POST TRAUMATIC STRESS DISORDER

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By far, the greatest problem facing Vietnam and other combat veterans, and their families, is that of Post Traumatic Stress Disorder. This debilitating mental illness can affect many aspects of a veteran's life, including work, family, relationships, legal problems and substance abuse.

The National Center for Post-Traumatic Stress Disorder (PTSD) was created within the Department of Veterans Affairs in 1989, in response to a Congressional mandate to address the needs of veterans with military-related PTSD. Its mission was, and remains: To advance the clinical care and social welfare of America's veterans through research, education, and training in the science, diagnosis, and treatment of PTSD and stress-related disorders. This website is provided as an educational resource concerning PTSD and other enduring consequences of traumatic stress.

What is Post Traumatic Stress Disorder?

Post Traumatic Stress Disorder, or PTSD, is a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair the person's daily life.

PTSD is marked by clear biological changes as well as psychological symptoms. PTSD is complicated by the fact that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health. The disorder is also associated with impairment of the person's ability to function in social or family life, including occupational instability, marital problems and divorces, family discord, and difficulties in parenting.

Understanding PTSD

PTSD is not a new disorder. There are written accounts of similar symptoms that go back to ancient times, and there is clear documentation in the historical medical literature starting with the Civil War, when a PTSD-like disorder was known as "Da Costa's Syndrome." There are particularly good descriptions of posttraumatic stress symptoms in the medical literature on combat veterans of World War II and on Holocaust survivors. Careful research and documentation of PTSD began in earnest after the Vietnam War. The National Vietnam Veterans Readjustment Study estimated in 1988 that the prevalence of PTSD in that group was 15.2% at that time and that 30% had experienced the disorder at some point since returning from Vietnam.

PTSD has subsequently been observed in all veteran populations that have been studied, including World War II, Korean conflict, and Persian Gulf populations, and in United Nations peacekeeping forces deployed to other war zones around the world. There are remarkably similar findings of PTSD in military veterans in other countries. For example, Australian Vietnam veterans experience many of the same symptoms that American Vietnam veterans experience.

PTSD is not only a problem for veterans, however. Although there are unique cultural-and gender-based aspects of the disorder, it occurs in men and women, adults and children, Western and non-Western cultural groups, and all socioeconomic strata. A national study of American civilians conducted in 1995 estimated that the lifetime prevalence of PTSD was 5% in men and 10% in women.

How does PTSD develop?

Most people who are exposed to a traumatic, stressful event experience some of the symptoms of PTSD in the days and weeks following exposure. Available data suggest that about 8% of men and 20% of women go on to develop PTSD, and roughly 30% of these individuals develop a chronic form that persists throughout their lifetimes.

The course of chronic PTSD usually involves periods of symptom increase followed by remission or decrease, although some individuals may experience symptoms that are unremitting and severe. Some older veterans, who report a lifetime of only mild symptoms, experience significant increases in symptoms following retirement, severe medical illness in themselves or their spouses, or reminders of their military service (such as reunions or media broadcasts of the anniversaries of war events).

How is PTSD assessed?

In recent years, a great deal of research has been aimed at developing and testing reliable assessment tools. It is generally thought that the best way to diagnose PTSD-or any psychiatric disorder, for that matter-is to combine findings from structured interviews and questionnaires with physiological assessments. A multi-method approach especially helps address concerns that some patients might be either denying or exaggerating their symptoms.

How common is PTSD?

An estimated 7.8 percent of Americans will experience PTSD at some point in their lives, with women (10.4%) twice as likely as men (5%) to develop PTSD. About 3.6 percent of U.S. adults aged 18 to 54 (5.2 million people) have PTSD during the course of a given year. This represents a small portion of those who have experienced at least one traumatic event; 60.7% of men and 51.2% of women reported at least one traumatic event. The traumatic events most often associated with PTSD for men are rape, combat exposure, childhood neglect, and childhood physical abuse. The most traumatic events for women are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.

About 30 percent of the men and women who have spent time in war zones experience PTSD. An additional 20 to 25 percent have had partial PTSD at some point in their lives. More than half of all male Vietnam veterans and almost half of all female Vietnam veterans have experienced "clinically serious stress reaction symptoms." PTSD has also been detected among veterans of the Gulf War, with some estimates running as high as 8 percent.

Who is most likely to develop PTSD?

1. Those who experience greater stressor magnitude and intensity, unpredictability, uncontrollability, sexual (as opposed to nonsexual) victimization, real or perceived responsibility, and betrayal.

2. Those with prior vulnerability factors such as genetics, early age of onset and longer-lasting childhood trauma, lack of functional social support, and concurrent stressful life events.

