POST-TRAUMATIC STRESS DISORDER

Post-traumatic stress disorder (PTSD) is the only psychiatric condition for which we claim to know the precise environmental cause. Although it is an ancient, very common condition, it is newly understood. Our knowledge of the way it develops is helping us understand how the brain works, both in health and in disease. Many forms of treatment are available, but so far, there is no best treatment. It is likely that many people will be affected by PTSD in the aftermath of the terrorist attacks in the United States and elsewhere. These events certainly qualify as traumas [significant, upsetting experiences or events that may precipitate or aggravate a mental disorder].

History. The disorder now known as PTSD was first described in wartime about 300 years ago. It has had many colorful names, such as "nostalgia" (Civil War), "shell shock" (World War I), and "traumatic war neurosis" (World War II). Other names have included "soldier's heart" and "railway spine." The term "post-traumatic stress disorder" was coined after the Vietnam War and formalized in 1980 with its inclusion in the definitive Diagnostic and Statistical Manual of Mental Disorders, Third Edition.

The new term was more than just a clever phrase; it reflected a change in the thinking about the how the disorder developed. Previously, childhood developmental problems were thought to be the basis for the symptoms. Now, current research and changing attitudes about mental illnesses were leading to a different conclusion-that lasting symptoms such as those in PTSD could result from exposure to severe trauma and intensely stressful situations. This newer model of the disorder was welcomed by many patients and families.

Epidemiology. At some point during their lifetime, more than 50 percent of the U.S. population experiences a trauma severe enough to cause PTSD, and almost 8 percent of the population is actually affected by the disorder. These figures show that almost 20 percent of people exposed to a trauma will go on to develop PTSD. Almost 4 percent of the U.S. population experiences PTSD in any given year.

We cannot predict with certainty who will develop PTSD after exposure to a severe trauma, but the some of the risk factors are prior traumatic experiences (especially in childhood); preexisting psychiatric disorders; poor social supports, and a family history of psychiatric disorders. A person's proximity to the traumatic event and the severity of the event are important. Not all traumatic events are equally likely to result in PTSD; for example, being raped is far more predisposing than is witnessing a killing, being seriously injured, or being caught up in a natural disaster. Being held hostage or being kidnapped are among the events most likely to cause the disorder. Women are twice as likely as men to have it.

Diagnosis and Symptoms. A diagnosis of PTSD is based on specific symptoms that begin after a person is exposed to a traumatic event. Here, the term "exposed" means that the person both

experienced, witnessed, or was confronted with an event involving actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and

experienced intense fear, helplessness, or horror.

The person then must develop symptoms from each of the following three clusters:

Reexperiencing: Remembering the traumatic event, sometimes intensely. This may

occur during waking or sleeping (dreams),

be triggered by external cues or (apparently) be spontaneous,

be so intense that the patient briefly believes he or she is back at the scene of the traumatic event,

take the form of a mental picture or just be a feeling, and

be associated with intense psychological stress.

Avoidance or numbing: Exerting effort to avoid anything that may trigger a memory of the traumatic event. Patients may

avoid people, places, activities, or conversation that might remind them of the event;

experience a numbing of emotional responsiveness and a suppression of feelings, leading them to withdraw from their usual social relationships; and

be unable to remember certain important aspects of the traumatic event.

Hyperarousal: Showing signs of an overexcited nervous system. The patient is

unable to fall or remain asleep, sometimes waking with nightmares;

irritable, and commonly has outbursts of anger;

continually tense and easily startled; and

unable to concentrate well and sometimes is continually on alert, looking for signs of danger.

The symptoms may begin immediately after a traumatic event, and they are considered normal for as long as a month afterwards. If the symptoms last three months or longer, the disorder is considered chronic; if they last less than three months, acute. If PTSD symptoms emerge months or years after a trauma, the disorder is called delayed-onset PTSD.

Treatment. We have a rich array of insufficiently tested treatments for PTSD. The disorder has generated a great deal of interest and study by psychiatrists and other health-care workers, perhaps because it causes so much suffering and its symptoms are dramatic. A tremendous amount of research on PTSD is under way, and we are beginning to get data on the effectiveness of various treatments. Because PTSD encompasses a variety of symptoms, and each patient has his or her unique mixture, no single treatment is likely to help everyone who has it.

Below are some guidelines that should help people decide what to do about their symptoms.

Get a diagnosis. All treatment depends on an accurate diagnosis. You must know what you are up against if you hope to overcome it.

Get treatment early. If left untreated, PTSD tends to become chronic and may have devastating psychological, physical, and social consequences. The earlier the treatment, the better the outcome.

Consider a combination of treatments. In 70 percent of cases, combining psychotherapy and medication will have an additive effect!

Treat any other conditions. People with PTSD very often have other disorders such as depression, alcoholism, or substance abuse, and are at an increased risk for suicide.

Try available psychotherapies. Behavioral, cognitive, interpersonal, and psychodynamic psychotherapies are at least partially effective. Group therapy and family therapy can help also. All these psychotherapies are designed to help people "process" the traumatic experience and move forward in their lives.

Consider, in consultation with your psychiatrist, the possibility of taking medications. They are often an important part of the treatment process. Medications may reduce the frequency and intensity of reexperiencing symptoms and dampen hyperarousal symptoms such as anxiety attacks, nightmares, and insomnia. Avoidance symptoms are difficult to treat with medications, but the SSRI [selective serotonin reuptake inhibitor] drugs (Zoloft, Paxil, Prozac) have shown some promise in this area. Medications may successfully treat concurrent psychiatric conditions. Finally, medications may quiet the nervous system enough to enable the patient to make use of psychotherapy and come to grips with what he or she has experienced.

Conclusion. Not only is PTSD a frightening and disabling disorder, it is also quite common. As we study this disorder, we become more able to help people who are suffering from it. Unfortunately, the tendency to avoid the reexperiencing symptoms and associated hyperarousal often keeps a person from getting help. Although there is no best treatment for PTSD, many available good and helpful treatments are evolving.

By David M. Goldstein, M.D.
Director, Mood Disorders Program
Clinical Professor of Psychiatry
Director, Psychopharmacologic Research
Georgetown University School of Medicine
Washington, DC

References

American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised. Washington: American Psychiatric Association, 1994.

Kessler, Ronald C., et al. Posttraumatic Stress Disorder in the National Comorbidity Survey. Archives of General Psychiatry 52 (Dec.), 1995.

Shalev, Arieh Y., et al. Treatment of Posttraumatic Stress Disorder: A Review. Psychosomatic Medicine 58: 165-182, 1996.

Foa, Edna B., et al. (eds.) Effective Treatments for PTSD. New York: Guilford Press, 2000.

International Society for Traumatic Stress Studies 60 Revere Drive, Suite 500 Northbrook IL 60062 www.ISTSS.org Tel: 847-480-9028

________________________

Reprinted from Smooth Sailing, Fall 2001, pages 1-3
Smooth Sailing, the quarterly newsletter of the Depression and Related Affective Disorders Association (DRADA)

DRADA, Meyer 3-181, 600 North Wolfe Street, Baltimore, MD 21287-7381

410-955-4647 or 202-955-5800
drada@jhmi.edu
www.hopkinsmedicine.org/drada

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