Posttraumatic Stress Disorder and 9-11 (cont.)
First, symptoms can be produced by re-experiencing the trauma, whereby the individual can have distressing recollections of the trauma. For example, the person may relive the experience as terrible dreams or nightmares or as daytime flashbacks of the event. Furthermore, external cues in the environment may remind the patient of the event. As a result, the psychological distress of the exposure to trauma is reactivated (brought back) by internal thoughts, memories, and even fantasies. Persons also can experience physical reactions to stress, such as sweating and rapid heart rate. (These reactions are similar to the "fight or flight" responses to emergencies described by Dr. Walter Cannon.) The patient's posttraumatic symptoms can be identical to those symptoms experienced when the actual trauma was occurring.
The second way that symptoms are produced is by persistent avoidance. The avoidance refers to the person's efforts to avoid trauma-related thoughts or feelings and activities or situations that may trigger memories of the trauma. This so-called psychogenic (emotionally caused) amnesia (loss of memory) for the event can lead to a variety of reactions. For example, the patient may develop a diminished interest in activities that used to give pleasure, detachment from other people, restricted range of feelings, and a sad affect that leads to the view that the future will be shortened.
The third way that symptoms are produced is by an increased state of arousal
of the affected person. These arousal symptoms include sleep disturbances,
irritability, outbursts of anger, difficulty concentrating, increased vigilance,
and an exaggerated startle response when shocked.
Research has shown that an immediate reduction of symptoms can be harmful in terms of the long-term outcome and persistent psychological illness. In other words, allowing an early peaking of the symptoms of depression and other PTSD problems is appropriate and preferable. Therefore, many of the treatments that psychiatrists have adopted are under the category (rubric) of what is referred to as stress debriefing (reviewing) of the critical incident (traumatic event). That is, we meet with the victims as soon as possible after the traumatic event. The purpose of the meeting is to discuss (debrief) the traumatic event in detail primarily with those most involved, and secondarily with those individuals who are involved at some distance. The specific goal is not to push the trauma away, but to get the people to talk about all aspects of the trauma and how it is affecting them.
Clinicians need to inquire very quickly about all aspects of the trauma and
the person's response to it. This information will lead to a more rapid,
specific diagnosis. We have found that with early management (intervention)
techniques, we are able to reduce the number of patients who go on to develop
full-blown acute (early) posttraumatic stress disorder and chronic (long
duration) posttraumatic stress disorder. The question then is, once PTSD has
been diagnosed, what are the most successful ways to treat it?
Various clinicians and clinics have their own methods for treating PTSD. A
survey of PTSD experts, however, seems to conclude that for milder acute (early)
PTSD, stress debriefing and early individual psychotherapy are especially
important. For more severe acute PTSD, medication, critical incident stress
debriefing, and group and individual psychotherapy should be started in
combination. For mild, chronic PTSD in children, adolescents, and geriatric
(senior) patients, the treatment is psychotherapy. For milder, chronic PTSD in
adults, combination treatment is again used with stress debriefing, medications,
and group and individual psychotherapy.
For example, intrusive (unwelcome) thoughts, flashbacks, panic, and avoidance
(actions to avoid emotional pain) are best treated by exposure therapy, anxiety
management, and cognitive therapy (see below). Exposure therapy consists
of education about common reactions to trauma, breathing retraining, (such
as breath counting and deep breathing), and repeated exposure to the past trauma
in graduated doses. As a result of exposure therapy, the traumatic issue or
event can be remembered without the anxiety or panic resulting.
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