3. Those who report greater perceived threat or danger, suffering, upset, terror, and horror or fear.

4. Those with a social environment that produces shame, guilt, stigmatization, or self-hatred.

What are the consequences associated with PTSD?

PTSD is associated with a number of distinctive neurobiological and physiological changes. PTSD may be associated with stable neurobiological alterations in both the central and autonomic nervous systems, such as altered brainwave activity, decreased volume of the hippocampus, and abnormal activation of the amygdala. Both the hippocampus and the amygdala are involved in the processing and integration of memory. The amygdala has also been found to be involved in coordinating the body's fear response.

Psychophysiological alterations associated with PTSD include hyper-arousal of the sympathetic nervous system, increased sensitivity of the startle reflex, and sleep abnormalities.

People with PTSD tend to have abnormal levels of key hormones involved in the body's response to stress. Thyroid function also seems to be enhanced in people with PTSD. Some studies have shown that cortisol levels in those with PTSD are lower than normal and epinephrine and norepinephrine levels are higher than normal. People with PTSD also continue to produce higher than normal levels of natural opiates after the trauma has passed. An important finding is that the neurohormonal changes seen in PTSD are distinct from, and actually opposite to, those seen in major depression. The distinctive profile associated with PTSD is also seen in individuals who have both PTSD and depression.

PTSD is associated with the increased likelihood of co-occurring psychiatric disorders. In a large-scale study, 88 percent of men and 79 percent of women with PTSD met criteria for another psychiatric disorder. The co-occurring disorders most prevalent for men with PTSD were alcohol abuse or dependence (51.9 percent), major depressive episodes (47.9 percent), conduct disorders (43.3 percent), and drug abuse and dependence (34.5 percent). The disorders most frequently comorbid with PTSD among women were major depressive disorders (48.5 percent), simple phobias (29 percent), social phobias (28.4 percent), and alcohol abuse/dependence (27.9 percent).

PTSD also significantly impacts psychosocial functioning, independent of comorbid conditions. For instance, Vietnam veterans with PTSD were found to have profound and pervasive problems in their daily lives. These included problems in family and other interpersonal relationships, problems with employment, and involvement with the criminal justice system.

Headaches, gastrointestinal complaints, immune system problems, dizziness, chest pain, and discomfort in other parts of the body are common in people with PTSD. Often, medical doctors treat the symptoms without being aware that they stem from PTSD.

How is PTSD treated?

PTSD is treated by a variety of forms of psychotherapy and drug therapy. There is no definitive treatment, and no cure, but some treatments appear to be quite promising, especially cognitive-behavioral therapy, group therapy, and exposure therapy. Exposure therapy involves having the patient repeatedly relive the frightening experience under controlled conditions to help him or her work through the trauma. Studies have also shown that medications help ease associated symptoms of depression and anxiety and help with sleep. The most widely used drug treatments for PTSD are the selective serotonin reuptake inhibitors, such as Prozac and Zoloft. At present, cognitive-behavioral therapy appears to be somewhat more effective than drug therapy. However, it would be premature to conclude that drug therapy is less effective overall since drug trials for PTSD are at a very early stage. Drug therapy appears to be highly effective for some individuals and is helpful for many more. In addition, the recent findings on the biological changes associated with PTSD have spurred new research into drugs that target these biological changes, which may lead to much increased efficacy.

How is PTSD Measured?

It can be difficult to know whether distress is a normal reaction or a symptom of something more serious. Even experts may require the results of a detailed evaluation to answer this question. Posttraumatic Stress Disorder (PTSD) is only one of many possible reactions to a traumatic experience. After a trauma, some people become anxious, some become depressed, and many find that they are not able to deal with their responsibilities as well as they had before the trauma. Although the majority of people are distressed for a while, over a period of a few weeks to a few months, most find that their upset lessens and they are better able to function. Someone who continues to be profoundly affected by their experience several months or even years later may be struggling with PTSD.

1. Trauma.

PTSD is different from most mental-health diagnoses because it is tied to a to particular life experience. A traumatic experience typically involves the potential for death or serious injury resulting in intense fear, helplessness, or horror.

2. Symptoms.

PTSD is characterized by a specific group of symptoms that sets it apart from other types of reactions to trauma. Increasingly, evidence points to four major types of symptoms: re-experiencing, avoidance, numbing, and arousal.

Re-experiencing symptoms involve a sort of mental replay of the trauma, often accompanied by strong emotional reactions. This can happen in reaction to thoughts or reminders of the experience when the person is awake or in the form of nightmares during sleep.

Avoidance symptoms are often exhibited as efforts to evade activities, places, or people that are reminders of the trauma.

Numbing symptoms are typically experienced as a loss of emotions, particularly positive feelings.

