Post-traumatic stress disorder
Encyclopedia
Posttraumatic
stress disorder (PTSD) is a severe anxiety disorder
that can develop after exposure to any event that results in psychological trauma
. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity, overwhelming the individual's ability to cope
. As an effect of psychological trauma
, PTSD is less frequent and more enduring than the more commonly seen acute stress response
. Diagnostic symptoms for PTSD include re-experiencing the original trauma(s) through flashbacks or nightmare
s, avoidance of stimuli associated with the trauma, and increased arousal
– such as difficulty falling or staying asleep, anger
, and hypervigilance
. Formal diagnostic criteria (both DSM-IV-TR and ICD-10) require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.
, characterized by aversive anxiety-related experiences, behaviors, and physiological responses that develop after exposure to a psychologically traumatic event (sometimes months after). Its features persist for longer than 30 days, which distinguishes it from the briefer acute stress disorder. These persisting posttraumatic stress symptoms cause significant disruptions of one or more important areas of life function. It has three sub-forms: acute, chronic, and delayed-onset.
or psychological trauma
, or more frequently a combination of both. According to Atkinson et al. (2000) PTSD is more likely to be caused by physical or psychological trauma caused by humans — such as rape, war, or terrorist attack — than by trauma caused by natural disasters. Possible sources of trauma include experiencing or witnessing childhood or adult physical
, emotional or sexual abuse
. In addition, experiencing or witnessing an event perceived as life-threatening such as physical assault
, adult experiences of sexual assault
, accidents, drug addiction, illnesses, medical complications
, or employment in occupations exposed to war (such as soldiers) or disaster (such as emergency service
workers).
Traumatic events that may cause PTSD symptoms to develop include violent assault, kidnapping, sexual assault, torture, being a hostage, prisoner of war or concentration camp victim, experiencing a disaster, violent automobile accidents or getting a diagnosis of a life-threatening illness. Children or adults may develop PTSD symptoms by experiencing bullying or mobbing
. Approximately 25% of children exposed to family violence can experience PTSD. Preliminary research suggests that child abuse may interact with mutations in a stress-related gene to increase the risk of PTSD in adults.
Multiple studies show that parental PTSD and other posttraumatic disturbances in parental psychological functioning can, despite a traumatized parent's best efforts, interfere with their response to their child as well as their child's response to trauma. Parents with violence-related PTSD may, for example, inadvertently expose their children to developmentally inappropriate violent media due to their need to manage their own emotional dysregulation. Clinical findings indicate that a failure to provide adequate treatment to children after they suffer a traumatic experience, depending on their vulnerability and the severity of the trauma, will ultimately lead to PTSD symptoms in adulthood.
views different types of fears and reactions caused by fears as adaptation
s that may have been useful in the ancestral environment in order to avoid or cope with various threats. Mammal
s generally display several defensive behaviors roughly dependent on how close the threat is: avoidance, vigilant immobility, withdrawal, aggressive defense, appeasement, and finally complete frozen immobility (the last possibly to confuse a predator's attack reflex or to simulate a dead and contaminated body). PTSD may correspond to and be caused by overactivation of such fear circuits. Thus, PTSD avoidance behaviors may correspond to mammal avoidance of and withdrawal from threats. Heightened memory of past threats may increase avoidance of similar situations in the future as well as be a prerequisite for analyzing the past threat and develop better defensive behaviors if the threat should reoccur. PTSD hyperarousal may correspond to vigilant immobility and aggressive defense. Complex post-traumatic stress disorder
(and phenomena such as the Stockholm syndrome
) may in part correspond to the appeasement stage and possibly the frozen immobility stage.
There may be evolutionary explanations for differences in resilience to traumatic events. Thus, PTSD is rare following traumatic fire which may be explained by events such as forest fires long being part of the evolutionary history of mammals. On the other hand, PTSD is much more common following modern warfare, which may be explained by modern warfare being a new development and very unlike the quick inter-group raids that are argued to have characterized the paleolithic
.
PTSD displays biochemical
changes in the brain and body that differ from other psychiatric disorders such as major depression. Individuals diagnosed with PTSD respond more strongly to a dexamethasone suppression test
than individuals diagnosed with clinical depression
.
In addition, most people with PTSD also show a low secretion of cortisol
and high secretion of catecholamine
s in urine
, with a norepinephrine
/cortisol ratio consequently higher than comparable non-diagnosed individuals. This is in contrast to the normative fight-or-flight response
, in which both catecholamine
and cortisol levels are elevated after exposure to a stressor.
Brain catecholamine
levels are high, and corticotropin-releasing factor (CRF) concentrations are high. Together, these findings suggest abnormality in the hypothalamic-pituitary-adrenal (HPA) axis
.
Given the strong cortisol suppression to dexamethasone
in PTSD, HPA axis abnormalities are likely predicated on strong negative feedback inhibition of cortisol, itself likely due to an increased sensitivity of glucocorticoid receptor
s. Some researchers have associated the response to stress in PTSD with long-term exposure to high levels of norepinephrine
and low levels of cortisol, a pattern associated with improved learning
in animals.
Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response through a hypersensitive, hyperreactive and hyperresponsive HPA axis.
Low cortisol
levels may predispose individuals to PTSD: Following war trauma, Swedish
soldiers serving in Bosnia and Herzegovina
with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels. Because cortisol is normally important in restoring homeostasis
after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD.
However, there is considerable controversy within the medical community regarding the neurobiology of PTSD. A review of existing studies on this subject showed no clear relationship between cortisol levels and PTSD. Only a slight majority have found a decrease in cortisol levels while others have found no effect or even an increase.
, amygdala
and hippocampus
. Much of this research has utilised PTSD victims from the Vietnam War. For example, a prospective study using the Vietnam Head Injury Study showed that damage to the prefrontal cortex may actually be protective against later development of PTSD. In a study by Gurvits et al., combat veterans of the Vietnam War
with PTSD showed a 20% reduction in the volume of their hippocampus
compared with veterans who suffered no such symptoms. This finding could not be replicated in chronic PTSD patients traumatized at an air show plane crash in 1988 (Ramstein, Germany).
In human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. Neuroimaging
studies in humans have revealed both morphological and functional aspects of PTSD.
The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex
and the hippocampus
particularly during extinction. This is consistent with an interpretation of PTSD as a syndrome of deficient extinction
ability. A study at the European Neuroscience Institute-Goettingen (Germany) found that fear extinction-induced IGF2/IGFBP7
signalling promotes the survival of 17–19-day-old newborn hippocampal neurons. This suggests that therapeutic strategies that enhance IGF2 signalling and adult neurogenesis
might be suitable to treat diseases linked to excessive fear memory such as PTSD. Further animal and clinical research into the amygdala and fear conditioning
may suggest additional treatments for the condition.
Recently, it has been found that several single-nucleotide polymorphisms (SNPs) in FK506 binding protein 5
(FKBP5) interact with childhood trauma to predict severity of adult PTSD. These findings suggest that individuals with these SNPs who are abused as children are more susceptible to PTSD as adults.
This is particularly interesting given that FKBP5 SNPs have previously been associated with peritraumatic dissociation (that is, dissociation at the time of the trauma), which has itself been shown to be predictive of PTSD. Furthermore, FKBP5 may be less expressed
in those with current PTSD. Another recent study found a single SNP in a putative estrogen response element on ADCYAP1R1
(encodes pituitary adenylate cyclase-activating polypeptide type I receptor or PAC1) to predict PTSD diagnosis and symptoms in females. Incidentally, this SNP is also associated with fear discrimination. The study suggests that perturbations in the PACAP-PAC1 pathway are involved in abnormal stress responses underlying PTSD.
Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood. This effect of childhood trauma, which is not well understood, may be a marker for both traumatic experiences and attachment problems. Proximity to, duration of, and severity of the trauma also make an impact; and interpersonal traumas cause more problems than impersonal ones.
s. Among those are:
They also identified certain protective factors, such as:
There may also be an attitudinal component; for example, a soldier who believes that they will not sustain injuries may be more likely to develop symptoms of PTSD than one who anticipates the possibility, should either be wounded. Likewise, the later incidence of suicide among those injured in home fires above those injured in fires in the workplace suggests this possibility.
in Oregon and Washington state, the rate of PTSD in adults who were in foster care
for one year between the ages of 14-18 was found to be higher than that of combat veterans. Up to 25 percent of those in the study meet the diagnostic criteria for PTSD as compared to 12-13 percent of Iraq war veterans and 15 percent of Vietnam War veterans, and a rate of 4 percent in the general population. The recovery rate for foster home alumni was 28.2% as opposed to 47% in the general population.
Dubner and Motta (1999) found that 60% of children in foster care who had experienced sexual abuse had PTSD, and 42% of those who had been physically abused met the PTSD criteria. PTSD was also found in 18% of the children who were not abused. These children may have developed PTSD due to witnessing violence in the home, or as a result of real or perceived parental abandonment.
IV (Text Revision) (DSM-IV-TR), may be summarized as:
memories, recurring distressing dreams, subjective re-experiencing of the traumatic event(s), or intense negative psychological or physiological response to any objective or subjective reminder of the traumatic event(s).
