These pages contain information on Post-Traumatic Stress Disorder which I
pulled off the web. Authors and sight address included when available.
National Center for Post-Traumatic Stress Disorder
Post-Traumatic Stress Disorder: An Overview
by Matthew J. Friedman, M.D., Ph.D.,
The risk of exposure to trauma has been a part of the human condition since we
have evolved as a species. Attacks by saber tooth tigers or twentieth century
terrorists have probably produced similar psychological sequelae in the
survivors of such violence. Shakespeare's Henry IV appears to have met many, if
not all, of the diagnostic criteria for post-traumatic stress disorder (PTSD),
as have other heroes and heroines throughout the world's literature.
In 1980, the American Psychiatric Association added PTSD to the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III). Although a controversial
diagnosis, PTSD filled an important gap in psychiatric theory and practice. The
significant change ushered in by the PTSD concept was the stipulation that the
etiological agent was outside the individual (i.e., the traumatic event) rather
than an inherent individual weakness (i.e., a traumatic neurosis). The key to
understanding the scientific basis and clinical expression of PTSD is the
concept of "trauma."
In its initial DSM-III formulation, a traumatic event was conceptualized as a
catastrophic stressor that was outside the range of usual human experience. The
framers of the original PTSD diagnosis had in mind events such as war, torture,
rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki,
natural disasters and human-made disasters. They considered traumatic events as
clearly different from the very painful stressors that constitute the normal
fluctuations of life such as divorce, failure, rejection, serious illness, and
the like. (By this logic, adverse psychological responses to such "ordinary
stressors" would, in DSM-III terms, be characterized as Adjustment Disorders
rather than PTSD.) This division between traumatic and other stressors was
based on the assumption that although most individuals have the ability to cope
with ordinary stress, their adaptive capacities are likely to be overwhelmed
when confronted by a traumatic stressor.
PTSD is unique among other psychiatric diagnoses because of the great
importance placed upon the traumatic stressor. In fact, one cannot make a PTSD
diagnosis unless the patient has actually met the "stressor criterion" where he
or she has been exposed to an historical traumatic event. Clinical experience
with the PTSD diagnosis has shown there are individual differences regarding
the capacity to cope with catastrophic stress. While some people exposed to
traumatic events do not develop PTSD, others go on to develop the full-blown
syndrome. Such observations have prompted a recognition that trauma, like pain,
is not an external phenomenon that can be completely objectified. Like pain,
the traumatic experience is filtered through mental and emotional processes
before it can be appraised as an extreme threat. Because of individual
differences in this evaluation process, different people appear to have
different trauma thresholds, some more protected and some more vulnerable to
developing clinical symptoms after exposure to extremely stressful situations.
It must be emphasized that exposure to events such as rape, torture, genocide,
and severe war zone stress, are experienced as traumatic events by nearly
everyone.
Diagnostic criteria for PTSD include a history of exposure to a "traumatic
event" and symptoms from each of three symptom clusters: unwelcome memories,
avoidant/numbing symptoms and hyperarousal symptoms. A fifth criterion concerns
duration of symptoms. One important finding is that it is relatively common.
Recent data indicate PTSD prevalence rates are 5% and 10% respectively among
American men and women (Kessler et al, 1996).
As noted above the "A" stressor criterion specifies that a person has been
exposed to a catastrophic event involving actual or threatened death or injury,
or a threat to the physical dignity of him/herself or others. During this
traumatic exposure, the survivor's personal response was marked by intense
fear, helplessness or horror.
The "B" or uninvited remembering criterion includes symptoms that are perhaps
the most distinctive and readily identifiable. For individuals with PTSD, the
traumatic event remains, sometimes for decades or a lifetime, a dominating
psychological experience that keeps its power to cause panic, terror, dread,
grief, or despair as seen in daytime fantasies, traumatic nightmares, and
psychotic re-enactments known as PTSD flashbacks. Furthermore, traumamimetic
stimuli that trigger recollections of the original event have the power to
evoke mental images, emotional responses, and psychological reactions
associated with the trauma. Researchers can reproduce PTSD symptoms in the
laboratory by exposing affected individuals to auditory or visual traumamimetic
triggers (Keane, et. al., 1987).
The "C" or avoidant/numbing criterion consists of symptoms showing behavioral,
cognitive, or emotional strategies by which patients attempt to reduce the
likelihood they will either expose themselves to traumamimetic events, or if
exposed, will minimize the intensity of their psychological response.
