Post Traumatic Stress Disorder

Definitions
o PTSD is an anxiety disorder in which a particularly stressful event, such as a
military combat, rape or natural disaster brings in its aftermath, intrusive re
experiencing of the trauma, a numbing of responsiveness to the outside world,
Estrangement from the others, a tendency to b easily startled, and nightmares,
recurrent dreams, and otherwise disturbed sleep is involved (Neil and Davison,
1997).
o An anxiety disorder in which the individual experiences several distressing
symptoms for more than a month following a traumatic event such as re
experiencing the traumatic event, an avoidance of reminders of the trauma, a
numbing of general responsiveness, and increased arousal (Halgin and Susan,
2003).
o Development of symptoms in response to events of such severity that most people
would be stressed by them. Symptoms often include a feeling of numbness in
response of psychological re experiencing of the event in thoughts, dreams or
nightmares (I.G. Sarson and B.R. Sarson).
o Post traumatic stress disorder introduced as a diagnosis in DSM III (1980), entails
an extreme response to a sever stressor, including increased anxiety, avoidance of
stimuli associated with trauma, and a numbing of emotional responses (Neil and
Davison).

Causal Factors
The cause of PTSD is primarily the event not the person.
Causes for PTSD are:
 to be victim of a disaster or catastrophe,
 physical torture,
 sexual assaultness,
 death of loved one
 acute loss in business,
  employment in occupations related to war(soldiers) or disasters(emergency service
workers)

PTSD involves more extreme experiences (such as disasters) whose effects may extend over
a long period.(sarson and sarson)

Diagnostic features
Like other disorders in DSM, PTSD is defined by a cluster of symptoms. but unlike the
definitions of other psychological disorders, the definition of PTSD includes part of its presumed
etiology namely, a traumatic event or events that the person has directly experienced or
witnessed involving actual or threaten death, or serious injury, or a threat to a physical integrity
of self or others. The event must have created intense fear horror or a sense of self helplessness.

In previous edition of DSM the traumatic event was defined as “outside of the range of
human experience”. This definition was too restrictive, as it would have ruled out the diagnosis
of PTSD following such events as automobiles accidents. The current broadened definition may
also be too restrictive, because it focuses on the events objective characteristics whereas the
subjective meaning of the event may be more critical (king et al., 1995). (neil and Davison)

Difference between PTSD and Acute Stress Disorder

There is a difference between PTSD and Acute Stress Disorder, a new diagnosis ion DSM
IV. Nearly everyone who encounters a trauma experiences stress, sometimes to a considerable
degree, this is normal. If the stressor causes a significant impairment in social or occupational
functioning, an acute stress disorder is diagnosed. About 60 percent of people recover from an
acute stress disorder within a month and go on to lead lives, that are not marked by PTSD.

The inclusion in the DSM of sever stress as a significant casual factor of PTSD was meant to
reflect a formal recognition that regardless of their history, many people my b adversely affected
by overwhelming catastrophic stress and that their reactions be distinguished from other
disorders; that is , the cause of PTSD is primarily the event, not the person. Instead of implicitly
concluding that the person would be all right were he or she made of sterner stuff, the importance
of traumatizing circumstances is formally acknowledged in this definition(haley, 1978).

Yet the inclusion of this diagnostic criterion is not without controversy. Many people
encounter traumatic life events but do not develop PTSD. For example, in one recent study of
only 25 percent of people who experienced a traumatic event leading to physical injury
subsequently developed PTSD (Shalev et al., 1996); thus the event itself cannot be the sole cause
for PTSD. Current research has moved in the direction of searching for factors that distinguish
between people who do and those who do not develop PTSD after experiencing severe stress.

The experience is so painful that people who suffer from P TSD intentionally go to great
lengths to avoid anything that may remind them of the trauma. For example a women avoids
driving by the site where her house burnt to the ground several years ago, because she knows that
even a fleeting reminder of the trauma will result in great psychological distress, nightmare, and
physical symptoms of anxiety and dread.

