What causes PTSD?
Virtually any trauma, defined as an event that is life threatening or that severely compromises the physical or emotional well-being of an individual or causes intense fear, may cause PTSD. Such events often include either experiencing or witnessing a severe accident or physical injury, receiving a life-threatening medical diagnosis, being the victim of kidnapping or torture, exposure to community violence, war combat, or to a natural disaster, exposure to other disaster (for example, plane crash) or terrorist attack, being the victim of rape, mugging, robbery, or assault, enduring physical, sexual, emotional, or other forms of abuse, as well as involvement in civil conflict. Although the diagnosis of PTSD currently requires that the sufferer has a history of experiencing a traumatic event as defined here, people may develop PTSD in reaction to events that may not qualify as traumatic but can be devastating life events like divorce or unemployment.
What are PTSD risk factors and protective factors?
Issues that tend to put people at higher risk for developing PTSD include increased duration of a traumatic event, higher number of traumatic events endured, higher severity of the trauma experienced, having an emotional condition prior to the event, or having little social support in the form of family or friends. In addition to those risk factors, children and adolescents, females, minority groups and people with learning disabilities or violence in the home seem to have a greater risk of developing PTSD after a traumatic event.
What are PTSD symptoms and signs?
According to the DSM-5, the following three groups of symptom criteria are required to assign the diagnosis of PTSD in the context of an individual who has a history of being exposed to an actual or perceived threat of death, serious injury, or sexual violence to self or others that does not involve exposure through media unless that is work related:
- Recurrent re-experiencing of the trauma (for example, troublesome memories, flashbacks usually caused by reminders of the traumatic events, recurring nightmares about the trauma and/or dissociative reliving of the trauma): In children, this may include repetitive play about the trauma.
- Avoidance to the point of having a phobia of places, people, and experiences that remind the sufferer of the trauma, or a general numbing of emotional responsiveness
- Negative changes in thinking and trouble remembering important aspects of the trauma, holding negative beliefs about him or herself, a tendency to blame oneself for the trauma, a persistently negative emotional state, inability to have positive emotions, low interest or participation in significant activities, and feeling detached from others
- Significant changes in arousal and reactivity related to the traumatic event(s), including sleep problems, trouble concentrating, irritability, anger, poor concentration, blackouts or difficulty remembering things, reckless or self-destructive behavior, increased tendency and reaction to being startled, and hypervigilance (excessive watchfulness) to threat
The emotional numbing of PTSD may present as a lack of interest in activities that used to be enjoyed (anhedonia), emotional deadness, distancing oneself from people, and/or a sense of a foreshortened future (for example, not being able to think about the future or make future plans, not believing one will live much longer). At least one re-experiencing symptom, one avoidance symptom, two negative changes in mood or thinking, and two hyperarousal (fight or flight) symptoms must be present for at least one month and must cause significant distress or impairment in functioning in order for the diagnosis of PTSD to be assigned.
A similar disorder in terms of symptom repertoire is acute stress disorder. The major differences between the two disorders are that acute stress disorder symptoms persist from three days to one month after the trauma exposure, and a fewer number of traumatic symptoms are required to make the diagnosis as compared to PTSD.
In children, re-experiencing the trauma may occur through repeated play that has trauma-related themes instead of or in addition to memories, and distressing dreams may have more general content rather than of the traumatic event itself. As in adults, at least one re-experiencing symptom, one avoidance/numbing symptom, and two hyperarousal symptoms must be present for at least one month and must cause significant distress or functional impairment in order for the diagnosis of PTSD to be assigned. When symptoms have been present for three days to one month, a health care provider can then make a diagnosis of acute stress disorder (ASD).
Symptoms of PTSD that tend to be associated with C-PTSD include problems regulating feelings, which can result in suicidal thoughts, explosive anger, or passive aggressive behaviors, a tendency to forget the trauma or feel detached from one's life (dissociation) or body (depersonalization), persistent feelings of helplessness, shame, guilt, or being completely different from others, feeling the perpetrator of trauma is all powerful, and preoccupation with either revenge against or allegiance with the perpetrator, and severe change in those things that give the sufferer meaning, like a loss of spiritual faith or an ongoing sense of helplessness, hopelessness, or despair.
What is the treatment for PTSD?
Treatments for PTSD usually include trauma-focused psychological and medical interventions. Providing information about the illness, helping the individual manage the trauma by talking about it directly, teaching the person ways to manage symptoms of PTSD, and exploration and modification of inaccurate ways of thinking about the trauma are the usual techniques used in psychotherapy for this illness. Education of PTSD sufferers usually involves teaching individuals about what PTSD is, how many others suffer from the same illness, that extraordinary stress causes PTSD rather than personal weakness, how it is treated, and what to expect in treatment. This education thereby increases the likelihood that inaccurate ideas the person may have about the illness are dispelled, and any shame they may feel about having it is minimized. This may be particularly important in populations like military personnel that may feel particularly stigmatized by the idea of seeing a mental health professional and therefore avoid doing so.
