Post-Traumatic Stress Disorder encompasses the multitude of disturbing symptoms that some people suffer following exposure to a life-threatening situation. Most people will experience a variety of unpleasant symptoms following a traumatic event. These include general tension and anxiety, difficulty returning to everyday life, and unpleasant memories of the trauma. When these symptoms become so severe that they continue to disrupt daily life for more than a month, that is the beginning of PTSD.
One of the most well-known aspects of PTSD is the phenomenon of flashbacks. Many people envision a veteran of war, now back home, hearing a car backfire or a door slam and being transported back to the violence of a battlefield. This kind of re-experiencing of the trauma can also come in the form of nightmares (common in young children with PTSD) and vivid, intrusive memories. Symptoms can be hard to detect in kids because they have difficulty communicating the details of what they are experiencing. While adults can feel guilt and may blame themselves, children usually don’t articulate these details and will generally appear to have a depressed or anxious mood.
PTSD can appear in anyone after the first year of life, and symptoms subside in half of patients in under three months of treatment. However, severe cases or those that go untreated can last for years or even decades. PTSD is often preceded by Acute Stress Disorder, which describes a similar set of symptoms that PTSD does. The major difference between the two is that Acute Stress Disorder only occurs up to one month after the trauma. Beyond that time, continued symptoms beg the diagnosis of PTSD. In more rare cases, symptoms can take some time, potentially 6 months or longer after the trauma, to set in before PTSD is recognized, and these are cases of “delayed expression”.
Causes and Risk Factors
In an average year, about 3.5% of Americans are diagnosed with PTSD. Women are at higher risk for developing PTSD and tend to suffer for longer, but part of this is because women are much more likely than men to be the victims of sexual and relationship violence. Lower levels of education, poverty, and a fractured family life (such as divorce, abandonment, and parental absence) also put people at higher risk.
An individual’s pre-exisiting psychology plays a significant role in how powerful the effect of trauma will be. Anxiety disorders, depression, Bipolar Disorder, and Obsessive Compulsive Disorder, especially if they occur early in life, all prime the brain to react negatively to traumatic events. Any previous experience of trauma early in life puts patients at greater risk for developing PTSD in response to more trauma later in life. This is especially true if the early trauma results in a stress disorder afterward.
Experiencing the trauma
One of the primary aspects of trauma that increases the likelihood of developing PTSD is the intensity. This encompasses how real the risk of death or injury is and how long it lasts for. People who are the direct victims of trauma are at higher risk than those who witness it happening to others (although both of these scenarios can lead to PTSD). The key in these situations is the intensity of the fear of death or injury that the patients experience.
Sources of trauma
People who experience trauma in a repeated or systematic way are also at higher risk of PTSD. Military service members in the line of duty are one of the biggest American populations who experience violence over lengthy time periods. The same goes for anyone living in or near active war zones or those who have been the victims of terrorist attacks, bombings, mass shootings, and even natural disasters. It can also be through a job, like emergency medical personnel, police, and firefighters, who are witness to graphic scenes on a routine basis. Finally, another major contributor to the PTSD population is interpersonal violence, most commonly in the form of child abuse, sexual assault, and abusive relationships.
How people deal with the trauma right after it occurs has a significant bearing on whether they will develop PTSD. People who develop Acute Stress Disorder after a trauma are more likely to develop PTSD later on down the road. Lack of emotional support from others in the aftermath of trauma leaves people without an outlet for their emotions and makes processing their situation more difficult.
Patients with PTSD are more likely to also suffer from anxiety, mood, and substance use disorders. Men with PTSD are more likely than women to have problems with substance use and behavioral problems. Major Depressive Disorder is one of the most common disorders appearing alongside PTSD, with about one third to one half of depressed patients also suffering from PTSD. This combination leads to greater disability, more severe and treatment-resistant depression, and greater risk of suicide. Among combat veterans, traumatic brain injury from repeated blasts and explosions accompanies PTSD about 50% of the time.
Diagnosing Post-Traumatic Stress Disorder
People develop PTSD from three main types of trauma: death, grave injury, or sexual abuse or assault. They can either be the primary victim or can have witnessed the trauma happen to someone else. PTSD can also evolve from discovering that a close family member or friend was subject to these traumas. People who are witness to the grisly aspects of multiple traumas over a long period of time can also develop PTSD. However, viewing traumatic media on tv or the internet does not lead to PTSD. The trauma is followed by at least a month of multiple types of symptoms that significantly disturb work, social, and home life.
Triggering memories and avoidance behavior
People experience at least one of several of types of unwanted reminders of the trauma. These can be disturbing memories that repeatedly come to mind, or unpleasant, recurring dreams about the trauma. In children, the memories usually appear as play behavior that is related to the trauma. People can even have flashbacks of the events, where they feel like they are back in time at the moment of the trauma. They also may suffer emotionally or have physical reactions (panic symptoms, for example) to things that remind them of the trauma.