.
and PTSD Symptom Scale
can be used to detect possible symptoms of posttraumatic stress disorder, and suggest the need for a formal diagnostic assessment.
research suggests that PTSD symptoms group empirically into four clusters, not the three currently described in the Diagnostic and Statistical Manual of Mental Disorders
. One model supported by this research divides the traditional avoidance symptoms into a cluster of numbing symptoms (such as loss of interest and feeling emotionally numb) and a cluster of behavioral avoidance symptoms (such as avoiding reminders of the trauma). An alternative model adds a fourth cluster of dysphoric symptoms. These include symptoms of emotional numbing, as well as anger, sleep disturbance, and difficulty concentrating (traditionally grouped under the hyperarousal cluster). A literature review and meta-analysis did not find strong support across the literature for one of these models over the other.
release of the DSM-5
, the fifth version of the American Psychiatric Association
's diagnostic manual, draft diagnostic criteria was released for public comment, followed by a two-year period of field testing. Proposed changes to the criteria (subject to ongoing review and research) include the following :
"Developmental trauma disorder", a proposed new diagnosis, was still under discussion at the time of the draft publication.
may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as the Red Cross
and the Salvation Army
provide counseling after major disasters as part of their standard procedures to curb severe cases of posttraumatic stress disorder.
began in 2005 after the VA had noted a 30% increase in PTSD claims in recent years. In 2005 the suicide rate among male Veteran VA users was 37.19 per 100,000, compared to 13.59 in females. This led to a backlash from veterans'-rights groups, and to some highly publicized suicides by veterans who feared losing their benefits, which in some cases constituted their only income. In response, on November 10, 2005, the Secretary of Veterans Affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for posttraumatic stress disorder..."
The diagnosis of PTSD in U.S. military veterans has been a subject of some controversy due to uncertainties in objectively diagnosing PTSD in those who may have been exposed to trauma
, and due to this diagnosis' association with some incidence
of compensation-seeking behavior.
Many veterans of the wars in Iraq and Afghanistan
returning home have faced significant physical, emotional and relational disruptions. In response, the United States Marine Corps
has instituted programs to assist them in re-adjusting to civilian life, especially in their relationships with spouses and loved ones, to help them communicate better and understand what the other has gone through. Walter Reed Army Institute of Research
(WRAIR) developed the Battlemind
program to assist service members avoid or ameliorate PTSD and related problems.
.
Veterans Affairs Canada
offers a new program that includes rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support.
has been suggested as a means of preventing PTSD but subsequent studies suggest the likelihood of its producing iatrogenic
outcomes. A review of multiple studies confirmed the finding of no benefit to trauma survivors from single-session early-response interventions, as well as a failure of blanket multiple-session prevention interventions to yield a benefit to all participants (some were even harmed).
volume were identified as linked to later PTSD development. However, both of these indicators are relatively difficult to test for and need specialized tests and or equipment to identify. A blood biomarker is much easier to test for. Van Zuiden et al. found just such a biomarker when testing U.S. Army soldiers prior to deployment. They found that soldiers with more glucocorticoid receptors (GR) were more likely to be diagnosed with PTSD six months after deployment. However, higher GR levels have not been identified as a cause of PTSD, and may instead be an intermediator, or even an indicator that the individual has previously experienced traumatic events. There is a great deal of overlap between high GR levels and those who later are diagnosed with and without PTSD. Thus, the identification of high GR is simply a vulnerability indicator at this time.
Delhanty found that biological precursors existed directly following traumatic exposure in those who later developed chronic PTSD and were significantly different from those who did not. Directly following the traumatic event later sufferers often have significantly lower levels of hypothalamic
pituitary-adrenal activity and a corresponding decrease in Cortisol.
Other methods of early detection include the identification of specific risk factors associated with later PTSD symptoms. Resnick, Acierno, Holmes, Kilpatrick, and Jager for example were able to identify that the forensic exam given to victims after a rape was associated with PTSD.
Finally, global treatments attempt to avoid the problems of early detection by simply treating everyone involved. However, many studies have found this to be often ineffective and for global treatments to at times increase prevalence rates of PTSD.
The first form of preventive treatment is that of a psychological debriefing. Psychological debriefing is the most often used preventive measure. One of the main reasons for this is the relative ease with which this treatment can be given to individuals directly following an event. It consists of interviews that are meant to allow individuals to directly confront the event and share their feelings with the counselor and to help structure their memories of the event.
However, while this form of therapy is the most often used it is actually the least effective. Studies have had mixed findings concerning psychological debriefings and have ranged from being of significant help to helping in the formation of PTSD in individuals who would otherwise have not developed PTSD. The greater number of studies tends to simply find that it is neither overly beneficial nor harmful.
Risk targeted interventions are those that attempt to mitigate specific formative information or events. It can target modeling normal behaviors, instruction on a task or giving information on the event. For example, rape victims were given an instruction video on the procedures for a forensic exam. Also included in the video was advice on how to identify and stop avoidance behavior and control anxiety. Finally, the individuals modeling the forensic exam were shown to be calm and relaxed. PTSD diagnosis for those who saw the video were thirty three percent less than for those who went through the standard forensic procedure.
Psychobiological treatments have also found success, especially with cortisol. Psychobiological treatments target biological changes that occur after a traumatic event. They also attempt to chemically alter learning or memory formation. Cortisol treatments after a traumatic event have found success in mitigating later diagnosis of PTSD. As discussed earlier Cortisol is often lower in individuals who are at risk of PTSD after a traumatic event than their counterparts. By increasing cortisol levels to normal levels this has been shown to reduce arousal post event as well prevent GR upregulation.
Stepped collaborative care is where individuals who are at risk are monitored for symptoms. As symptoms of PTSD appear the level of care is increased to treat those symptoms.
The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral programs, variants of exposure therapy
, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing
(EMDR), and many combinations of these procedures. A 2010 review disagrees that these treatments have proven efficacy, and points out methodological flaws in the studies and previous meta-analyses.
EMDR or trauma-focused cognitive behavioral therapy (TFCBT) was recommended as first-line treatments for trauma victims in a 2007 review; however, "the evidence base [for EMDR] was not as strong as that for TFCBT ... Furthermore, there was limited evidence that TFCBT and EMDR were superior to supportive/non-directive treatments, hence it is highly unlikely that their effectiveness is due to non-specific factors such as attention." A meta-analytic
comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in terms of effectiveness in treating PTSD; however "the contribution of the eye movement component in EMDR to treatment outcome" is unclear.
In CBT, individuals learn to identify thoughts that make them feel afraid or upset, and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.
Recent research on contextually based third-generation behavior therapies suggests that they may produce results comparable to some of the better validated therapies. Many of these therapy methods have a significant element of exposure, and have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms.
Exposure therapy is a type of cognitive behavioral therapy that involves assisting trauma survivors to re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders; this therapy modality is well supported by clinical evidence. Indeed, the success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD. Some organizations have endorsed the need for exposure. The US Department of Veterans Affairs has been actively training mental health treatment staff in prolonged exposure therapy
and Cognitive Processing Therapy
in an effort to better treat US Veterans with PTSD.
(EMDR) is specifically targeted as a treatment for PTSD. Based on the evidence of controlled research, the American Psychiatric Association
and the United States Department of Veterans Affairs and Department of Defense have placed EMDR in the highest category of effectiveness and research support in the treatment of trauma. Several international bodies have made similar recommendations. However, some reviewers no longer believe that the eye movements assist in recovery, proposing instead that the review of and engagement with memories, processing of cognitions, and rehearsal of coping skills are the psychotherapeutically effective components of the procedure.
, and relaxation therapy.
s). SSRIs are considered to be a first-line drug treatment. SSRIs for which there are data to support use include: citalopram
, escitalopram
, fluoxetine
, fluvoxamine
, paroxetine
, and sertraline
.
Among the anti-depressants described in this section, bupropion and venlafaxine
have the lowest patient drop-out rates. Sertraline, fluoxetine
, and nefazodone
have a modestly higher drop-out rate (~15%), and the heterocyclics and paroxetine have the highest rates (~20%+). Where drop-out is caused or feared because of medication side-effects, it should be remembered that most patients do not experience such side-effects.
Alpha-adrenergic antagonists. Prazosin
("Minipress"), in a small study of combat veterans, has shown substantial benefit in relieving or reducing nightmares. Clonidine ("Catapres") can be helpful with startle, hyperarousal, and general autonomic hyperexcitability.
Anti-convulsants, mood stabilizer
s, anti-aggression agents. Carbamazepine
("Tegretol") has likely benefit in reducing arousal symptoms involving noxious affect, as well as mood or aggression. Topiramate
("Topamax") has been effective in achieving major reductions in flashbacks and nightmares, and no reduction of effect was seen over time. Zolpidem
("Ambien") has also proven useful in treating sleep disturbances.
Lamotrigine
("Lamictal") may be useful in reducing reexperiencing symptoms, as well as avoidance and emotional numbing. Valproic acid
("Depakene") and has shown reduction of symptoms of irritability, aggression, and impulsiveness, and in reducing flashbacks. Similarly, lithium carbonate has worked to control mood and aggressions (but not anxiety) symptoms. Buspirone
("BuSpar") has an effect similar to that of lithium, with the additional benefit of working to reduce hyperarousal symptoms.
Antipsychotic
s. Risperidone
can be used to help with dissociation
, mood issues, and aggression.
Atypical antidepressant
s. Nefazodone ("Serzone") can be effective with sleep disturbance symptoms, and with secondary depression
, anxiety
, and sexual dysfunction
symptoms. Trazodone
("Desyrel") can also reduce or eliminate problems with disturbed sleep, and with anger and anxiety.
Beta blockers. Propranolol ("Inderal") has demonstrated possibilities in reducing hyperarousal symptoms, including sleep disturbances.
Benzodiazepines. These can be used with caution for short-term anxiety relief, hyperarousal, and sleep disturbance. While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD, or are at all effective in the treatment of posttraumatic stress disorder. Additionally benzodiazepines may reduce the effectiveness of psychotherapeutic interventions and there is some evidence that benzodiazepines may contribute to the development and chronification of PTSD. Other drawbacks include the risk of developing a benzodiazepine dependence
and withdrawal syndrome
; additionally individuals with PTSD are at an increased risk of abusing benzodiazepines.
Glucocorticoids. Additionally, post-stress high dose corticosterone
administration was recently found to reduce 'PTSD-like' behaviors in a rat model of PTSD. In this study, corticosterone impaired memory performance, suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories. The neurodegenerative effects of the glucocorticoids, however, may prove this treatment counterproductive.
