, or emotions, or avoidance of places or situations reminiscent of the event.
  4. Changes in thinking or mood that begin or worsen after the traumatic event.
  5. Marked changes in arousal and reactivity related to the traumatic event that begin or worsen after the traumatic event. Such as irritable mood, hypervigilance, difficulty concentrating, difficulty sleeping, and startle reactions.

Traumatic events that can trigger it

Experienced traumatic events that can directly trigger post-traumatic stress disorder may include any situation in which the person felt in serious danger. For example

  • military combat
  • violent personal assault
  • kidnapping
  • terrorist attack
  • torture
  • imprisonment as a prisoner of war or in a concentration camp
  • natural or man-made disasters
  • serious automobile accidents
  • rape.

Witnessed events include observing situations in which another person is seriously injured. Or witnessing the unnatural death of another person due to violent assault, accident, war, or disaster. Or being unexpectedly confronted with a dead body.

Even learning that a family member or close friend has been assaulted, had an accident, or died (especially if the death was sudden and unexpected) can trigger post-traumatic stress disorder.

Aggravating factors

The disorder can be particularly severe and prolonged if the stressful event is man-made (e.g., torture, kidnapping).

The likelihood of developing it may increase with the intensity and physical proximity of the stressor.

Treatment of post traumatic stress disorder

For the treatment of posttraumatic stress disorder, currently the strategy of first choice is psychotherapy (Yehuda et al., 2015). This may be supplemented by psychopharmacological therapy. Possible drug therapy may be necessary if the symptoms of posttraumatic stress disorder are particularly disabling or if psychiatric disorders are present in comorbidity (Ipser et al., 2011). Therefore, an initial psychiatric evaluation is essential to allow the clinician to assess the patient’s health and determine an appropriate course of treatment.

Secondarily, a course of psychotherapy with a psychotherapist may be initiated. In general, psychotherapists who specialize in psychotraumatology use psychometric testing in addition to clinical interviewing to assess the presence or absence of a psychological storyline, dissociative symptoms, and PTSD symptoms in general.

Cognitive behavioral psychotherapies

Among the most studied forms of trauma-focused psychotherapy are cognitive-behavioral psychotherapies (trauma-focused CBTs). These forms of psychotherapy aim, on the one hand, to provide patients with strategies to improve their emotional regulation. On the other hand, they invite patients to expose themselves to triggering stimuli that reactivate trauma-related feelings in order to produce a gradual extinction of the stimulus and thus reduce experiential avoidance (Rauch et al., 2012). From a cognitive perspective, thoughts of guilt, shame, and mistrust that arise from the traumatic event are specifically restructured.

Eye movement desensitization and reprocessing [EMDR]

Another trauma-centered therapy is EMDR, a technique that integrates several aspects such as cognitive restructuring, desensitization, and exposure. During an EMDR session, the therapist uses various forms of bilateral stimulation (most commonly lateral eye movement) and asks the patient to reenact the traumatic memory (Leer et al., 2013) to facilitate processing and change negative cognitions.

EMDR is an evidence-based technique recognized by the WHO as a first-line treatment for trauma. In fact, EMDR for posttraumatic stress disorder makes it possible to facilitate the processing of the traumatic experience by working on the memories related to the trauma: their emotional charge is reduced, intrusive thoughts become less frequent.

Is it possible to recover from post-traumatic stress disorder? To manage this disorder, psychological treatment is certainly more than recommended: the person gradually acquires the ability to distinguish between real and feared dangers and to use his or her own resources to cope.

Both EMDR and trauma-focused CBT psychotherapies have been shown to be equally effective in treating posttraumatic stress disorder (Seidler et al., 2006).