Teaching people with PTSD practical approaches to coping with what can be very intense and disturbing symptoms is a useful way to treat the illness. Specifically, helping sufferers learn how to manage their anger and anxiety, improve their communication skills, and use breathing and other relaxation techniques can help individuals with PTSD gain a sense of mastery over their emotional and physical symptoms. The health care professional might also use exposure-based cognitive behavioral therapy by having the person with PTSD recall their traumatic experiences using images or verbal recall while using the coping mechanisms they learned. Individual or group cognitive behavioral psychotherapy can help people with PTSD recognize and adjust trauma-related thoughts and beliefs by educating sufferers about the relationships between thoughts and feelings, exploring common negative thoughts held by traumatized individuals, developing alternative interpretations, and by practicing new ways of looking at things. This treatment also involves practicing learned techniques in real-life situations. Intensive exposure therapy, which often involves multiple extensive sessions over several days followed by several weekly sessions over six months or more, is an evidence-based treatment that has been found to help people who have chronic PTSD. The Veterans Administration has invested in expanding the availability of this treatment to the people it serves.
Eye-movement desensitization and reprocessing (EMDR) is a form of cognitive therapy in which the health care professional guides the person with PTSD in talking about the trauma suffered and the negative feelings associated with the events, while focusing on the professional's rapidly moving finger during one-on-one treatment sessions. While some research indicates this treatment may be effective, it is unclear if this is any more effective than cognitive therapy done without the use of rapid eye movement.
Helping PTSD sufferers maintain their employment and other tasks of their daily lives is an important part of treatment. Occupational therapy (OT) is an important treatment modality in that regard, in that it focuses on rehabilitation and recovery through participation in activities. This can range from assisting helping people with PTSD regain independence in basic self-care to helping them reintegrate into previously held work and community roles. Another potentially powerfully positive activity-based intervention for individuals with PTSD can be the use of a service dog. Particularly toward the completion of more conventional treatments, service dogs have been found to be effective in improving PTSD suffers' sense of safety, responsibility, optimism, and self-awareness.
Families of PTSD individuals, as well as the sufferer, may benefit from family counseling, couples counseling, parenting classes, and conflict-resolution education. Family members may also be able to provide relevant history about their loved one (for example, about emotions and behaviors, drug abuse, sleeping habits, and socialization) that people with the illness are unable or unwilling to share.
Directly addressing the sleep problems that can be part of PTSD not only helps alleviate those problems but thereby helps decrease the symptoms of PTSD in general. Specifically, rehearsing adaptive ways of coping with nightmares (imagery rehearsal therapy), training in relaxation techniques, positive self-talk, and screening for other sleep problems can be helpful in decreasing the sleep problems associated with PTSD.
Medications that help PTSD sufferers include serotonergic antidepressants (SSRIs), like fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), and medicines that help decrease the physical symptoms associated with illness, like prazosin (Minipress), clonidine (Catapres), guanfacine (Tenex), and propranolol. Individuals with PTSD are much less likely to experience a relapse of their illness if the person continues antidepressant treatment for at least a year. SSRIs are the first group of medications that have received approval by the U.S. Food and Drug Administration (FDA) for the treatment of PTSD. Treatment guidelines provided by the American Psychiatric Association describe these medicines as being particularly helpful for people whose PTSD is the result of trauma that is not combat related. SSRIs tend to help PTSD sufferers modify information that is taken in from the environment (stimuli) and to decrease fear. Research also shows that this group of medicines tends to decrease anxiety, depression, and panic. SSRIs may also help reduce aggression, impulsivity, and suicidal thoughts that can be associated with this disorder. For combat-related PTSD, there is more and more evidence that prazosin can be particularly helpful. Although other medications like duloxetine (Cymbalta), bupropion (Wellbutrin), venlafaxine (Effexor), and desvenlafaxine (Pristiq) sometimes treat PTSD, little research has studied their effectiveness in treating this illness.
Other less directly effective but nevertheless potentially helpful medications for managing PTSD include mood stabilizers like lamotrigine (Lamictal), tiagabine (Gabitril), and divalproex sodium (Depakote), as well as mood stabilizers that are also antipsychotics, like risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), asenapine (Saphris), and paliperidone (Invega). Antipsychotic medicines seem to be most useful in the treatment of PTSD in those who suffer from agitation, dissociation, hypervigilance, intense suspiciousness (paranoia), or brief breaks in being in touch with reality (brief psychotic reactions). The antipsychotic medications are helpful treatment options for managing PTSD when used in combination with an SSRI.
Benzodiazepines (tranquilizers) such as diazepam (Valium) and alprazolam (Xanax) have unfortunately been associated with a number of problems, including withdrawal symptoms, and risks of overdose and addiction, and have not been found to be significantly effective for helping individuals with PTSD.
Medically Reviewed on 9/14/2018
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