Heterocyclic
/ Tricyclic anti-depressants
anti-depressants. Amitriptyline
("Elavil") has shown benefit for positive distress symptoms, and for avoidance, and Imipramine
("Tofranil") has shown benefit for intrusive symptoms.
Monoamine-oxidase inhibitors (MAOIs)
. Phenelzine
("Nardil") has for some time been observed to be effective with hyperarousal and depression, and is especially effective with nightmares.
Miscellaneous other medications. Clinical trial
s evaluating methylenedioxymethamphetamine
(MDMA, "Ecstasy") in conjunction with psychotherapy are being conducted in Switzerland and Israel.
Alpha-adrenergic antagonists. Anecdotal report of success in using clonidine
("Catapres") to reduce traumatic stress symptoms suggests that it may have benefit in preventing PTSD.
Beta blockers. Propranolol ("Inderal"), similarly to clonidine, may be useful if there are significant symptoms of "over-arousal". These may inhibit the formation of traumatic memories by blocking adrenaline's effects on the amygdala
.
Glucocorticoid
s. There is some evidence suggesting that administering glucocorticoid
s immediately after a traumatic experience may help prevent PTSD. Several studies have shown that individuals who receive high doses of hydrocortisone for treatment of septic shock
, or following surgery, have a lower incidence and fewer symptoms of PTSD.
Opiates. In a retrospective analysis of combat injury field data for US troops in Iraq, it was found that those who received morphine in the early stages of their treatment had a significantly lower rate of subsequent PTSD, when compared with those who did not receive morphine at that time.
Some medications can also help with symptoms which may occur secondary to PTSD.
and drug abuse
commonly co-occur with PTSD. Recovery from posttraumatic stress disorder or other anxiety disorders may be hindered, or the condition worsened, by medication or substance overuse, abuse, or dependence; resolving these problems can bring about a marked improvement in an individual's mental health status and anxiety levels.
Benzodiazepines are risky in several ways. They can be especially addictive when PTSD is present, and this is especially true with the fast-acting ones. Dis-inhibition upon initiation of treatment is another risk with this medication class. Finally, termination of the drug can be especially difficult. Recovery from benzodiazepine abuse or dependence tends to take a lot longer than recovery from alcohol abuse or dependence, but people can regain their previous good health. PTSD symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.
Yohimbine (not considered specifically appropriate for PTSD) increases arousal by increasing release of endogenous norepinephrine, and can worsen PTSD symptoms.
rates have not changed significantly.
Disability-Adjusted Life Year (DALY) rate, the top half of the ranked list is dominated by Asian/Pacific countries, the USA, and Egypt. Ranking the countries by the male-only or female-only rates produces much the same result, but with less meaningfulness, as the score range in the single sex rankings is much reduced (4 for women, 3 for men, as compared with 14 for the overall score range), suggesting that the differences between female and male rates, within each country, is what drives the distinctions between the countries.
The United States Department of Veterans Affairs
estimates that 830,000 Vietnam War veterans suffered symptoms of PTSD. The National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5% of female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was 30.9% for males and 26.9% for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans suffered from PTSD symptoms (but not the disorder itself). Four out of five reported recent symptoms when interviewed 20–25 years after Vietnam.
s suffering from posttraumatic stress reactions, the latter from seeing members of their herd shot by hunters. Service dogs used overseas in the military have been said to develop posttraumatic stress after witnessing war.
. In 490 BC/BCE he described, during the Battle of Marathon
, an Athenian soldier who suffered no injury from war but became permanently blind after witnessing the death of a fellow soldier.
According to Stéphane Audoin-Rouzeau and Annette Becker, "One-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and after thirty-five days of uninterrupted combat, 98% of them manifested psychiatric disturbances in varying degrees."
Although PTSD-like symptoms have also been recognized in combat veterans of many military conflicts since, the modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by US military veterans of the war in Vietnam
.
Previous diagnoses now considered historical equivalents of PTSD include railway spine
, stress syndrome, shell shock
, battle fatigue, or traumatic war neurosis.
and Chaim F. Shatan
, who worked with them and coined the term post-Vietnam Syndrome; the condition was added to the DSM-III as posttraumatic stress disorder.
Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders. The term was formally recognized in 1980. (In the DSM-IV, the spelling "posttraumatic stress disorder" is used, while in the ICD-10
the spelling is "post-traumatic...". Elsewhere, especially in less formal writing, the term may be rendered as two words — "post traumatic stress disorder".)
stress disorder (PTSD) is a severe anxiety disorder
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...
that can develop after exposure to any event that results in psychological trauma
Psychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity, overwhelming the individual's ability to cope
Coping (psychology)
Coping has been defined in psychological terms by Susan Folkman and Richard Lazarus as "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing" or "exceeding the resources of the person".Coping is thus expending...
. As an effect of psychological trauma
Psychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
, PTSD is less frequent and more enduring than the more commonly seen acute stress response
Acute stress reaction
Acute stress reaction is a psychological condition arising in response to a terrifying or traumatic event...
. Diagnostic symptoms for PTSD include re-experiencing the original trauma(s) through flashbacks or nightmare
Nightmare
A nightmare is an unpleasant dream that can cause a strong negative emotional response from the mind, typically fear or horror, but also despair, anxiety and great sadness. The dream may contain situations of danger, discomfort, psychological or physical terror...
s, avoidance of stimuli associated with the trauma, and increased arousal
Arousal
Arousal is a physiological and psychological state of being awake or reactive to stimuli. It involves the activation of the reticular activating system in the brain stem, the autonomic nervous system and the endocrine system, leading to increased heart rate and blood pressure and a condition of...
– such as difficulty falling or staying asleep, anger
Anger
Anger is an automatic response to ill treatment. It is the way a person indicates he or she will not tolerate certain types of behaviour. It is a feedback mechanism in which an unpleasant stimulus is met with an unpleasant response....
, and hypervigilance
Hypervigilance
Hypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Other symptoms include: abnormally increased arousal, a...
. Formal diagnostic criteria (both DSM-IV-TR and ICD-10) require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.
Classification
Posttraumatic stress disorder is classified as an anxiety disorderAnxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...
, characterized by aversive anxiety-related experiences, behaviors, and physiological responses that develop after exposure to a psychologically traumatic event (sometimes months after). Its features persist for longer than 30 days, which distinguishes it from the briefer acute stress disorder. These persisting posttraumatic stress symptoms cause significant disruptions of one or more important areas of life function. It has three sub-forms: acute, chronic, and delayed-onset.
Psychological trauma
PTSD is believed to be caused by either physical traumaPhysical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
or psychological trauma
Psychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
, or more frequently a combination of both. According to Atkinson et al. (2000) PTSD is more likely to be caused by physical or psychological trauma caused by humans — such as rape, war, or terrorist attack — than by trauma caused by natural disasters. Possible sources of trauma include experiencing or witnessing childhood or adult physical
Physical abuse
Physical abuse is abuse involving contact intended to cause feelings of intimidation, injury, or other physical suffering or bodily harm.-Forms of physical abuse:*Striking*Punching*Belting*Pushing, pulling*Slapping*Whipping*Striking with an object...
, emotional or sexual abuse
Sexual abuse
Sexual abuse, also referred to as molestation, is the forcing of undesired sexual behavior by one person upon another. When that force is immediate, of short duration, or infrequent, it is called sexual assault. The offender is referred to as a sexual abuser or molester...
. In addition, experiencing or witnessing an event perceived as life-threatening such as physical assault
Assault
In law, assault is a crime causing a victim to fear violence. The term is often confused with battery, which involves physical contact. The specific meaning of assault varies between countries, but can refer to an act that causes another to apprehend immediate and personal violence, or in the more...
, adult experiences of sexual assault
Sexual assault
Sexual assault is an assault of a sexual nature on another person, or any sexual act committed without consent. Although sexual assaults most frequently are by a man on a woman, it may involve any combination of two or more men, women and children....
, accidents, drug addiction, illnesses, medical complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
, or employment in occupations exposed to war (such as soldiers) or disaster (such as emergency service
Emergency service
Emergency services are organizations which ensure public safety and health by addressing different emergencies. Some agencies exist solely for addressing certain types of emergencies whilst others deal with ad hoc emergencies as part of their normal responsibilities...
workers).
Traumatic events that may cause PTSD symptoms to develop include violent assault, kidnapping, sexual assault, torture, being a hostage, prisoner of war or concentration camp victim, experiencing a disaster, violent automobile accidents or getting a diagnosis of a life-threatening illness. Children or adults may develop PTSD symptoms by experiencing bullying or mobbing
Mobbing
Mobbing in the context of human beings either means bullying of an individual by a group in any context. Identified as emotional abuse in the workplace, such as "ganging up" by co-workers, subordinates or superiors, to force someone out of the workplace through rumor, innuendo, intimidation,...
. Approximately 25% of children exposed to family violence can experience PTSD. Preliminary research suggests that child abuse may interact with mutations in a stress-related gene to increase the risk of PTSD in adults.
Multiple studies show that parental PTSD and other posttraumatic disturbances in parental psychological functioning can, despite a traumatized parent's best efforts, interfere with their response to their child as well as their child's response to trauma. Parents with violence-related PTSD may, for example, inadvertently expose their children to developmentally inappropriate violent media due to their need to manage their own emotional dysregulation. Clinical findings indicate that a failure to provide adequate treatment to children after they suffer a traumatic experience, depending on their vulnerability and the severity of the trauma, will ultimately lead to PTSD symptoms in adulthood.