Many people from with this disorder seem to shut down in a sort of numbness, which causes
them to b generally unresponsive in most situations. For example, a woman finds that she is
unable to feel and express love for her husband that was so evident prior to trauma. A
traumatized man loses interest in the activities that had been pleasurable for so much of his life.
For an extended period of time , these individuals feel an increased level of arousal that is
evident in sleep difficulty, anger outbursts, concentration problems an exaggerated startle
response, or general hyper vigilance.

The symptoms for PTSD seems to fall in two clusters

 Intrusions and avoidance

 Hyperarousal and numbing

Intrusions and avoidance include intrusive thoughts recurrent dreams flashbacks

 hyperactivity to cues of the trauma, and avoidance of thoughts or reminders.

Hyper arousal and numbing includes symptoms that involve detachment, a loss of
interest in everyday activities, sleep disturbance, irritability and a sense of foreshortened
future. Thus, intrusive thoughts give rise to the avoidance of disturbing reminders, and
hyperarousal leads to a numbing response (Taylor et al., 1989).

Following a traumatic life event, people go through a series-of characteristic responses,

identified as occurring in two phases (Horowitz, 1986).

Outcry phase
The initial reaction is the outcry phase, during which the person reacts with alarm and a
strong emotion, such as fear or sadness. The person may shriek or hit something during this
phase. When the event involves the immediate threat of personal danger, such as in an
earthquake, me outcry phase may not occur immediately, because people need to cope with the
situation at hand. The outcry takes place later, perhaps in a safer place, when the imminent threat
has passed.
Denial/intrusive phase
The second phase of response to a traumatic life event is the denial/intrusive phase during
which the person alternates between denial, the experience of forgetting the event or pretending
it did not occur, and intrusion, the experience of disruptive thoughts and feelings about the
event. Sometimes it is not until days or months following the trauma that' intruding thoughts
first emerge. Some people find that the traumatic event repeatedly intrudes into consciousness in
the form of a flashback, a recurrence of a powerful feeling or perceptual experience from the
past, sometimes involving graphic and terrifying illusions and hallucinations. Nightmares and
unwanted 'thoughts about the event may plague the individual during this phase, along with
physical symptoms, such as a racing heart beat or heavy sweating. Consider a young man, Gary,
who was in a car accident that killed his friend. Gary had recurrent images of the scene of the
fatal crash-When riding in cars; he overreacted to every approaching car, repeatedly bracing
himself for another imagined crash. He thought he could hear the voice of his deceased friend
crying, "Watch out!" For weeks following the accident, he repeatedly "saw" his friend's face
when he tried to sleep. He could not get out of his mind the
thought that he should have done something to prevent his friend's death.

In the 1980s\when the diagnosis of PTSD was added to the DSM, the media drew attention to
the psychological aftereffects of combat experienced by Vietnam War veterans. The Vietnam
War was the most publicized, but certainly not the only, war to produce psychological casualties.
Reports of psychological dysfunction following exposure to combat emerged after the Civil War
(Hyams, Wignall, & Rosweil, 1996). Following World War 1 and World War II, there were
numerous reports of psychological impairment described with such terms as "shell shock,"
"traumatic neurosis." "Combat stress." and "combat fatigue."Concentration camp survivors were
also reported to suffer long-term psychological effects, including the "survivor syndrome" of
chronic depression, anxiety, and difficulties in interpersonal relationships (Chodoff, 1963; Baton,
Sigal, & Weinfeld, 1982).

Television reports brought the Vietnam War, and the horrors of combat, into American living
rooms each night, perhaps leading to greater concern on the part of the public and professionals
about the lasting effects of war on those involved. Many studies about the post-traumatic effects
of the war were initialed, several of which continue decades after the end of the conflict. The
statistics emerging from these studies are not always consistent, however, with estimates of the
incidence of PTSD among Vietnam veterans ranging from 19 to 30 percent of those who
exposed to low levels of combat, and 25 to 70 percent of those exposed to high levels. Although
the customary image of the Vietnam veteran is a male, there were also many women involved in
the conflict, many of whom have also suffered from PTSD (Zatzick el al., 1997).