Behavioral strategies include avoiding any situation in which they perceive a
risk of confronting such an event. In its most extreme manifestation, avoidant
behavior may superficially resemble agoraphobia because the PTSD individual is
afraid to leave the house for fear of confronting reminders of the traumatic
event(s). Dissociation and psychological amnesia are included among
avoidant/numbing symptoms. Finally, since individuals with PTSD cannot
tolerate strong emotions, especially those associated with the traumatic
experience, they separate the rational from the emotional aspects of
psychological experience and perceive only the former. Such "psychic numbing"
is an emotional anesthesia that makes it extremely difficult for people with
PTSD to participate in meaningful interpersonal relationships.
Symptoms included in the "D" or hyperarousal criterion most closely resemble
those seen in panic and generalized anxiety disorder. Whereas symptoms such as
hypervigilance and startle are more unique. The hypervigilance may sometimes
become so intense as to appear like frank paranoia. The startle response has a
unique neurobiological substrate and may actually be the most pathognomonic
symptom (Friedman, 1991,).
The "E" or duration criterion specifies how long symptoms must persist in order
to qualify for the (chronic or delayed) PTSD diagnosis. In DSM-III-R the
duration is one month.
The new "F" or significance criterion specifies that the survivor must
experience significant social, occupational, or other distress as a result of
these symptoms.
Neurobiological research indicates that PTSD may be associated with stable
neurobiological alterations in both the central and autonomic nervous systems.
Psychophysiological alterations associated with PTSD include hyperarousal of
the sympathetic nervous system, increased sensitivity and an increase of the
acoustic-startle eye-blink reflex, a reducer pattern of auditory caused
cortical potentials, and sleep abnormalities. Neuropharmacologic and
neuroendocrine abnormalities have been detected in the noradrenergic,
hypothalamic-pituitary-adrenocortical, and endogenous opioid systems.
Longitudinal research has shown that PTSD can become a chronic psychiatric
disorder that can persist for decades and sometimes for a lifetime. Patients
with chronic PTSD often exhibit a longitudinal course marked by remissions and
relapses. There is a delayed variant of PTSD in which individuals exposed to a
traumatic event do not exhibit the PTSD syndrome until months or years
afterwards. Usually, the immediate precipitant is a situation that resembles
the original trauma in a significant way; (for example, a rape survivor who is
sexually harassed or assaulted years later).
If an individual meets diagnostic criteria for PTSD, it is likely that he or
she will meet DSM-IV criteria for one or more additional diagnoses (Kulka, et.
al., 1990; Davidson & Foa, 1993). Most often these co-morbid diagnoses include
major affective disorders, dysthymia, alcohol or substance abuse disorders,
anxiety disorders, or personality disorders. There is a legitimate question
whether the high rate of diagnostic co-morbidity seen with PTSD is a token of
our current decision rules for making the PTSD diagnosis. In any case, high
rates of co-morbidity complicate treatment decisions concerning patients with
PTSD since the clinician must decide whether to treat the co-morbid disorders
together or sequentially.
Although PTSD continues to be classified as an Anxiety Disorder, areas of
disagreement about its medical science and phenomenology remain. Questions
about the syndrome itself include: what is the clinical course of untreated
PTSD; are there different subtypes of PTSD; what is the distinction between
traumatic simple phobia and PTSD; and what is the clinical phenomenology of
prolonged and repeated trauma. With regard to the latter, Herman (1992) has
argued that the current PTSD formulation fails to characterize the major
symptoms of PTSD commonly seen in victims of prolonged, repeated interpersonal
violence such as domestic or sexual abuse and political torture. She has
proposed an alternative diagnostic formulation that emphasizes: multiple
symptoms, excessive somatization, dissociation, changes in affect, pathological
changes in relationships and pathological changes in identity.
PTSD has also been criticized from the perspective of cross-cultural psychology
and medical anthropology, because it has usually been diagnosed by clinicians
from Western industrialized nations working with patients from a similar
background. Major gaps remain in our understanding of the effects of ethnicity
and culture on the clinical phenomenology of post-traumatic syndromes. We have
only just begun to apply vigorous ethnocultural research strategies to
delineate possible differences between Western and non-Western societies
regarding the psychological impact of traumatic exposure and the clinical
manifestations of such exposure (Marsella, et. al., 1996).
Before closing, it is necessary to discuss treatment. The most successful
interventions are those implemented immediately after a civilian disaster or
war zone trauma. This is often referred to as critical incident stress
debriefing (CISD) or some variant of that term. It is clear that the best
outcomes are obtained when the trauma survivor receives CISD within hours or
days of exposure. Such interventions not only lessen the acute response to
trauma but often forestall the later development of PTSD.