These unpleasant reminders lead people to attempt to avoid thinking about anything associated with the traumatic events. They can also change their behavior to avoid encountering any external triggers that could bring back memories of the trauma.
Mood and mind changes
People suffer at least two of seven different kinds of changes in their emotions and memories surround the events. They may be unable to consciously remember some or all of the trauma or have an altered memory of the events where they incorrectly blame themselves or others. People may develop unrelenting, extreme negative thoughts about themselves or others that lead to a very negative and distrustful view of the world. A predominance of negative emotions and moods as well as feeling alone and abandoned by others plague these patients. They also experience difficulty feeling positive emotions and frequently lose interest in activities they previously enjoyed.
Individuals have at least two of several physical symptoms, which are mostly related to negative assumptions and expectations about their environments. They are typically irritable and are quick to become aggressive or even violent. They can even act with little regard for their own safety and end up hurting themselves and others. PTSD patients frequently feel tense and anxious and frighten easily. They also have problems sleeping and difficulty concentrating.
Depersonalization and derealization
These terms describe two types of breaks from reality that PTSD patients can encounter occasionally. The first denotes the sensation of feeling separated from one’s own body. In contrast, the second term implies a feeling that the surrounding world is not real.
Treating Post-Traumatic Stress Disorder
The most common forms of therapy for PTSD are Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR).
Cognitive Behavioral Therapy takes place over 3-4 months of weekly sessions that can be customized to treat trauma in a variety of ways. The two primary parts of CBT are exposure therapy and cognitive restructuring. When exposure is the primary component of the therapy, it is called Prolonged Exposure. This involves learning relaxation methods like controlled breathing and then confronting parts of the trauma in limited ways, such as visualization or revisiting reminders of the trauma. By doing this in a controlled, safe environment and gradually increasing the intensity of the exposure over time, patients can learn to confront their fears and decrease their sensitivity. Cognitive Processing Therapy is a customized form of CBT that focuses primarily on cognitive restructuring. Patients learn how PTSD can color their view of the world around them and the trauma they experienced. This form of therapy helps patients compare the facts of the trauma with how the they perceive the trauma. This involves delving into the misperceptions people have about their trauma (such as shame, guilt, jumbled memories, or missing pieces) and rectifying those with the truth of what actually happened.
Eye Movement Desensitization and Reprocessing is a relatively new form of therapy specifically designed to treat trauma. The therapy works by having patients bring to mind their memories of the trauma while at the same time focusing their attention on alternating sources of light, sound, or hand-taps. Although there is disagreement in medical community about how exactly EMDR works, it is clear that it is at least as effective as trauma-focused CBT.
Guidelines from the American Psychological Association recommend the following selective serotonin reuptake inhibitors (SSRIs) for treating PTSD: Prozac (fluoxetine), Paxil (paroxetine), and Zoloft (sertraline). Although these medications do not treat the core issues of PTSD, they can help reduce the intensity of the negative mood symptoms that frequently strike these patients. Although it is not approved by the Food and Drug Administration for this use, Minipress (prazosin) can help with the disturbing dreams and poor sleep that comes with PTSD. Medication is most frequently used in addition to psychotherapy and is only very rarely used alone.
Managing Post-Traumatic Stress Disorder
Drugs and alcohol in PTSD
All too commonly people resort to using drugs and alcohol to deal with the emotional disturbances of trauma, but substance use ends up making PTSD worse. War veterans and women, especially those who have suffered sexual violence, are at higher risk of drinking problems associated with PTSD. People often drink to try to help with the disturbed sleep of PTSD or to escape memories of trauma. However, drinking actually reduces the quality of sleep and prolongs patients’ suffering by letting them avoid doing the emotional work they need to do to deal with PTSD. Problem drinking causes social and family problems, leads to people isolating themselves, and ultimately worsens the symptoms of PTSD. Drinking also aggravates coexisting mental health conditions like anxiety and depression and can prolong pain from injuries related to the trauma. For example, veterans with PTSD who have trouble with drinking are at increased risk of suicide.
Natural instincts that help people recover from traumatic situations are called “resilience factors”, and they help predict who will develop PTSD and who will not. One major set of resilience factors centers around seeking and gaining support from others. Sharing emotional distress from trauma with others helps patients feel less separated and gives them a sense of community. People can trade techniques for dealing with stress and gain assurance that others understand what they are going through. Another important factor for successfully managing PTSD is trusting in the process and believing that things will work out. A general positive outlook on one’s treatment plan and faith that the situation will improve both predict better results for PTSD patients.
General relaxation methods are a good start to self-guided coping for PTSD. These include mild exercise, yoga, meditation, focused breathing, or prayer. People also frequently struggle with disturbing memories, vivid dreams, and traumatic flashbacks. When these strike, the best strategy is to focus on your surroundings. Remind yourself that the events in your dreams, memories, and flashbacks happened in the past and are not recurring right now (despite how real the experience may seem). Talk to someone close to you or talk aloud to yourself. Get up and move around, take a shower, or step outside. The key is to bring yourself back to the present.