Posttraumatic stress disorder

PTSD, Chronic Posttraumatic Stress, Prolonged Posttraumatic Stress

What is posttraumatic stress disorder?

Posttraumatic stress disorder (PTSD) is a group of highly disturbing symptoms of anxiety, resulting from an extraordinarily frightening experience (trauma) such as surviving a plane crash. The trauma is repeatedly re-experienced in ways that are nearly as distressing as the original trauma.

Symptoms may consist of being constantly anxious and alert because danger is imagined to be everywhere, being irritable and easily startled because the slightest additional stress is intolerable, and having disturbed sleep and ability to concentrate. These symptoms were not present before the trauma, and have been present for at least one month. The symptoms result in a significant decline in social or occupational functioning.

It is not known why some individuals will develop posttraumatic stress disorder while others, having shared the same experience, will not. For example, of all Vietnam War veterans, only a fraction of the combatants who were exposed to horrifying events developed PTSD. The same holds true across a wide spectrum of "survivors," whether accident victims, battered wives, hostages, or prisoners of war.

There are personality factors that promote either emotional resilience after a trauma, or predispose to significant disability. The prevailing belief is that every individual, however well adjusted, has a "breaking point" which if exceeded, will result in posttraumatic stress disorder. For example, wounded veterans have five times the likelihood of later developing PTSD as their uninjured comrades.

Most estimates of overall lifetime prevalence are one to ten percent. In groups that are at risk (combatants, victims of natural disasters or criminal violence), prevalence ranges from three to sixty percent. Women appear to have two to three times higher risk of developing posttraumatic stress disorder than men.

How is it diagnosed?

History: The diagnostic criteria from the DSM-IV are based entirely on the history.

Symptoms of anxiety, preoccupation and avoidance must be present, and these symptoms were not present prior to the trauma. Some or all of these symptoms may appear almost immediately. The symptoms must persist for one month to support the diagnosis of posttraumatic stress disorder. If the symptoms do not appear until six months after the original event, it is considered to be PTSD with delayed onset. In this case, a second, lesser traumatic event may have added to and reinforced the original trauma.

A cardinal feature of PTSD is the presence of high levels of anxiety such that the individual frequently appears on edge.

He or she may startle easily or seem to be suspicious and always on guard. Commonly, the individual is tense, testy, unpredictable, and quick-tempered.

He or she may explode in rage over trifling irritations or act recklessly in a nearly suicidal fashion.

Almost invariably, sleep is disturbed to some extent.

Sufferers of PTSD must show evidence of preoccupation with the original trauma. This may take any of several forms, such as recurrent nightmares or frequently feeling as if the event was happening again or just about to happen. In the most dramatic case, the event is vividly re-experienced as a "flashback," which completely replaces normal awareness (a form of dissociation).

More typically, this preoccupation is in the form of intrusive memories and thoughts that constantly compete with normal attention, which are triggered by cues reminding them of the trauma. As a result, performance of even simple tasks such as freeway driving may become impossible. In an effort to ward off painful memories and feelings, victims of posttraumatic stress disorder will begin to avoid situations that remind them of the trauma.

This can take the form of pretending the trauma never happened (denial). Sometimes, the mind attempts to forget the trauma so that important pieces of the trauma are missing (repression). As the severity of posttraumatic stress disorder increases, this process becomes more generalized. The diagnostic guidelines are quite specific as to what qualifies as a trauma.

DSM-IV states that the person was involved with an event that threatened death or serious injury, accompanied by intense fear, helplessness, or horror. These are key criteria that exclude from consideration such "normal traumas" as minor accidental injury, the expected loss of a loved one, divorce, most major illnesses, and occupational or financial setbacks.

The original criteria, that of "outside the normal realm of human experience," while vague, conveys in spirit the requirement of an abrupt, shocking event so utterly beyond the ordinary stresses of daily life that it overwhelms our usual psychological defenses. Of special importance for diagnosis is the timing of the traumatic event and subsequent development of each symptom, how previous stressful events were handled, and how these symptoms have specifically impacted the level of current functioning. Whenever possible, family members or other sources should be called upon to corroborate the extent and duration of symptoms.

Physical exam is not helpful for this diagnosis. But, it might reveal signs of a physical trauma, like burn scars.