Results with chronic PTSD patients are often less successful. Perhaps the best
therapeutic option for mild-to-moderately affected PTSD patients is group
therapy. In such a setting the PTSD patient can discuss traumatic memories,
PTSD symptoms and functional deficits with others who have had similar
experiences. This approach has been most successful with war veterans,
rape/incest victims and natural disaster survivors. For many severely affected
patients with chronic PTSD a number of treatment options are available (often
offered in combination) such as psychodynamic psychotherapy, behavioral therapy
(direct therapeutic exposure) and pharmacotherapy. Results have been mixed and
few well-controlled therapeutic trials have been published to date. It is
important that therapeutic goals be realistic because in some cases, PTSD is a
chronic and severely debilitating psychiatric disorder resistant to current
available treatments. The hope remains that our growing knowledge about PTSD
will enable us to design more effective interventions for all patients
afflicted with this disorder.
This page was last updated on 27 March 1997 by the National Center for PTSD.
For more information send email to ptsd@dartmouth.edu
Anxiety Disorders
Anxiety is as much a part of life as eating and sleeping. Under the right
circumstances, anxiety is beneficial. It heightens alertness and readies the
body for action. Faced with an unfamiliar challenge, a person is often spurred
by anxiety to prepare for the upcoming event. For example, many people practice
speeches and study for tests as a result of mild anxiety. Likewise, anxiety or
fear and the urge to flee are a protection from danger.
Fears are not normal, however, when they become overwhelming and interfere with
daily living. They are symptoms of an anxiety disorder, the most common and
most successfully treated form of mental illness.
As a group, anxiety disorders afflict nearly nine percent of Americans during
any six-month period. Symptoms can be so severe that patients are almost
totally disabled--too terrified to leave their homes, to enter the elevator
that takes them to their offices, to attend parties or to shop for food.
"Anxiety" is a word so commonly used that many people don't understand what it
means in mental health care. Complicating matters, is the fact that "anxiety"
and fear are often used to describe the same thing. When the word "anxiety" is
used to discuss a group of mental illnesses, it refers to an unpleasant and
overriding mental tension that has no apparent identifiable cause. Fear, on the
other hand, causes mental tension due to a specific, external reason, such as
when your car skids out of control on ice.
Post-Traumatic Stress Disorder (PTSD)
Often associated with war veterans, post-traumatic stress disorder can occur in
anyone who has experienced a severe and unusual physical or mental trauma.
People who have witnessed a mid-air collision or survived a life-threatening
crime may develop this illness. The severity of the disorder increases if the
trauma was unanticipated. For that reason, not all war veterans develop PTSD,
despite prolonged and brutal combat. Soldiers expect a certain amount of
violence. Rape victims, however, are unsuspecting of the attack on their lives.
People who suffer from PTSD re-experience the event that traumatized them
through:
1) Nightmares, night terrors or flashbacks of the event. In rare cases, the
person falls into a temporary dislocation from reality in which he or she
relives the trauma. This can last for seconds or days.
2) "Psychic numbing," or emotional anesthesia(loss of bodily sensation with or
without loss of consciousness). Victims have decreased interest in or
involvement with people or activities they once enjoyed.
3) Excessive alertness and highly sharpened startle reaction. A car backfiring
may cause people once subjected to gunfire to instinctively drop to the ground.
4) General anxiety, depression, inability to sleep, poor memory, difficulty
concentrating or completing tasks, survivor's guilt.
Theories About Causes:
Probably no single situation or condition causes anxiety disorders. Rather,
physical and environmental triggers may combine to create a particular anxiety
illness.
Psychoanalytic theory suggests that anxiety stems from unconscious conflicts
that arose from discomfort during infancy or childhood. For example, a person
may carry the unconscious conflict of sexual feelings toward the parent of the
opposite sex. Or the person may have developed problems from experiencing an
illness, fright or other emotionally laden event as a child. By this theory,
anxiety can be resolved by identifying and resolving the unconscious conflict.
The symptoms that symbolize the conflict would then disappear.
Learning theory says that anxiety is a learned behavior that can be unlearned.
People who feel uncomfortable in a given situation or near a certain object
will begin to avoid it. However, such avoidance can limit a patient's ability
to live a normal life.
More recently, research has indicated that biochemical imbalances are culprits.
Many scientists say all thoughts and feelings result from complex
electrochemical interactions in the central nervous system. Moreover, some
studies indicate that infusions of certain biochemicals can cause a panic
attack in some people. According to this theory, treatment of anxiety should
correct these biochemical imbalances. Although medications first come to mind
with this theory, remember that studies have found biochemical changes can
occur as a result of emotional, psychological or behavioral changes.