Many children also develop PTSD each year, with symptoms arising from their exposure to
various kinds of trauma, many taking place in or near the home. There have been reports of
children developing PTSD after witnessing violent family arguments and beatings (Kilpatrick &
Williams, 1997) and of others becoming symptomatic following the loss of a sibling to violence
and murder (Freeman, Shatter, & Smith, 1996). Voting' children who have survived a trauma
commonly develop symptoms that differ from those found in adults; rather than feeling as if they
are reexperiencing the traumatic event, they are likely to engage in repetitive trauma-related
play. For example, a young girl who was involved in a serious car accident may repeatedly
reenact car crashes with her toys. She is also like to develop physical symptoms, such as
headaches or stomachaches, as reflections of her heightened state of distress (American
Psychiatric Association, 2000).

Theories and Treatment

BIOLOGICAL PERSPECTIVES Although by definition PTSD has its origins in life
experiences, researchers have increasingly been turning up evidences linking its symptoms to
biological abnormalities. In recent years, some researchers have formulated the theory [hat, once
a traumatic experience has occurred, parts of the individual's nervous system become primed or
hypersensitive to possible danger in the future. Subcortical pathways in the central nervous
system, as well as structures in the sympathetic nervous system, are permanently on "alert" for
signs of impending harm (Heim, Owens, Piotsky, & Nemeroff, 1997; Stanford et al., 2001).
These disturbances show up as altered EEG patterns (Begic, Hutujac, & Jokic-Begic. 2001).
Altered neurotransmitter functioning would also play a role in this scenario.

For some individuals with PTSD, alterations seem to occur in the norepi-nephrine pathways,
while in others abnormalities in the serotonin pathways are more likely (Southwick el al., 1997).
Dopamine, particularly in neurons in the prefronlal area that are sensitive to stress, may also be
involved in the symptoms of PTSD (Merger & Roth, 1996). The endocrine system may also play
a role in altering the individual’s response to stress following trauma.
In one study of 5- to 7-year-old girls, sexual abuse was found to produce abnormalities in the
stress hormone cortisol, suggesting that impaired hypothalamic pituitary may play a role in
predisposing women to later vulnerabilities to stress (King ct al., 2001).
It seems that even the structure of the brain can change as a result of trauma; for example,
researchers have noted that women with PTSD who had been victimized in childhood show brain
changes similar to those of combat veterans—namely, a reduction in the size of the hippocampus
(Stein, Koverola et al., 1997). This surprising observation suggests that some of the symptoms of
PTSD may be associated with changes in the temporal lobe of the brain, resulting from the
experience of trauma. Changes in the hippocampus may result from hyperarousal of the
amygdala, a limbic system structure that mediates emotional responses (Villarreal & King,
2001). Finally, genetic predisposition may also play a role in the development of PTSD. In one
study of more than 4,000 twin pairs who fought in Vietnam, genetic factors seemed to play an
important role in their susceptibility to the development of reexperiencing, avoidance, and
arousal symptoms (True el al., 1993). Evidence has also emerged that people with first-degree
relatives with a history of depression have an increased vulnerability !o developing PTSD in
response to traumatic life events (American Psychiatric Association. 2000).

PSYCHOLOGICAL PERSPECTIVES It is clear that psychological factors play a central role

in the development of PTSD. Theorists have discussed and studied human responses to trauma
for many decades. Freud described symptoms such as those in the disorder currently labeled
PTSD as representing a flooding of the ego's defenses, with uncontrollable anxiety originating
from the intense and threatening experiences. The experiences themselves may be traumatic
enough to cause this reaction, or they may trigger painful memories of earlier unresolved
unconscious conflicts and may cause anxiety to overflow as a result of an inability to keep these
memories repressed (Lidz, 1946). For example, the experience of killing another person in battle
may stimulate the emergence of previously repressed aggressive impulses. Anxiety over the
expression of these impulses could trigger the stress reaction.

According to classical behavioral approaches, it is assumed that the person with PTSD has
acquired a conditioned fear to the stimuli that were present at the time of the trauma-Because of
a learned association, the individual experiences anxiety when these or similar stimuli are
present, even in the absence of the traumatizing experience. Presumably, such reactions lead to
avoidance. To escape, at least in fantasy, from the traumatic event becomes reinforcing for the
individual and this reinforcement then strengthens the withdrawal reaction seen in PTSD victims.