Arousal symptoms reflect excessive physiological activation and include a heightened sense of being on guard as well as difficulty with sleep and concentration.

3. Length and Severity.

To qualify for a formal diagnosis, the symptoms must persist for over one month, cause significant distress, and affect the individual's ability to function socially, occupationally, or domestically.

How do you get an evaluation?

While it may be tempting to identify PTSD for yourself or someone you know, the diagnosis generally is made by a mental-health professional. This will usually involve a formal evaluation by a psychiatrist, psychologist, or clinical social worker who is specifically trained to assess psychological problems.

What can I expect from an evaluation for PTSD?

The nature of an evaluation for PTSD can vary widely depending on how the evaluation will be used and the training of the professional evaluator. An interviewer may take as little as 15 minutes to get a sense of your traumatic experience and the effect it has had on your life in order to determine whether treatment for PTSD is called for. On the other hand, a specialized PTSD assessment can take eight or more 1-hour sessions when the information is needed for legal or disability claims. Regardless of the length of the evaluation, you can expect to be questioned in depth about experiences that may have been traumatic for you and about symptoms you may be experiencing as a result of these experiences. Evaluations that are more thorough are likely to involve detailed, structured interviews and psychological tests on which you record your thoughts and feeling. Your spouse or partner may be asked to provide additional information, and you may undergo a procedure that examines your physiological reactions to mild reminders of your trauma. Whatever the particulars of your situation, you should always be able to find out in advance from the professional conducting the evaluation what the assessment will involve and what information it is expected to provide.

What are some of the common assessments for PTSD?

As noted above, two main categories of PTSD evaluations are structured interviews and self-report questionnaires. The Clinician Administered PTSD Scale (CAPS) was developed by National Center for PTSD staff and is among the most widely used types of interviews. It has a format that requests information about the frequency and intensity of the core PTSD symptoms and of some common associated symptoms, which may have important implications for treatment and recovery. Another widely used interview is the Structured Clinical Interview for DSM (SCID). The SCID can be used to assess a range of psychiatric disorders including PTSD. Other interview instruments include the Anxiety Disorders Interview Schedule-Revised (ADIS), the PTSD-Interview, the Structured Interview for PTSD (SI-PTSD), and the PTSD Symptom Scale Interview (PSS-I). Each has unique features that might make it a good choice for a particular evaluation.

Several self-report measures have also been developed as time- and cost-efficient vehicles for obtaining information about PTSD-related distress. These measures provide a single score representing the amount of distress an individual is experiencing. Among this set is another widely used measure developed by National Center for PTSD staff, the PTSD Checklist (PCL). This measure comes in two versions, one oriented for civilians and another specifically designed for military personnel and veterans. Other widely used self-report measures are the Impact of Event Scale-Revised (IES-R), the Keane PTSD Scale of the MMPI-2, the Mississippi Scale for Combat Related PTSD and the Mississippi Scale for Civilians, the Posttraumatic Diagnostic Scale (PDS), the Penn Inventory for Posttraumatic Stress, and the Los Angeles Symptom Checklist (LASC).

Steps in Managing Traumatic Stress

Step One is recognizing the signs of posttraumatic stress. Trauma is so shocking that it causes memories that are impossible to forget or sometimes impossible to recall. Trauma memories often repeatedly come back when you are not trying to think about them. Memories arise as unpleasant thoughts or nightmares. Sometimes you may feel as if you cannot stop reliving the event. The shock of trauma also may create blank spaces in your memory because it is too much for the mind to handle, and so the mind takes a time out.

Traumatic stress reactions are normal responses to abnormal events. Most people experience posttraumatic stress reactions for days or even weeks after a trauma. Usually these reactions become less severe over time, but they may persist and become a problem.

Step Two is recognizing the ways of coping with traumatic stress that are natural but don't work, because they actually prolong and worsen the normal posttraumatic stress reactions. The ways of coping that do not work include:

Trying to avoid people, places, or thoughts that are reminders;
Shutting off feelings or connections to other people that are reminders;
Being hyper-vigilant or on guard; and
Trying to avoid bad memories, trying to shut out feelings or people, or trying to stay always alert may seem; reasonable. However, they don't work because trauma controls your life if you run from it.

Step Three is to get help from one of several special VA services for veterans (and their families) who are coping with traumatic stress reactions or PTSD. Trauma memories cannot be erased, but the stress they cause can become very manageable.

Find out more about PTSD resources for veterans and families by calling directly or discussing the programs with your physician or nurse. Contact your local Vet Center or one of the VA's specialized PTSD treatment programs.

Source: Department of Veterans Affairs, National Center for PTSD (2003)

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