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.

The diagnosis and initial approach to PTSD

Anyone can normally have any combination of the above-described symptoms during the first month after a significant trauma. If, however, the duration of these symptoms is more than one month and causes significant distress, or the symptoms impair the person's ability to function, then the diagnosis of PTSD can be made. In addition, if the duration of symptoms is more than three months, a diagnosis of chronic (long duration) PTSD is made. In some cases, oddly enough, the onset of symptoms is not until six months after the stressful events. This situation is referred to as delayed onset of PTSD, for which the outcome (prognosis) is often worse.

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?

The tools to treat PTSD

The basic tools for the treatment of posttraumatic stress disorder are:

• Individual psychotherapy that is targeted at symptom clusters
• Peer group support, especially for chronic PTSD
• Medication

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.

The types of psychotherapy

The next question is, what kind of psychotherapy should be used for PTSD? Some people will have a history of previous severe trauma in childhood, such as sexual or physical abuse. These people may be particularly sensitive (vulnerable) if they are re-traumatized by the therapy itself. That is to say, with review and discussion of the traumatic event, they may develop a more severe and perhaps chronic (long duration) variant of PTSD. So, for these patients, longer-term psychodynamic psychotherapy is usually indicated. In psychodynamic psychotherapy, there is a focus on past traumas and how they are rekindled by the present experiences. For most suffers of PTSD, however, a combination of cognitive and behavioral strategies (psychotherapy) that focus on the symptoms would usually be recommended.

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.

Cognitive therapy involves separating the intrusive thoughts from the associated anxiety that they produce. Additionally, it involves changing the sequence of thought patterns that occurs whenever the patient is exposed to the traumatic stimulus. Cognitive therapy also helps patients that have avoidance because with this therapy, these patients no longer need to avoid situations or places that may be reminders of the trauma. You see, cognitive therapy seriously diminishes the power of these reminders to cause severe reactions. What is more, patients can work on these issues outside of the doctor's office by using audiotapes and/or videotapes and by keeping a journal.