Evolutionary psychology
Evolutionary psychologyEvolutionary psychology
Evolutionary psychology is an approach in the social and natural sciences that examines psychological traits such as memory, perception, and language from a modern evolutionary perspective. It seeks to identify which human psychological traits are evolved adaptations, that is, the functional...
views different types of fears and reactions caused by fears as adaptation
Adaptation
An adaptation in biology is a trait with a current functional role in the life history of an organism that is maintained and evolved by means of natural selection. An adaptation refers to both the current state of being adapted and to the dynamic evolutionary process that leads to the adaptation....
s that may have been useful in the ancestral environment in order to avoid or cope with various threats. Mammal
Mammal
Mammals are members of a class of air-breathing vertebrate animals characterised by the possession of endothermy, hair, three middle ear bones, and mammary glands functional in mothers with young...
s generally display several defensive behaviors roughly dependent on how close the threat is: avoidance, vigilant immobility, withdrawal, aggressive defense, appeasement, and finally complete frozen immobility (the last possibly to confuse a predator's attack reflex or to simulate a dead and contaminated body). PTSD may correspond to and be caused by overactivation of such fear circuits. Thus, PTSD avoidance behaviors may correspond to mammal avoidance of and withdrawal from threats. Heightened memory of past threats may increase avoidance of similar situations in the future as well as be a prerequisite for analyzing the past threat and develop better defensive behaviors if the threat should reoccur. PTSD hyperarousal may correspond to vigilant immobility and aggressive defense. Complex post-traumatic stress disorder
Complex post-traumatic stress disorder
Complex post-traumatic stress disorder is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma with lack or loss of control, disempowerment, and in the context of either captivity or entrapment, i.e. the lack of a viable escape route for the...
(and phenomena such as the Stockholm syndrome
Stockholm syndrome
In psychology, Stockholm Syndrome is an apparently paradoxical psychological phenomenon wherein hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them...
) may in part correspond to the appeasement stage and possibly the frozen immobility stage.
There may be evolutionary explanations for differences in resilience to traumatic events. Thus, PTSD is rare following traumatic fire which may be explained by events such as forest fires long being part of the evolutionary history of mammals. On the other hand, PTSD is much more common following modern warfare, which may be explained by modern warfare being a new development and very unlike the quick inter-group raids that are argued to have characterized the paleolithic
Paleolithic
The Paleolithic Age, Era or Period, is a prehistoric period of human history distinguished by the development of the most primitive stone tools discovered , and covers roughly 99% of human technological prehistory...
.
Neuroendocrinology
PTSD symptoms may result when a traumatic event causes an over-reactive adrenaline response, which creates deep neurological patterns in the brain. These patterns can persist long after the event that triggered the fear, making an individual hyper-responsive to future fearful situations.PTSD displays biochemical
Biochemistry
Biochemistry, sometimes called biological chemistry, is the study of chemical processes in living organisms, including, but not limited to, living matter. Biochemistry governs all living organisms and living processes...
changes in the brain and body that differ from other psychiatric disorders such as major depression. Individuals diagnosed with PTSD respond more strongly to a dexamethasone suppression test
Dexamethasone suppression test
The dexamethasone suppression test is designed to diagnose and differentiate among the various types of Cushing's syndrome and other hypercortisol states.It has also been used in the research of depression.-Physiology:...
than individuals diagnosed with clinical depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
.
In addition, most people with PTSD also show a low secretion of cortisol
Cortisol
Cortisol is a steroid hormone, more specifically a glucocorticoid, produced by the adrenal gland. It is released in response to stress and a low level of blood glucocorticoids. Its primary functions are to increase blood sugar through gluconeogenesis; suppress the immune system; and aid in fat,...
and high secretion of catecholamine
Catecholamine
Catecholamines are molecules that have a catechol nucleus consisting of benzene with two hydroxyl side groups and a side-chain amine. They include dopamine, as well as the "fight-or-flight" hormones adrenaline and noradrenaline released by the adrenal medulla of the adrenal glands in response to...
s in urine
Urine
Urine is a typically sterile liquid by-product of the body that is secreted by the kidneys through a process called urination and excreted through the urethra. Cellular metabolism generates numerous by-products, many rich in nitrogen, that require elimination from the bloodstream...
, with a norepinephrine
Norepinephrine
Norepinephrine is the US name for noradrenaline , a catecholamine with multiple roles including as a hormone and a neurotransmitter...
/cortisol ratio consequently higher than comparable non-diagnosed individuals. This is in contrast to the normative fight-or-flight response
Fight-or-flight response
The fight-or-flight response was first described by Walter Bradford Cannon....
, in which both catecholamine
Catecholamine
Catecholamines are molecules that have a catechol nucleus consisting of benzene with two hydroxyl side groups and a side-chain amine. They include dopamine, as well as the "fight-or-flight" hormones adrenaline and noradrenaline released by the adrenal medulla of the adrenal glands in response to...
and cortisol levels are elevated after exposure to a stressor.
Brain catecholamine
Catecholamine
Catecholamines are molecules that have a catechol nucleus consisting of benzene with two hydroxyl side groups and a side-chain amine. They include dopamine, as well as the "fight-or-flight" hormones adrenaline and noradrenaline released by the adrenal medulla of the adrenal glands in response to...
levels are high, and corticotropin-releasing factor (CRF) concentrations are high. Together, these findings suggest abnormality in the hypothalamic-pituitary-adrenal (HPA) axis
Hypothalamic-pituitary-adrenal axis
The hypothalamic-pituitary-adrenal axis , also known as thelimbic-hypothalamic-pituitary-adrenal axis and, occasionally, as the hypothalamic-pituitary-adrenal-gonadotropic axis, is a complex set of direct influences and feedback interactions among the hypothalamus, the pituitary gland ,...
.
Given the strong cortisol suppression to dexamethasone
Dexamethasone
Dexamethasone is a potent synthetic member of the glucocorticoid class of steroid drugs. It acts as an anti-inflammatory and immunosuppressant...
in PTSD, HPA axis abnormalities are likely predicated on strong negative feedback inhibition of cortisol, itself likely due to an increased sensitivity of glucocorticoid receptor
Glucocorticoid receptor
The glucocorticoid receptor also known as NR3C1 is the receptor to which cortisol and other glucocorticoids bind....
s. Some researchers have associated the response to stress in PTSD with long-term exposure to high levels of norepinephrine
Norepinephrine
Norepinephrine is the US name for noradrenaline , a catecholamine with multiple roles including as a hormone and a neurotransmitter...
and low levels of cortisol, a pattern associated with improved learning
Learning
Learning is acquiring new or modifying existing knowledge, behaviors, skills, values, or preferences and may involve synthesizing different types of information. The ability to learn is possessed by humans, animals and some machines. Progress over time tends to follow learning curves.Human learning...
in animals.
Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response through a hypersensitive, hyperreactive and hyperresponsive HPA axis.
Low cortisol
Cortisol
Cortisol is a steroid hormone, more specifically a glucocorticoid, produced by the adrenal gland. It is released in response to stress and a low level of blood glucocorticoids. Its primary functions are to increase blood sugar through gluconeogenesis; suppress the immune system; and aid in fat,...
levels may predispose individuals to PTSD: Following war trauma, Swedish
Sweden
Sweden , officially the Kingdom of Sweden , is a Nordic country on the Scandinavian Peninsula in Northern Europe. Sweden borders with Norway and Finland and is connected to Denmark by a bridge-tunnel across the Öresund....
soldiers serving in Bosnia and Herzegovina
Bosnia and Herzegovina
Bosnia and Herzegovina , sometimes called Bosnia-Herzegovina or simply Bosnia, is a country in Southern Europe, on the Balkan Peninsula. Bordered by Croatia to the north, west and south, Serbia to the east, and Montenegro to the southeast, Bosnia and Herzegovina is almost landlocked, except for the...
with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels. Because cortisol is normally important in restoring homeostasis
Homeostasis
Homeostasis is the property of a system that regulates its internal environment and tends to maintain a stable, constant condition of properties like temperature or pH...
after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD.
However, there is considerable controversy within the medical community regarding the neurobiology of PTSD. A review of existing studies on this subject showed no clear relationship between cortisol levels and PTSD. Only a slight majority have found a decrease in cortisol levels while others have found no effect or even an increase.
Neuroanatomy
Three areas of the brain whose function may be altered in PTSD have been identified: the prefrontal cortexPrefrontal cortex
The prefrontal cortex is the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas.This brain region has been implicated in planning complex cognitive behaviors, personality expression, decision making and moderating correct social behavior...
, amygdala
Amygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...
and hippocampus
Hippocampus
The hippocampus is a major component of the brains of humans and other vertebrates. It belongs to the limbic system and plays important roles in the consolidation of information from short-term memory to long-term memory and spatial navigation. Humans and other mammals have two hippocampi, one in...
. Much of this research has utilised PTSD victims from the Vietnam War. For example, a prospective study using the Vietnam Head Injury Study showed that damage to the prefrontal cortex may actually be protective against later development of PTSD. In a study by Gurvits et al., combat veterans of the Vietnam War
Vietnam War
The Vietnam War was a Cold War-era military conflict that occurred in Vietnam, Laos, and Cambodia from 1 November 1955 to the fall of Saigon on 30 April 1975. This war followed the First Indochina War and was fought between North Vietnam, supported by its communist allies, and the government of...
with PTSD showed a 20% reduction in the volume of their hippocampus
Hippocampus
The hippocampus is a major component of the brains of humans and other vertebrates. It belongs to the limbic system and plays important roles in the consolidation of information from short-term memory to long-term memory and spatial navigation. Humans and other mammals have two hippocampi, one in...
compared with veterans who suffered no such symptoms. This finding could not be replicated in chronic PTSD patients traumatized at an air show plane crash in 1988 (Ramstein, Germany).
In human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. Neuroimaging
Neuroimaging
Neuroimaging includes the use of various techniques to either directly or indirectly image the structure, function/pharmacology of the brain...
studies in humans have revealed both morphological and functional aspects of PTSD.