Treatments
Generally, anxiety disorders are treated by a combination approach. Phobias and
obsessive-compulsive disorders often are treated by behavior therapy. This
involves exposing the patient to the feared object or situation under
controlled circumstances, until the fear is cured or significantly reduced.
Successfully treated with this method, many phobia patients have long-term
recovery.
Medications are effective treatments, sometimes used alone and often in
combination with behavior therapy or other psychotherapy techniques. In
addition to behavior modification techniques and medication, talking issues out
in psychotherapy can be crucial.
There is good reason for optimism about treatment of even the most severe
anxiety disorders. Research indicates that 65 percent of the phobic and
obsessive-compulsive patients who can cooperate with the therapist and
conscientiously follow instructions will recover with behavior therapy. Studies
have shown that while they are taking the medications, 70 percent of the
patients who suffer from panic attacks improve. Medication is effective for
about half of those suffering from obsessive-compulsive disorder.
Post-Traumatic Stress Disorder (PTSD)
Although the understanding of post-traumatic stress disorder is based primarily
on studies of trauma in adults, PTSD also occurs in children as well. It is
known that traumatic occurrences--sexual or physical abuse, loss of parents,
the disaster of war--often have a profound impact on the lives of children. In
addition to PTSD symptoms, children may develop learning disabilities and
problems with attention and memory. They may become anxious or clinging, and
may also abuse themselves or others.
Symptoms
The symptoms of PTSD may initially seem to be part of a normal response to an
overwhelming experience. Only if those symptoms persist beyond three months do
we speak of them being part of a disorder. Sometimes the disorder surfaces
months or even years later. Psychiatrists categorize PTSD's symptoms in three
categories: intrusive symptoms, avoidant symptoms, and symptoms of hyperarousal.
Intrusive Symptoms
Often people suffering from PTSD have an episode where the traumatic event
"intrudes" into their current life. This can happen in sudden, vivid memories
that are accompanied by painful emotions. Sometimes the trauma is
"re-experienced." This is called a flashback - a recollection that is so strong
that the individual thinks he or she is actually experiencing the trauma again
or seeing it unfold before his or her eyes. In traumatized children, this
reliving of the trauma often occurs in the form of repetitive play.
At times, the re-experiencing occurs in nightmares. In young children,
distressing dreams of the traumatic event may evolve into generalized
nightmares of monsters, of rescuing others or of threats to self or others.
At times, the re-experience comes as a sudden, painful onslaught of emotions
that seem to have no cause. These emotions are often of grief that brings
tears, fear or anger. Individuals say these emotional experiences occur
repeatedly, much like memories or dreams about the traumatic event.
Symptoms of Avoidance
Another set of symptoms involves what is called avoidance phenomena. This
affects the person's relationships with others, because he or she often avoids
close emotional ties with family, colleagues and friends. The person feels
numb, has diminished emotions and can complete only routine, mechanical
activities. When the symptoms of "re-experiencing" occur, people seem to spend
their energies on suppressing the flood of emotions. Often, they are incapable
of mustering the necessary energy to respond appropriately to their environment:
PTSD Diagnosis and Treatment for Mental Health Clinicians
by Matthew J. Friedman, M.D., Ph.D.
Abstract
This article focuses on four issues: PTSD assessment, treatment approaches,
therapist issues, and current controversies. Important assessment issues
include the trauma history, comorbid disorders, and chronicity of PTSD.
Effective intervention for acute trauma usually requires a variant of critical
incident stress debriefing. Available treatments for chronic PTSD include
group, cognitive-behavioral, psychodynamic, and pharmacological therapy.
Therapist self-care is essential when working with PTSD patients since this
work may be functionally disruptive and psychologically destabilizing. Current
controversies include advocacy vs. therapeutic neutrality, eye movement
desensitization and reprocessing (EMDR), the so-called false memory syndrome,
and the legitimacy of complex PTSD as a unique diagnostic entity.
Originally published in Community Mental Health Journal 32(2): 173-189, (April
1996).
Making the Diagnosis
The switch from DSM-III-R (American Psychiatric Association, 1987) to DSM-IV
(American Psychiatric Association, 1994) will bring few changes in the
diagnostic criteria for PTSD. The stressor criterion (A1) will no longer
characterize trauma as outside the range of normal human experience since we
have been forced to recognize that exposure to catastrophic stress is an
unwelcome but not unusual aspect of the human condition. Furthermore, the
stressor criterion (A2) now requires that in addition to exposure, the patient
need also have an intense emotional reaction to the traumatic event such as
panic, terror, grief, or disgust.