References

  1. DSM-5. (n.d.). Retrieved April 4, 2022, from https://www.psychiatry.org/psychiatrists/practice/dsm
  2. Berntsen, D., & Rubin, D. C. (2014). Involuntary Memories and Dissociative Amnesia: Assessing Key Assumptions in PTSD Research. Clinical Psychological Science : A Journal of the Association for Psychological Science2(2), 174. https://doi.org/10.1177/2167702613496241
  3. Bisson, J., & Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, (3). https://doi.org/10.1002/14651858.CD003388.pub3
  4. Cominski, T. P., Jiao, X., Catuzzi, J. E., Stewart, A. L., & Pang, K. C. H. (2014). The role of the hippocampus in avoidance learning and anxiety vulnerability. Frontiers in Behavioral Neuroscience8(AUG). https://doi.org/10.3389/FNBEH.2014.00273
  5. Dohrenwend, B. P., Turner, J. B., Turse, N. A., Adams, B. G., Koenen, K. C., & Marshall, R. (2006). The Psychological Risks of Vietnam for U.S. Veterans: A Revisit with New Data and Methods. Science (New York, N.Y.)313(5789), 979. https://doi.org/10.1126/SCIENCE.1128944
  6. Friedman, M. J., Resick, P. A., Bryant, R. A., Strain, J., Horowitz, M., & Spiegel, D. (2011). CLASSIFICATION OF TRAUMA AND STRESSOR-RELATED DISORDERS IN DSM-5. DEPRESSION AND ANXIETY28, 737–749. https://doi.org/10.1002/da.20845
  7. Gupta, M. A. (2013). Review of somatic symptoms in post-traumatic stress disorder. International Review of Psychiatry (Abingdon, England)25(1), 86–99. https://doi.org/10.3109/09540261.2012.736367
  8. Ipser, J. C., & Stein, D. J. (2012). Evidence-based pharmacotherapy of post-traumatic stress disorder (PTSD). The International Journal of Neuropsychopharmacology15(6), 825–840. https://doi.org/10.1017/S1461145711001209
  9. Karam, E. G., Friedman, M. J., Hill, E. D., Kessler, R. C., McLaughlin, K. A., Petukhova, M., … Koenen, K. C. (2014). Cumulative traumas and risk thresholds: 12-month PTSD in the World Mental Health (WMH) surveys. Depression and Anxiety31(2), 130–142. https://doi.org/10.1002/DA.22169
  10. Kessler, R. C., Wai, T. C., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry62(6), 617–627. https://doi.org/10.1001/ARCHPSYC.62.6.617
  11. Koenigs, M., & Grafman, J. (2009). Posttraumatic stress disorder: the role of medial prefrontal cortex and amygdala. The Neuroscientist : A Review Journal Bringing Neurobiology, Neurology and Psychiatry15(5), 540–548. https://doi.org/10.1177/1073858409333072
  12. Leer, A., Engelhard, I. M., Altink, A., & van den Hout, M. A. (2013). Eye movements during recall of aversive memory decreases conditioned fear. Behaviour Research and Therapy51(10), 633–640. https://doi.org/10.1016/J.BRAT.2013.07.004
  13. Pohar, R., & Argáez, C. (2017). Acceptance and Commitment Therapy for Post-Traumatic Stress Disorder, Anxiety, and Depression: A Review of Clinical Effectiveness [Internet]. Acceptance and Commitment Therapy for Post-Traumatic Stress Disorder, Anxiety, and Depression: A Review of Clinical Effectiveness, 1–32. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30226695/
  14. Rauch, S. A. M., Eftekhari, A., & Ruzek, J. I. (2012). Review of exposure therapy: a gold standard for PTSD treatment. Journal of Rehabilitation Research and Development49(5), 679–688. https://doi.org/10.1682/JRRD.2011.08.0152
  15. Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E., & et al. (1993). Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology61(6), 984–991. https://doi.org/10.1037//0022-006X.61.6.984
  16. Seidler, G. H., & Wagner, F. E. (2006). Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychological Medicine36(11), 1515–1522. https://doi.org/10.1017/S0033291706007963
  17. Yehuda, R., Hoge, C. W., McFarlane, A. C., Vermetten, E., Lanius, R. A., Nievergelt, C. M., … Hyman, S. E. (2015, October 8). Post-traumatic stress disorder. Nature Reviews Disease Primers, Vol. 1. https://doi.org/10.1038/nrdp.2015.57
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