The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex
Prefrontal cortex
The prefrontal cortex is the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas.This brain region has been implicated in planning complex cognitive behaviors, personality expression, decision making and moderating correct social behavior...
and the hippocampus
Hippocampus
The hippocampus is a major component of the brains of humans and other vertebrates. It belongs to the limbic system and plays important roles in the consolidation of information from short-term memory to long-term memory and spatial navigation. Humans and other mammals have two hippocampi, one in...
particularly during extinction. This is consistent with an interpretation of PTSD as a syndrome of deficient extinction
Extinction (psychology)
Extinction is the conditioning phenomenon in which a previously learned response to a cue is reduced when the cue is presented in the absence of the previously paired aversive or appetitive stimulus.-Fear conditioning:...
ability. A study at the European Neuroscience Institute-Goettingen (Germany) found that fear extinction-induced IGF2/IGFBP7
IGFBP7
Insulin-like growth factor-binding protein 7 is a protein that in humans is encoded by the IGFBP7 gene. The major function of the protein is the regulation of availability of insulin-like growth factors in tissue as well as in modulating IGF binding to its receptors. IGFBP7 binds to IGF with high...
signalling promotes the survival of 17–19-day-old newborn hippocampal neurons. This suggests that therapeutic strategies that enhance IGF2 signalling and adult neurogenesis
Neurogenesis
Neurogenesis is the process by which neurons are generated from neural stem and progenitor cells. Most active during pre-natal development, neurogenesis is responsible for populating the growing brain with neurons. Recently neurogenesis was shown to continue in several small parts of the brain of...
might be suitable to treat diseases linked to excessive fear memory such as PTSD. Further animal and clinical research into the amygdala and fear conditioning
Fear conditioning
Fear conditioning is a behavioral paradigm in which organisms learn to predict aversive events. It is a form of learning in which an aversive stimulus is associated with a particular neutral context or neutral stimulus , resulting in the expression of fear responses to the originally neutral...
may suggest additional treatments for the condition.
Genetics
There is evidence that susceptibility to PTSD is hereditary. For twin pairs exposed to combat in Vietnam, having a monozygotic (identical) twin with PTSD was associated with an increased risk of the co-twin having PTSD compared to twins that were dizygotic (non-identical twins).Recently, it has been found that several single-nucleotide polymorphisms (SNPs) in FK506 binding protein 5
FKBP5
FK506 binding protein 5, also known as FKBP5, is a protein which in humans is encoded by the FKBP5 gene.- Function :The protein encoded by this gene is a member of the immunophilin protein family, which play a role in immunoregulation and basic cellular processes involving protein folding and...
(FKBP5) interact with childhood trauma to predict severity of adult PTSD. These findings suggest that individuals with these SNPs who are abused as children are more susceptible to PTSD as adults.
This is particularly interesting given that FKBP5 SNPs have previously been associated with peritraumatic dissociation (that is, dissociation at the time of the trauma), which has itself been shown to be predictive of PTSD. Furthermore, FKBP5 may be less expressed
Gene expression
Gene expression is the process by which information from a gene is used in the synthesis of a functional gene product. These products are often proteins, but in non-protein coding genes such as ribosomal RNA , transfer RNA or small nuclear RNA genes, the product is a functional RNA...
in those with current PTSD. Another recent study found a single SNP in a putative estrogen response element on ADCYAP1R1
ADCYAP1R1
Pituitary adenylate cyclase-activating polypeptide type I receptor also known as PAC1, is a protein that in humans is encoded by the ADCYAP1R1 gene. This receptor binds pituitary adenylate cyclase activating peptide....
(encodes pituitary adenylate cyclase-activating polypeptide type I receptor or PAC1) to predict PTSD diagnosis and symptoms in females. Incidentally, this SNP is also associated with fear discrimination. The study suggests that perturbations in the PACAP-PAC1 pathway are involved in abnormal stress responses underlying PTSD.
Risk factors
Although most people (50-90%) encounter trauma over a lifetime, only about 8% develop full PTSD. Vulnerability to PTSD presumably stems from an interaction of biological diathesis, early childhood developmental experiences, and trauma severity.Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood. This effect of childhood trauma, which is not well understood, may be a marker for both traumatic experiences and attachment problems. Proximity to, duration of, and severity of the trauma also make an impact; and interpersonal traumas cause more problems than impersonal ones.
Military experience
Schnurr, Lunney, and Sengupta identified risk factors for the development of PTSD in Vietnam veteranVietnam veteran
Vietnam veteran is a phrase used to describe someone who served in the armed forces of participating countries during the Vietnam War.The term has been used to describe veterans who were in the armed forces of South Vietnam, the United States armed forces, and countries allied to them, whether or...
s. Among those are:
- Hispanic ethnicity, coming from an unstable family, being punished severely during childhood, childhood asocial behavior and depression as pre-military factors
- War-zone exposure, peritraumatic dissociation, depression as military factors
- Recent stressful life events, post-VietnamVietnam WarThe Vietnam War was a Cold War-era military conflict that occurred in Vietnam, Laos, and Cambodia from 1 November 1955 to the fall of Saigon on 30 April 1975. This war followed the First Indochina War and was fought between North Vietnam, supported by its communist allies, and the government of...
trauma and depression as post-military factors
They also identified certain protective factors, such as:
- Japanese-American ethnicity, high school degree or college education, older age at entry to war, higher socioeconomic status and a more positive paternal relationship as pre-military protective factors
- Social support at homecoming and current social support as post-military factors. Other research also indicates the protective effects of social support in averting PTSD or facilitating recovery if it develops.
There may also be an attitudinal component; for example, a soldier who believes that they will not sustain injuries may be more likely to develop symptoms of PTSD than one who anticipates the possibility, should either be wounded. Likewise, the later incidence of suicide among those injured in home fires above those injured in fires in the workplace suggests this possibility.
Foster care
In the Casey Family Northwest Alumni Study, conducted in conjunction with researchers from the Harvard Medical SchoolHarvard Medical School
Harvard Medical School is the graduate medical school of Harvard University. It is located in the Longwood Medical Area of the Mission Hill neighborhood of Boston, Massachusetts....
in Oregon and Washington state, the rate of PTSD in adults who were in foster care
Foster care
Foster care is the term used for a system in which a minor who has been made a ward is placed in the private home of a state certified caregiver referred to as a "foster parent"....
for one year between the ages of 14-18 was found to be higher than that of combat veterans. Up to 25 percent of those in the study meet the diagnostic criteria for PTSD as compared to 12-13 percent of Iraq war veterans and 15 percent of Vietnam War veterans, and a rate of 4 percent in the general population. The recovery rate for foster home alumni was 28.2% as opposed to 47% in the general population.
Dubner and Motta (1999) found that 60% of children in foster care who had experienced sexual abuse had PTSD, and 42% of those who had been physically abused met the PTSD criteria. PTSD was also found in 18% of the children who were not abused. These children may have developed PTSD due to witnessing violence in the home, or as a result of real or perceived parental abandonment.
Criteria
The diagnostic criteria for PTSD, stipulated in the Diagnostic and Statistical Manual of Mental DisordersDiagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
IV (Text Revision) (DSM-IV-TR), may be summarized as:
A: Exposure to a traumatic event
This must have involved both (a) loss of "physical integrity", or risk of serious injury or death, to self or others, and (b) a response to the event that involved intense fear, horror or helplessness (or in children, the response must involve disorganized or agitated behavior). (The DSM-IV-TR criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience.")B: Persistent re-experiencing
One or more of these must be present in the victim: flashbackFlashback (psychological phenomenon)
A flashback, or involuntary recurrent memory, is a psychological phenomenon in which an individual has a sudden, usually powerful, re-experiencing of a past experience or elements of a past experience. These experiences can be happy, sad, exciting, or any other emotion one can consider...
memories, recurring distressing dreams, subjective re-experiencing of the traumatic event(s), or intense negative psychological or physiological response to any objective or subjective reminder of the traumatic event(s).
C: Persistent avoidance and emotional numbing
This involves a sufficient level of:- avoidance of stimuli associated with the trauma, such as certain thoughts or feelings, or talking about the event(s);
- avoidance of behaviors, places, or people that might lead to distressing memories;
- inability to recall major parts of the trauma(s), or decreased involvement in significant life activities;
- decreased capacity (down to complete inability) to feel certain feelings;
- an expectation that one's future will be somehow constrained in ways not normal to other people.
D: Persistent symptoms of increased arousal not present before
These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or hypervigilanceHypervigilance
Hypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Other symptoms include: abnormally increased arousal, a...
.
E: Duration of symptoms for more than 1 month
If all other criteria are present, but 30 days have not elapsed, the individual is diagnosed with Acute stress disorder.F: Significant impairment
The symptoms reported must lead to "clinically significant distress or impairment" of major domains of life activity, such as social relations, occupational activities, or other "important areas of functioning".Assessment
Since the introduction of DSM-IV, the number of possible events which might be used to diagnose PTSD has increased; one study suggests that the increase is around 50%. Various scales exist to measure the severity and frequency of PTSD symptoms. Standardized screening tools such as Trauma Screening QuestionnaireTrauma Screening Questionnaire
Trauma Screening Questionnaire abbreviated as is a questionnaire developed for screening of posttraumatic stress disorder. The TSQ was adapted from the PTSD Symptom Scale – Self-Report Version . This self-reported assessment scale consists of 10 items, which cover one of the main signs of PTSD....
and PTSD Symptom Scale
PTSD Symptom Scale – Self-Report Version
PTSD Symptom Scale – Self-Report Version is a 17-item self-reported questionnaire to assess symptoms of posttraumatic stress disorder. Each of the 17 items describe PTSD symptoms which respondents rate in terms of their frequency or severity using a Likert-type scale ranging from 0 to 3...
can be used to detect possible symptoms of posttraumatic stress disorder, and suggest the need for a formal diagnostic assessment.