PTSD patients are stuck in time and are continually re-exposed to the traumatic
event through daytime memories that persistently interrupt ongoing thoughts,
actions, or feelings. They are assaulted by terrifying nightmares that awaken
them and make them afraid to go back to sleep. They cannot tolerate any
reminders of the trauma since these often trigger intense fear, anxiety, guilt,
rage, or disgust. In some cases, they suffer PTSD flashbacks, psychotic
episodes in which reality dissolves and they are plunged back into the apparent
reality of a traumatic event that has haunted them for years or decades. During
such episodes they find themselves fighting off rapists, being attacked by
enemies, or fleeing from explosions with the same intense feelings they
experienced during the initial trauma. Such intrusive recollections (Criterion
B) can persist for over 50 years (Schnurr, 1992) and may get worse, rather than
better, with time (Archibald and Tuddenham, 1965).
PTSD patients develop avoidant/numbing symptoms (Criterion C) to ward off the
intolerable emotions and memories recurrently stirred up by these intrusive
recollections. Sometimes they develop dissociative or amnestic symptoms which
buffer them from painful feelings and recollections. They also adopt
obsessional defenses and other behavioral strategies such as drug and alcohol
abuse, eating disorders, sexual acting out and workaholism, to ward off
intrusive recollections.
Finally, PTSD patients suffer from autonomic hyperarousal (Criterion D). Such
symptoms include insomnia, irritability that may progress to rage, agitation
and jumpiness manifested by an exaggerated startle response, and hypervigilence
that may become indistinguishable from frank paranoia. PTSD patients are always
on guard, dedicated to avoiding ever being re-exposed to the terrifying
circumstances that changed their lives forever. It is difficult for them to
trust other people or the environment. The need for safety and protection may
outweigh all other considerations including intimacy, socialization and other
pleasurable pursuits.
In other words, the clinician attempting to engage the PTSD patient in
treatment is asking the patient to take a tremendous risk. S/he is asking the
patient to give up all the protective behaviors and psychological strategies
that have emerged to ward off intrusive recollections and hyperarousal
symptoms. Therefore, the therapist must recognize that assessment and treatment
are potentially destabilizing. Therapy can only succeed in an environment of
sensitivity, trust, and safety (Herman 1992). Therapists must recognize that it
may take a long time for patients to shed the many layers of protective
symptoms that have evolved over countless years since the trauma. It is
important for the therapist to let the patient know as soon as possible that
s/he recognizes that the prospect of therapy is frightening and painful. It is
also important that therapists suppress their own need to get a trauma history
as soon as possible and set a pace that the patient can tolerate.
Some patients may be so relieved that they finally have an opportunity to
discuss long-suppressed, painful, and possibly shameful past events, that they
cannot wait to review such material with a therapist. A second group may be
equally motivated but may appear resistant because of fears that therapy will
stir up intolerable feelings. They require the safety mentioned earlier. A
third group may have sought treatment for depression, anxiety, chemical
dependency, eating disorders, somatic complaints, or adjustment disorders
rather than for PTSD. Indeed, among cohorts of treatment seeking PTSD patients,
up to 80% have at least one additional psychiatric diagnosis including
affective disorders (26-65%), anxiety disorders (30-60%), alcoholism or drug
abuse (60-80%), or personality disorders (40-60%) (Friedman, 1990; Jordan, et
al., 1991; Kulka, et al., 1990). For such patients, PTSD sometimes emerges as a
diagnostic possibility only after the clinician has obtained a careful trauma
history as part of a comprehensive assessment. Finally, there is a group of
difficult patients who present, because of disruptive or self-destructive
behaviors and who initially appear to suffer primarily from a personality
disorder. Patients in this latter category may be adult survivors of protracted
childhood sexual abuse whose trauma history may be obscured by DSM-III-R labels
such as borderline personality disorder (BPD), multiple personality disorder
(MPD), and somatoform disorder. In addition to PTSD symptoms, they often
present with problems of affect regulation, impulsive behavior, dissociative
symptoms, problems of trust, inappropriate sexual behavior, and a wide variety
of somatic complaints (Herman, 1992). These latter problems may demand the
lion's share of therapy. Treatment of these patients may be further complicated
by fragmented thought processes, incomplete memories, and dissociative symptoms.
The trauma history is essential. Given high rates of co-morbidity mentioned
earlier, and given a significant amount of overlap between symptoms seen in
PTSD, depres
PTSD
Executive Director, National Center for PTSD
Professor of Psychiatry and Pharmacology, Dartmouth Medical School
Executive Director, National Center for PTSD
Professor of Psychiatry and Pharmacology, Dartmouth Medical School