Cognitive-behavioral theorists (Poa, Stcketec, & Roth-baum, 1989) have incorporated

the concept of how people's beliefs about a traumatic event influence how they cope with it.
Thoughts that are likely to have a detrimental effect, and can ultimately lead to PTSD, include
excessive self-blame for events that are beyond personal control, as wel! as guilt over the
outcome of these events (Kubany, 1994; Ramsay, Gorst-Unsworth, & Turner, 1993). The
individual's unsuccessful attempts to reduce the stress experienced in the aftermath of the event
can also increase the risk for PTSD. Some of these problematic coping methods include avoiding
of problems for long periods of time, blaming and lashing out a! other people, adopting a cynical
and pessimistic view of life, catastrophising or exaggerating the extent of current difficulties,
isolating oneself socially, and abusing drugs and alcohol (Hobfall et al., 1991).

Clearly, not everyone exposed to traumatic experiences, combat-related or otherwise,

suffers from PTSD. What are the factors lhat increase the likelihood thai a particular individual
will become one of the victims of trauma-related symptoms? One has to do with the nature of the
traumatic experience itself. A general principle that emerges from a variety of studies on trauma
victims is that there is a direct relationship between the severity of the trauma and the
individual's risk of developing PTSD later (Davidson & Foa, 1991). This principle applies to
war-related combat experiences (Spiro, Schnurr, & Aldwin. 1994; Sutker, Uddo, Brailey, &
Allain, 1993), natural disasters (Goenjian et al., 2001; Lonigan et al.. 1994), the torture of polit-
ical prisoners (Lavik, Hauff, Skrondal, & Solberg, 1996; Ramsay et al., 1993), crime (Resnick et
al.. 1993), physical abuse (Silva et al., 1997), sexual abuse in childhood (Bassuk, Daw-son,
Perloff, & Weinreb, 2001), the severity of injuries in an accident (Kamphuis & Emmelkamp.
2001), and the experience of living in a country ravaged by war and political or religious
violence (Macksoud & Aber, 1996; Weine et al., 1995). Underlying these experiences is the
individual's perceived threat to life.

In their studies of the kinds of experiences associated with PTSD symptoms, experts have
identified a number of fascinating correlates. For example, in a study of soldiers involved in
Operation Desert Storm in 1991. individuals who had the job of handling human remains were
more likely to develop intrusive and avoidant symptoms of PTSD. Experienced workers were
less likely to suffer these symptoms, but even among experienced workers there was a positive
relationship between the number of body remains that they handled and the degree of their
symptoms (McCarroll, Ursano, & Fullerton, 1993). Even 1 year later, those who handled human
remains still suffered psychological disturbance (McCarroll, Ursano, & Fullerton, 1995).

Individuals vary in their propensity to suffer from PTSD. One factor that mediates the
relationship between the extent of trauma and PTSD symptoms is the individual's state of mind
while the trauma is occurring- People who experience a period of dissociation during the
traumatic episode are more likely to be the ones who will develop PTSD after the trauma has
ended (Koopman, Classen, & Spiegel, 1994; Mannar et al., 1994; Shalve, Peri, canetti, and
Schreiber, 1996). In some cases, the individual's reaction to trauma may take precedence over the
severity of the trauma as a risk factor. For example, there has not been a general relationship
observed between the extent of exposure to trauma in motor vehicle accidents and the severity of
PTSD symptoms. Instead, the individual's tendency to worry about the flashbacks and intrusions
that occur in the weeks and months after the accident seems to be most .predictive of the
emergence of later symptoms (Ehlers, Mayou. & Bryant, 1998). '.

Investigators have long wondered whether some people might be predisposed 10 develop
PTSD as a result of prior trauma, or even some characterological traits that put them at greater
risk of a more intense reaction to adversity. As is line for other anxiety disorders, women are
more likely than men to suffer from PTSD symptoms, even when exposed lo the same trauma
(Kessler et ai., 1995). The co-existence of other psychological disorders is another predisposing
risk factor. These disorders include depression (Bleich, Koslowsky, Dolev, & Lerer, 1997),
schizophrenia or another anxiety disorder (Cottier, Nihish, & Compton, 2001), and substance
abuse (Najavits, Weiss, & Shaw, 1997). The relationship between PTSD and other disorders also
cuts the other way, because people who develop PTSD are also at higher risk for the subsequent
development of both depression and substance abuses Bresiau et al., 1997).