Research-based alternative symptom groups
Emerging factor analyticFactor analysis
Factor analysis is a statistical method used to describe variability among observed, correlated variables in terms of a potentially lower number of unobserved, uncorrelated variables called factors. In other words, it is possible, for example, that variations in three or four observed variables...
research suggests that PTSD symptoms group empirically into four clusters, not the three currently described in the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
. One model supported by this research divides the traditional avoidance symptoms into a cluster of numbing symptoms (such as loss of interest and feeling emotionally numb) and a cluster of behavioral avoidance symptoms (such as avoiding reminders of the trauma). An alternative model adds a fourth cluster of dysphoric symptoms. These include symptoms of emotional numbing, as well as anger, sleep disturbance, and difficulty concentrating (traditionally grouped under the hyperarousal cluster). A literature review and meta-analysis did not find strong support across the literature for one of these models over the other.
DSM-5 proposed diagnostic criteria changes
In preparation for the May 2013release of the DSM-5
DSM-5
The next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , commonly called DSM-5 , is currently in consultation, planning and preparation...
, the fifth version of the American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
's diagnostic manual, draft diagnostic criteria was released for public comment, followed by a two-year period of field testing. Proposed changes to the criteria (subject to ongoing review and research) include the following :
- Criterion A (prior exposure to traumatic events) is more specifically stated, and evaluation of an individual's emotional response at the time (current criterion A2) is dropped.
- Several items in Criterion B (intrusion symptoms) are rewritten to add or augment certain distinctions now considered important.
- Special consideration is given to developmentally appropriate criteria for use with children and adolescents. This is especially evident in the restated Criterion B - intrusion symptoms. Development of age-specific criteria for diagnosis of PTSD is ongoing at this time.
- Criterion C (avoidance and numbing) has been split into "C" and "D":
- Criterion C (new version) now focuses solely on avoidance of behaviors or physical or temporal reminders of the traumatic experience(s). What were formerly two symptoms are now three, due to slight changes in descriptions.
- New Criterion D focuses on negative alterations in cognition and mood associated with the traumatic event(s), and contains two new symptoms, one expanded symptom, and four largely unchanged symptoms specified in the previous criteria.
- Criterion E (formerly "D"), which focuses on increased arousal and reactivity, contains one modestly revised, one entirely new, and four unchanged symptoms.
- Criterion F (formerly "E") still requires duration of symptoms to have been at least one month.
- Criterion G (formerly "F") stipulates symptom impact ("disturbance") in the same way as before.
- The "acute" vs "delayed" distinction is dropped; the "delayed" specifier is considered appropriate if clinical symptom onset is no sooner than 6 months after the traumatic event(s).
"Developmental trauma disorder", a proposed new diagnosis, was still under discussion at the time of the draft publication.
Public policy response
In recent history, catastrophes (by human means or not) such as the 2004 Indian Ocean tsunami2004 Indian Ocean earthquake
The 2004 Indian Ocean earthquake was an undersea megathrust earthquake that occurred at 00:58:53 UTC on Sunday, December 26, 2004, with an epicentre off the west coast of Sumatra, Indonesia. The quake itself is known by the scientific community as the Sumatra-Andaman earthquake...
may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as the Red Cross
International Red Cross and Red Crescent Movement
The International Red Cross and Red Crescent Movement is an international humanitarian movement with approximately 97 million volunteers, members and staff worldwide which was founded to protect human life and health, to ensure respect for all human beings, and to prevent and alleviate human...
and the Salvation Army
Salvation Army
The Salvation Army is a Protestant Christian church known for its thrift stores and charity work. It is an international movement that currently works in over a hundred countries....
provide counseling after major disasters as part of their standard procedures to curb severe cases of posttraumatic stress disorder.
United States - veterans
A review of the provision of compensation to veterans for PTSD by the United States Department of Veterans AffairsUnited States Department of Veterans Affairs
The United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense...
began in 2005 after the VA had noted a 30% increase in PTSD claims in recent years. In 2005 the suicide rate among male Veteran VA users was 37.19 per 100,000, compared to 13.59 in females. This led to a backlash from veterans'-rights groups, and to some highly publicized suicides by veterans who feared losing their benefits, which in some cases constituted their only income. In response, on November 10, 2005, the Secretary of Veterans Affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for posttraumatic stress disorder..."
The diagnosis of PTSD in U.S. military veterans has been a subject of some controversy due to uncertainties in objectively diagnosing PTSD in those who may have been exposed to trauma
Psychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
, and due to this diagnosis' association with some incidence
Incidence (epidemiology)
Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...
of compensation-seeking behavior.
Many veterans of the wars in Iraq and Afghanistan
War in Afghanistan (2001–present)
The War in Afghanistan began on October 7, 2001, as the armed forces of the United States of America, the United Kingdom, Australia, and the Afghan United Front launched Operation Enduring Freedom...
returning home have faced significant physical, emotional and relational disruptions. In response, the United States Marine Corps
United States Marine Corps
The United States Marine Corps is a branch of the United States Armed Forces responsible for providing power projection from the sea, using the mobility of the United States Navy to deliver combined-arms task forces rapidly. It is one of seven uniformed services of the United States...
has instituted programs to assist them in re-adjusting to civilian life, especially in their relationships with spouses and loved ones, to help them communicate better and understand what the other has gone through. Walter Reed Army Institute of Research
Walter Reed Army Institute of Research
This article is about the U.S. Army medical research institute . Otherwise, see Walter Reed .The Walter Reed Army Institute of Research is the largest biomedical research facility administered by the U.S. Department of Defense...
(WRAIR) developed the Battlemind
Battlemind
Battlemind is both the mental orientation developed during a combat zone deployment and a program developed at Walter Reed Army Institute of Research intended to reduce its impact on personal post-deployment issues.-Mental orientation:...
program to assist service members avoid or ameliorate PTSD and related problems.
Other countries - veterans
In the UK, there has been some controversy that National Health Service is dumping veterans on service charities like Combat StressCombat Stress
Combat Stress is a UK charity offering residential treatment to ex-servicemen and women suffering from Post Traumatic Stress Disorder and other mental health issues....
.
Veterans Affairs Canada
Veterans Affairs Canada
The Department of Veterans Affairs , also referred to as Veterans Affairs Canada , is the department within the government of Canada with responsibility for pensions/benefits and services for war veterans, retired personnel of the Canadian Forces and Royal Canadian Mounted Police, their families,...
offers a new program that includes rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support.
Prevention and early intervention strategies
Modest benefits have been seen from early access to cognitive behavioral therapy, as well as from some medications such as propranolol. Critical incident stress managementCritical Incident Stress Management
Critical incident stress management is an adaptive short term helping process that focuses solely on an immediate and identifiable problem. It spans pre-incident preparedness to acute crisis to post-crisis follow up. Its stated purpose is to enable people to return to their daily routine more...
has been suggested as a means of preventing PTSD but subsequent studies suggest the likelihood of its producing iatrogenic
Iatrogenesis
Iatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...
outcomes. A review of multiple studies confirmed the finding of no benefit to trauma survivors from single-session early-response interventions, as well as a failure of blanket multiple-session prevention interventions to yield a benefit to all participants (some were even harmed).
Early detection
The ability to prescreen individuals would be of great help in getting treatment to those who are at risk of PTSD prior to development of the syndrome. Several biological indicators have been identified that are related to later PTSD development. First, Delhanty found that higher response times and a smaller hippocampalHippocampus
The hippocampus is a major component of the brains of humans and other vertebrates. It belongs to the limbic system and plays important roles in the consolidation of information from short-term memory to long-term memory and spatial navigation. Humans and other mammals have two hippocampi, one in...
volume were identified as linked to later PTSD development. However, both of these indicators are relatively difficult to test for and need specialized tests and or equipment to identify. A blood biomarker is much easier to test for. Van Zuiden et al. found just such a biomarker when testing U.S. Army soldiers prior to deployment. They found that soldiers with more glucocorticoid receptors (GR) were more likely to be diagnosed with PTSD six months after deployment. However, higher GR levels have not been identified as a cause of PTSD, and may instead be an intermediator, or even an indicator that the individual has previously experienced traumatic events. There is a great deal of overlap between high GR levels and those who later are diagnosed with and without PTSD. Thus, the identification of high GR is simply a vulnerability indicator at this time.
Delhanty found that biological precursors existed directly following traumatic exposure in those who later developed chronic PTSD and were significantly different from those who did not. Directly following the traumatic event later sufferers often have significantly lower levels of hypothalamic
Hypothalamus
The Hypothalamus is a portion of the brain that contains a number of small nuclei with a variety of functions...
pituitary-adrenal activity and a corresponding decrease in Cortisol.
Other methods of early detection include the identification of specific risk factors associated with later PTSD symptoms. Resnick, Acierno, Holmes, Kilpatrick, and Jager for example were able to identify that the forensic exam given to victims after a rape was associated with PTSD.
Finally, global treatments attempt to avoid the problems of early detection by simply treating everyone involved. However, many studies have found this to be often ineffective and for global treatments to at times increase prevalence rates of PTSD.
Psychological debriefing
The first form of preventive treatment is that of a psychological debriefing. Psychological debriefing is the most often used preventive measure. One of the main reasons for this is the relative ease with which this treatment can be given to individuals directly following an event. It consists of interviews that are meant to allow individuals to directly confront the event and share their feelings with the counselor and to help structure their memories of the event.
However, while this form of therapy is the most often used it is actually the least effective. Studies have had mixed findings concerning psychological debriefings and have ranged from being of significant help to helping in the formation of PTSD in individuals who would otherwise have not developed PTSD. The greater number of studies tends to simply find that it is neither overly beneficial nor harmful.