Tests: The mental status exam will show signs of increased and persistent anxiety. Evidence of impaired attention and concentration may be present; also, the range of expressed emotion or affect may be considerably reduced. In other words, the individual may appear numb, withdrawn, and unreceptive to humor. Psychological testing can be helpful in substantiating the diagnosis, but by itself is of little value. There are a few tests designed specifically to detect PTSD, but these are limited to combat veterans. Because PTSD is characterized by states of increased arousal, one way of attempting to validate the diagnosis is through physiologic monitoring similar to a lie detector test. Blood pressure, heart rate and other physical parameters are measured while the individual is instructed to reenact the trauma.

How is posttraumatic stress disorder treated?

Generally, treatment consists of individual and group psychotherapy. But, there are no standard approaches.

Retelling of the event is encouraged, especially in groups composed of fellow trauma victims. Most commonly, posttraumatic stress disorder and other anxiety disorders are treated by desensitization and related techniques.

Drug therapy is a frequent adjunct to treatment, primarily the use of antidepressants and sedatives. Occasionally, tranquilizers may be used; this should be done cautiously and only after a thorough assessment is made for alcohol and/or drug abuse.

The best treatment is preventive in nature, and should start soon after the trauma. Every effort should be made to develop the person's social support network. Of all identified risk factors for PTSD, probably the most important is the lack of a supportive network of friends and family.

Unfortunately, many individuals in the early phases of PTSD assume that their symptoms will resolve with time, and do not seek attention until much later when the symptoms are more entrenched.

Medications

Information Brand Generic Label Rating
Paroxetine Oral Paxil Paroxetine On-Label
Amitriptyline tablets Elavil Amitriptyline On-Label
Buy Gabapentin Neurontin Gabapentin On-Label
Sertraline Oral Zoloft Sertraline On-Label

Celexa (Citalopram), Desyrel (Trazodone), Pamelor (Nortriptyline), Prozac (Fluoxetine), Luvox (Fluvoxamine), Sinequan (Doxepin), Depakote (Divalproex), Periactin (Cyproheptadine), Tegretol (Carbamazepine), Topamax (Topiramate), Remeron (Mirtazapine), Klonopin (Clonazepam), Valium (Diazepam), Ativan (Lorazepam)

What might complicate it?

Significant disruption of relationships is a common complication, with high rates of unemployment and divorce. This may be the result of irritability, isolation, anger, and compromised coping skills in general. A number of other psychiatric syndromes may appear. Substance abuse and major depression are among the more serious of these and will require treatment in their own right. These individuals are at particularly high risk of suicide. Other psychiatric complications include generalized anxiety and panic attacks. Less clear is the connection between chronic anxiety and the development of physical disease.

Predicted outcome

Outcomes vary greatly. In its most mild form, PTSD may resolve spontaneously with no long-term complications. Indeed, most individuals subjected to experience outside the "normal" realm of human experience never become symptomatic. In other cases, it may lead to a lifelong incapacitating illness that makes it all but impossible to maintain employment or close relationships. Generally useful predictors of more severe PTSD include a history of decreased functioning following previous stresses, lack of a support system, substance abuse, and the coexistence of other psychiatric disturbances.

Alternatives

Acute stress disorder has the same symptoms but a shorter duration. The symptoms of posttraumatic stress disorder overlap with that of other syndromes, including other anxiety disorders, depression, and obsessive-compulsive disorder. Although substance abuse is a frequent complication of PTSD, one should be alert to the possibility that substance abuse may be the primary problem. Alcoholics and heavy drug abusers often over-emphasize the role of a distant trauma as a cause of their problems and to justify their habits. Careful studies have failed to demonstrate this association, and note only a tendency to blame external causes.

Various personality disorders can also resemble PTSD. Of these, borderline personality disorder has perhaps the closest resemblance to PTSD. Some therapists even consider borderline personality disorder a form of posttraumatic stress disorder in which the traumatic event(s) occurred in childhood. Psychosis with hallucinations can resemble PTSD.

But what distinguishes PTSD from other psychiatric disorders is the appearance of symptoms in response to a definite catastrophic event, with a subsequent decline in function. Over activity of the thyroid gland (hyperthyroidism) or adrenal gland (a pheochromocytoma) can mimic the high level of arousal seen in PTSD. Malingering is another possibility, if there is a financial or legal advantage to having the diagnosis of posttraumatic stress disorder. While the diagnostic criteria for PTSD are quite explicit, it can be a tricky diagnosis to establish in practice.

Many practitioners will diagnose PTSD without having all the criteria met if, in their opinion, substantial stress-related disability is present. It should therefore only be made by a psychiatrist, psychologist, or well-trained social worker with experience in this area.

Appropriate specialists

Psychiatrist, psychologist and licensed clinical social worker.

Last updated 21 December 2011


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