Conversely, a sense of optimism can help mediate the response to trauma. In a study of
rescuers working at the site of an airplane crash, researchers found that those with optimistic
personality traits were
more likely to seek social support, which in turn reduced their experience of stress. Optimism
further contributed to reduced stress by leading to more effective use of problem-focused coping
(Dougall et al., 2001).

SOCIO-CULTURAL PERSPECTIVES As mentioned, the devastating wars in the second half

of the twentieth century— most notably, the conflict in Vietnam—brought many cases of PTSD
to the attention of clinicians and researchers, and they provided important opportunities to
understand some sociocultural contributions to the development of this disorder. Investigators
were particularly attuned to the fact that, for many Vietnam soldiers, symptoms did not emerge
until they returned home. In explaining this phenomenon, researchers point out that the Vietnam
War was not politically popular, instead of receiving a hero's welcome on their return home,
many soldiers felt that their efforts were neither valued nor respected. This lack of social support,
rather than the combat experience itself, may have contributed to the development of the disorder
(Span APankratz, 1983).

With information available on the Vietnam War experience, mental health professionals were
better prepared to develop strategies for helping the veterans of the 1991 Operation Desert Storm
action cope following their return from active duty (Hobfall et al., 1991). Outreach workers were
available to help soldiers in the early days of the conflict, and it is thought that this early
recognition played an important role in helping alleviate PTSD symptoms among those exposed
to combat (West, Mercer, & Altheuner, 1993). Even with this proactive approach, however,
approximately 8 percent of those returning from Operation Desert Storm developed PTSD
symptoms (Stretch el al., 1996). As with the veterans of the Vietnam War. lack of support on
their return from action seemed to play a role in the Gulf War veterans' development of PTSD
symptoms (Viola, Hicks, & Porter, 1993).

Other sociocultural factors, such as education, income level, and social status, provide
additional pieces to the puzzle of PTSD. Consider one study of Vietnam veterans, in which such
factors as precombat personality, intensity of combat experiences, and postcombat experiences
and social support were compared as predictors of PTSD symptoms (Green et al., 1990). What
emerged from this study was the notion that people with certain backgrounds are more likely to
get involved in exactly the high-exposure combat situations that would place them at most risk
for later psychological problems. Soldiers with histories of mood disorder or substance abuse
were more likely to become involved in situations in which they were
exposed to grotesque combat experiences, such as witnessing or participating in the mutilation of
Vietnamese citizens. On their return home, these veterans were also the least likely to engage in
behaviors that might help reduce their anxiety symptoms, such as talking to friends or seeking
outside help.

Interestingly, among World War II veterans, the picture seemed to be somewhat different.
The unusual circumstances of one particular study (Lee. Vaillant. Torrey, & Elder. 1995) has
shed some important light on the relationship between prewar personality and subsequent
development of PTSD symptoms. This study, the Harvard Grant Study, was conducted between
1939 and 1944 on a group of 268 men, consisting of the top half of the undergraduate class (all
men), considered medically and psychologically healthy and having a high potential for success.
A number of notable individuals were included in this sample, many of whom went on to
achieve national and international renown for their life's accomplishments. George Vaillant.
working in the 1970s at Harvard Medical School, undertook a follow-up of these individuals at
midlife, and he and his colleagues have continued their studies up to the present time. Having
extensive data available on the college years of these men. the Harvard researchers had the
unusual opportunity to examine the relationship between predisposing factors to trauma and
PTSD in the war-related experiences that 90 percent of the sample had shortly after their college
graduation. Among this group, the relatively economically advantaged were more likely to enter
combat roles in World War II. The men who experienced heavy combat were also more
athletically active and more enthusiastic about their involvement in the armed forces. High
combat exposure, in turn, was associated with more symptoms of PTSD; however, these
symptoms did not interfere with the veterans' subsequent psychological adjustment. Those who
engaged in heavy combat were more likely to appear in the prestigious Who's Who in America
and lo have more satisfying work and family lives. The subjective distress of PTSD did not
interfere with their ability to function in the world. Furthermore, PTSD symptoms were not
related to people who live in certain sociocultural contexts are more likely lo be victimized
(Ensink, Robertson, Zissis, & Leger, 1997). Living in high-crime urban neighborhoods increases
the likelihood of exposure to traumatizing events and makes it difficult for individuals to receive
services, particularly for low-income women (Bassuk et ai.. 2001). Living in impoverished
locales in developing countries where the inadequacy of support and mental health services in
the event of a disaster can aggravate the psychological responses of large numbers of people
(Lima, Pai, Santacruz, & Lozano, 1991).
 Cultural factors are also evident in the ways that people from various ethnic groups respond
to traumatic events, such as disasters or devastation (de Silva, 1993b). In some groups,
tremendous stigma is associated with the idea of seeking professional psychological help,
regardless of the severity of the distress. Lacking sufficient emotional support, in the family and
in one's social group, can aggravate the experience of PTSD symptoms for same.