Risk Targeted Interventions
Risk targeted interventions are those that attempt to mitigate specific formative information or events. It can target modeling normal behaviors, instruction on a task or giving information on the event. For example, rape victims were given an instruction video on the procedures for a forensic exam. Also included in the video was advice on how to identify and stop avoidance behavior and control anxiety. Finally, the individuals modeling the forensic exam were shown to be calm and relaxed. PTSD diagnosis for those who saw the video were thirty three percent less than for those who went through the standard forensic procedure.
Psychobiological Treatments
Psychobiological treatments have also found success, especially with cortisol. Psychobiological treatments target biological changes that occur after a traumatic event. They also attempt to chemically alter learning or memory formation. Cortisol treatments after a traumatic event have found success in mitigating later diagnosis of PTSD. As discussed earlier Cortisol is often lower in individuals who are at risk of PTSD after a traumatic event than their counterparts. By increasing cortisol levels to normal levels this has been shown to reduce arousal post event as well prevent GR upregulation.
Stepped Collaborative Care
Stepped collaborative care is where individuals who are at risk are monitored for symptoms. As symptoms of PTSD appear the level of care is increased to treat those symptoms.
Psychotherapeutic interventions
Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling practices common to many treatment responses for PTSD include education about the condition and provision of safety and support.The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral programs, variants of exposure therapy
Exposure therapy
Exposure therapy is a technique in behavior therapy intended to treat anxiety disorders and involves the exposure to the feared object or context without any danger in order to overcome their anxiety. Procedurally it is similar to the fear extinction paradigm in rodent work...
, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing
Eye Movement Desensitization and Reprocessing
Eye Movement Desensitization and Reprocessing is a form of psychotherapy that was developed by Francine Shapiro to resolve the development of trauma-related disorders caused by exposure to distressing events such as rape or military combat...
(EMDR), and many combinations of these procedures. A 2010 review disagrees that these treatments have proven efficacy, and points out methodological flaws in the studies and previous meta-analyses.
EMDR or trauma-focused cognitive behavioral therapy (TFCBT) was recommended as first-line treatments for trauma victims in a 2007 review; however, "the evidence base [for EMDR] was not as strong as that for TFCBT ... Furthermore, there was limited evidence that TFCBT and EMDR were superior to supportive/non-directive treatments, hence it is highly unlikely that their effectiveness is due to non-specific factors such as attention." A meta-analytic
Meta-analysis
In statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. In its simplest form, this is normally by identification of a common measure of effect size, for which a weighted average might be the output of a meta-analyses. Here the...
comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in terms of effectiveness in treating PTSD; however "the contribution of the eye movement component in EMDR to treatment outcome" is unclear.
Behavioral and Cognitive Behavioral therapy
Cognitive behavioral therapy (CBT) seeks to change the way a trauma victim feels and acts by changing the patterns of thinking and/or behavior responsible for negative emotions. CBT have been proven to be an effective treatment for PTSD, and is currently considered the standard of care for PTSD by the United States Department of DefenseUnited States Department of Defense
The United States Department of Defense is the U.S...
In CBT, individuals learn to identify thoughts that make them feel afraid or upset, and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.
Recent research on contextually based third-generation behavior therapies suggests that they may produce results comparable to some of the better validated therapies. Many of these therapy methods have a significant element of exposure, and have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms.
Exposure therapy is a type of cognitive behavioral therapy that involves assisting trauma survivors to re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders; this therapy modality is well supported by clinical evidence. Indeed, the success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD. Some organizations have endorsed the need for exposure. The US Department of Veterans Affairs has been actively training mental health treatment staff in prolonged exposure therapy
Prolonged exposure therapy
Prolonged exposure therapy is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder, characterized by re-experiencing the traumatic event through remembering it and engaging with, rather than avoiding, reminders of the trauma...
and Cognitive Processing Therapy
Cognitive Processing Therapy
Cognitive processing therapy is an adaptation of the evidence-based therapy known as cognitive behavioral therapy used by clinicians to help consumers explore recovery from posttraumatic stress disorder and related conditions....
in an effort to better treat US Veterans with PTSD.
Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessingEye Movement Desensitization and Reprocessing
Eye Movement Desensitization and Reprocessing is a form of psychotherapy that was developed by Francine Shapiro to resolve the development of trauma-related disorders caused by exposure to distressing events such as rape or military combat...
(EMDR) is specifically targeted as a treatment for PTSD. Based on the evidence of controlled research, the American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
and the United States Department of Veterans Affairs and Department of Defense have placed EMDR in the highest category of effectiveness and research support in the treatment of trauma. Several international bodies have made similar recommendations. However, some reviewers no longer believe that the eye movements assist in recovery, proposing instead that the review of and engagement with memories, processing of cognitions, and rehearsal of coping skills are the psychotherapeutically effective components of the procedure.
Interpersonal psychotherapy
Other approaches, particularly involving social supports, may also be important. An open trial of interpersonal psychotherapy reported high rates of remission from PTSD symptoms without using exposure. A current, NIMH-funded trial in New York City is now (and into 2013) comparing interpersonal psychotherapy, prolonged exposure therapyProlonged exposure therapy
Prolonged exposure therapy is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder, characterized by re-experiencing the traumatic event through remembering it and engaging with, rather than avoiding, reminders of the trauma...
, and relaxation therapy.
Medication
A variety of medications has shown adjunctive benefit in reducing PTSD symptoms, but "there is no clear drug treatment for PTSD". Positive symptoms (re-experiencing, hypervigilance, increased arousal) generally respond better to medication than negative symptoms (avoidance, withdrawal), and it is recommended that any drug trial last for at least 6–8 weeks.Symptom management: potentially useful medication classes
SSRIs (selective serotonin reuptake inhibitorSelective serotonin reuptake inhibitor
Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...
s). SSRIs are considered to be a first-line drug treatment. SSRIs for which there are data to support use include: citalopram
Citalopram
Citalopram brand names: Celexa, Cipramil) is an antidepressant drug of the selective serotonin reuptake inhibitor class. It has U.S...
, escitalopram
Escitalopram
Escitalopram is an antidepressant of the selective serotonin reuptake inhibitor class. It is approved by the U.S...
, fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
, fluvoxamine
Fluvoxamine
Fluvoxamine is an antidepressant which functions as a selective serotonin reuptake inhibitor . Fluvoxamine was first approved by the U.S. Food and Drug Administration in 1993 for the treatment of obsessive compulsive disorder . Fluvoxamine CR is approved to treat social anxiety disorder...
, paroxetine
Paroxetine
Paroxetine is an SSRI antidepressant. Marketing of the drug began in 1992 by the pharmaceutical company SmithKline Beecham, now GlaxoSmithKline...
, and sertraline
Sertraline
Sertraline hydrochloride is an antidepressant of the selective serotonin reuptake inhibitor class. It was introduced to the market by Pfizer in 1991. Sertraline is primarily used to treat major depression in adult outpatients as well as obsessive–compulsive, panic, and social anxiety disorders in...
.
Among the anti-depressants described in this section, bupropion and venlafaxine
Venlafaxine
Venlafaxine is an antidepressant of the serotonin-norepinephrine reuptake inhibitor class. First introduced by Wyeth in 1993, now marketed by Pfizer, it is licensed for the treatment of major depressive disorder , as a treatment for generalized anxiety disorder, and comorbid indications in...
have the lowest patient drop-out rates. Sertraline, fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
, and nefazodone
Nefazodone
Nefazodone is an antidepressant marketed by Bristol-Myers Squibb. Its sale was discontinued in 2003 in some countries due to the rare incidence of hepatotoxicity , which could lead to the need for a liver transplant, or even death. The incidence of severe liver damage is approximately 1 in every...
have a modestly higher drop-out rate (~15%), and the heterocyclics and paroxetine have the highest rates (~20%+). Where drop-out is caused or feared because of medication side-effects, it should be remembered that most patients do not experience such side-effects.
Alpha-adrenergic antagonists. Prazosin
Prazosin
Prazosin, trade names Minipress, Vasoflex, Pressin and Hypovase, is a sympatholytic drug used to treat high blood pressure and Anxiety, PTSD and Panic Disorder. It belongs to the class of alpha-adrenergic blockers. Specifically, prazosin is selective for the alpha-1 receptors on vascular smooth...
("Minipress"), in a small study of combat veterans, has shown substantial benefit in relieving or reducing nightmares. Clonidine ("Catapres") can be helpful with startle, hyperarousal, and general autonomic hyperexcitability.
Anti-convulsants, mood stabilizer
Mood stabilizer
A mood stabilizer is a psychiatric medication used to treat mood disorders characterized by intense and sustained mood shifts, typically bipolar disorder.-Uses:...
s, anti-aggression agents. Carbamazepine
Carbamazepine
Carbamazepine is an anticonvulsant and mood-stabilizing drug used primarily in the treatment of epilepsy and bipolar disorder, as well as trigeminal neuralgia...
("Tegretol") has likely benefit in reducing arousal symptoms involving noxious affect, as well as mood or aggression. Topiramate
Topiramate
Topiramate is an anticonvulsant drug. It was originally produced by Ortho-McNeil Neurologics and Noramco, Inc., both divisions of the Johnson & Johnson Corporation. This medication was discovered in 1979 by Bruce E. Maryanoff and Joseph F. Gardocki during their research work at McNeil...
("Topamax") has been effective in achieving major reductions in flashbacks and nightmares, and no reduction of effect was seen over time. Zolpidem
Zolpidem
Zolpidem is a prescription medication used for the short-term treatment of insomnia, as well as some brain disorders. It is a short-acting nonbenzodiazepine hypnotic of the imidazopyridine class that potentiates gamma-aminobutyric acid , an inhibitory neurotransmitter, by binding to GABAA...
("Ambien") has also proven useful in treating sleep disturbances.