TREATMENT

Within the biological perspective, clinical investigators have reported the successful treatment of
PTSD symptoms with a variety of medications, with the choice relying primarily on the client's
particular symptoms (Maxmen & Ward, 1995). For example, clients with symptoms involving
hyperexcitability and startle reactions may benefit from antianxiety medications, such as
benzodiazepines. Those contending with irritability, aggression, impulsiveness, or flashbacks
may find anticonvulsants, such as carbamazepine or valproic acid are helpful, Antidepressants,
such as selective serotonin reuptake inhibitors and monoamine-oxidase inhibitors, are often
therapeutic in treating the symptoms of numbing, intrusion, and social withdrawal (Londborg et
al., 2001; Seedai et al., 2001).

Even though medications can provide some symptom relief, it would be naive to think that
medication alone is sufficient for ameliorating the distressing psychological and interpersonal
problems that burden those with PTSD. Consequently, clinicians recommend ongoing
psychotherapy, not only to deal with emotional issues but also to monitor the individual's
reactions to medical treatments (Southwick & Yehuda, 1993). The most effective psychological
treatments for PTSD involve a combination of two techniques:
 Covering techniques
 Uncovering techniques
"Covering" techniques, such as supportive therapy and stress management, help the client
seal over the pain of the trauma. They may also help the client reduce stress more effectively
and, in the process, eliminate some of the secondary problems that the symptoms cause. For
example, PTSD victims who isolate themselves from friends and family are cutting themselves
off from social support, which is an important therapeutic agent. By learning alternate coping
methods, clients can become better able to seek out this kind of support.

"Uncovering" techniques, which involve a reliving of the trauma, include the behavioral
treatments of imaginal flooding and systematic desensitization. Exposing the person with PTSD
to cues that bring back memories of the event in a graded fashion, or in a situation in which the
individual is taught simultaneously to relax, can eventually break the conditioned anxiety
reaction- Other treatments, such as psychodrama, can also be useful in bringing to conscious
awareness, under a controlled setting, repressed memories of the traumatic event.
PTSD victims can also learn to reduce stress by approaching their situations more rationally and
by breaking down their problems into manageable units. They can work toward achieving a
better balance between self-blame and avoidance. Individuals who feel excessively guilty for
their role in the traumatic incident can learn to see that their responsibility was not as great as
imagined. Conversely, those who feel they have no control over what happens to them and,
therefore, avoid confronting problems can learn to feel a greater sense of mastery over the course
of their lives (Hobfall et al., 1991).
Donald Meichenbaum (1998) describes a six-step cognitive-behavioral therapy plan (hat
incorporates strategies he has found beneficial for clients suffering from PTSD:

1. Establish a good working relationship with clients, characterized by nurturance and

compassion.
2. Encourage clients to view their symptoms in a more positive light; for example, numbing
can be viewed as a way of slowing the pace in order to deal with intense levels of distress.
3. Help clients translate global problem descriptions into specific, problem-solving terms.
4. Take behavioral steps, such as confronting the feared situation, in thoughts and in real
settings.
5. Confront barriers in the form of feelings (e.g., fears, guilt, depression) and distorted beliefs
(e.g., negative self-views) that get in the way of implementing change and mustering hope.
6. Help clients anticipate possible lapses (e.g., a recurrence of flashbacks, bouts of anxiety or
depression).