Lamotrigine
Lamotrigine
Lamotrigine, marketed in the US and most of Europe as Lamictal by GlaxoSmithKline, is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. It is also used as an adjunct in treating depression, though this is considered off-label usage...
("Lamictal") may be useful in reducing reexperiencing symptoms, as well as avoidance and emotional numbing. Valproic acid
Valproic acid
Valproic acid is a chemical compound that has found clinical use as an anticonvulsant and mood-stabilizing drug, primarily in the treatment of epilepsy, bipolar disorder, and, less commonly, major depression. It is also used to treat migraine headaches and schizophrenia...
("Depakene") and has shown reduction of symptoms of irritability, aggression, and impulsiveness, and in reducing flashbacks. Similarly, lithium carbonate has worked to control mood and aggressions (but not anxiety) symptoms. Buspirone
Buspirone
Buspirone is an anxiolytic psychoactive drug of the azapirone chemical class, and is primarily used to treat generalized anxiety disorder Bristol-Myers Squibb gained FDA approval of buspirone in 1986 for treatment of GAD...
("BuSpar") has an effect similar to that of lithium, with the additional benefit of working to reduce hyperarousal symptoms.
Antipsychotic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
s. Risperidone
Risperidone
Risperidone is a second generation or atypical antipsychotic, sold under the trade name . It is used to treat schizophrenia , schizoaffective disorder, the mixed and manic states associated with bipolar disorder, and irritability in people with autism...
can be used to help with dissociation
Dissociation
Dissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
, mood issues, and aggression.
Atypical antidepressant
Antidepressant
An antidepressant is a psychiatric medication used to alleviate mood disorders, such as major depression and dysthymia and anxiety disorders such as social anxiety disorder. According to Gelder, Mayou &*Geddes people with a depressive illness will experience a therapeutic effect to their mood;...
s. Nefazodone ("Serzone") can be effective with sleep disturbance symptoms, and with secondary depression
Mood disorder
Mood disorder is the term designating a group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders classification system where a disturbance in the person's mood is hypothesized to be the main underlying feature...
, anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
, and sexual dysfunction
Sexual dysfunction
Sexual dysfunction or sexual malfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal or orgasm....
symptoms. Trazodone
Trazodone
Trazodone is an antidepressant of the serotonin antagonist and reuptake inhibitor class. It is a phenylpiperazine compound...
("Desyrel") can also reduce or eliminate problems with disturbed sleep, and with anger and anxiety.
Beta blockers. Propranolol ("Inderal") has demonstrated possibilities in reducing hyperarousal symptoms, including sleep disturbances.
Benzodiazepines. These can be used with caution for short-term anxiety relief, hyperarousal, and sleep disturbance. While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD, or are at all effective in the treatment of posttraumatic stress disorder. Additionally benzodiazepines may reduce the effectiveness of psychotherapeutic interventions and there is some evidence that benzodiazepines may contribute to the development and chronification of PTSD. Other drawbacks include the risk of developing a benzodiazepine dependence
Benzodiazepine dependence
Benzodiazepine dependence or benzodiazepine addiction is a condition during which a person is dependent on benzodiazepine drugs. Dependence can be either a psychological dependence, physical dependence, or a combination of the two...
and withdrawal syndrome
Benzodiazepine withdrawal syndrome
Benzodiazepine withdrawal syndrome—often abbreviated to benzo withdrawal—is the cluster of symptoms which appear when a person who has taken benzodiazepines long term and has developed benzodiazepine dependence stops taking benzodiazepine drug or during dosage reductions...
; additionally individuals with PTSD are at an increased risk of abusing benzodiazepines.
Glucocorticoids. Additionally, post-stress high dose corticosterone
Corticosterone
Corticosterone is a 21-carbon steroid hormone of the corticosteroid type produced in the cortex of the adrenal glands.-Roles:In many species, including amphibians, reptiles, rodents and birds, corticosterone is a main glucocorticoid, involved in regulation of fuel, immune reactions, and stress...
administration was recently found to reduce 'PTSD-like' behaviors in a rat model of PTSD. In this study, corticosterone impaired memory performance, suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories. The neurodegenerative effects of the glucocorticoids, however, may prove this treatment counterproductive.
Heterocyclic
Heterocyclic antidepressant
A Heterocyclic antidepressant inhibits the nerve cells' ability reuptake norepinphrine and serotonin. This group of drugs, once the mainstay of treatment, includes tricyclic , modified tricyclic, and tetracyclic antidepressants.- External links :* * *...
/ Tricyclic anti-depressants
Tricyclic
Tricyclics are chemical compounds that contain three interconnected rings of atoms.Many compounds have a tricyclic structure, but in pharmacology, the term has traditionally been reserved to describe heterocyclic drugs...
anti-depressants. Amitriptyline
Amitriptyline
Amitriptyline is a tricyclic antidepressant . It is the most widely used TCA and has at least equal efficacy against depression as the newer class of SSRIs...
("Elavil") has shown benefit for positive distress symptoms, and for avoidance, and Imipramine
Imipramine
Imipramine , also known as melipramine, is an antidepressant medication, a tricyclic antidepressant of the dibenzazepine group...
("Tofranil") has shown benefit for intrusive symptoms.
Monoamine-oxidase inhibitors (MAOIs)
Monoamine oxidase inhibitor
Monoamine oxidase inhibitors are a class of antidepressant drugs prescribed for the treatment of depression. They are particularly effective in treating atypical depression....
. Phenelzine
Phenelzine
Phenelzine is a non-selective and irreversible monoamine oxidase inhibitor of the hydrazine class which is used as an antidepressant and anxiolytic...
("Nardil") has for some time been observed to be effective with hyperarousal and depression, and is especially effective with nightmares.
Miscellaneous other medications. Clinical trial
Clinical trial
Clinical trials are a set of procedures in medical research and drug development that are conducted to allow safety and efficacy data to be collected for health interventions...
s evaluating methylenedioxymethamphetamine
Methylenedioxymethamphetamine
MDMA is an entactogenic drug of the phenethylamine and amphetamine class of drugs. In popular culture, MDMA has become widely known as "ecstasy" , usually referring to its street pill form, although this term may also include the presence of possible adulterants...
(MDMA, "Ecstasy") in conjunction with psychotherapy are being conducted in Switzerland and Israel.
Symptom prevention: potentially useful medication classes
Some medications have shown benefit in preventing PTSD or reducing its incidence, when given in close proximity to a traumatic event. These medications include:Alpha-adrenergic antagonists. Anecdotal report of success in using clonidine
Clonidine
Clonidine is a sympatholytic medication used to treat medical conditions, such as high blood pressure, some pain conditions, ADHD and anxiety/panic disorder...
("Catapres") to reduce traumatic stress symptoms suggests that it may have benefit in preventing PTSD.
Beta blockers. Propranolol ("Inderal"), similarly to clonidine, may be useful if there are significant symptoms of "over-arousal". These may inhibit the formation of traumatic memories by blocking adrenaline's effects on the amygdala
Amygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...
.
Glucocorticoid
Glucocorticoid
Glucocorticoids are a class of steroid hormones that bind to the glucocorticoid receptor , which is present in almost every vertebrate animal cell...
s. There is some evidence suggesting that administering glucocorticoid
Glucocorticoid
Glucocorticoids are a class of steroid hormones that bind to the glucocorticoid receptor , which is present in almost every vertebrate animal cell...
s immediately after a traumatic experience may help prevent PTSD. Several studies have shown that individuals who receive high doses of hydrocortisone for treatment of septic shock
Septic shock
Septic shock is a medical emergency caused by decreased tissue perfusion and oxygen delivery as a result of severe infection and sepsis, though the microbe may be systemic or localized to a particular site. It can cause multiple organ dysfunction syndrome and death...
, or following surgery, have a lower incidence and fewer symptoms of PTSD.
Opiates. In a retrospective analysis of combat injury field data for US troops in Iraq, it was found that those who received morphine in the early stages of their treatment had a significantly lower rate of subsequent PTSD, when compared with those who did not receive morphine at that time.
Medications by symptom group affected
Medications can affect one or more of the symptoms, in one or more of the three major symptom classes involved in diagnosing PTSD, which can be summarized in the following table:| Symptom class | Symptom | Medication |
|---|---|---|
| Reexperiencing | ||
| intrusive recall | amitriptyline; fluoxetine; imipramine; lamotrigine; sertraline | |
| intrusive reexperiencing | amitriptyline; fluoxetine; imipramine; nefazodone; sertraline (women only); topiramate; | |
| sleep disturbance, nightmares | benzodiazepines; carbamazepine; clonidine; nefazodone; phenelzine; prazosin; topiramate; trazodone; zolpidem | |
| dissociative recall | risperidone | |
| intense psychological distress (anger, anxiety) when exposed to reminders of traumatic event(s) | benzodiazepines; buspirone; carbamazepine; lithium (not for anxiety); nefazodone; trazodone | |
| Avoidance | ||
| avoidance | amitriptyline; fluoxetine; lamotrigine; nefazodone; sertraline | |
| feelings of detachment or estrangement from others | amitriptyline; risperidone | |
| restricted range of affect (numbing) | amitriptyline; lamotrigine; sertraline (women only) | |
| Hyperarousal | ||
| general hyperarousal | amitriptyline; nefazodone; phenelzine; sertraline (women only) | |
| sleep disturbance, nightmares | benzodiazepines; carbamazepine; clonidine; nefazodone; phenelzine; trazodone; zolpidem | |
| irritability, anger (and impulsiveness) | carbamazepine; nefazodone; valproic acid | |
| anger | buspirone; fluoxetine; lithium; trazodone | |
| aggression | risperidone | |
| exaggerated startle response; general autonomic hyperexcitability | benzodiazepines; buspirone; carbamazepine; clonidine; propranolol; valproic acid | |
Some medications can also help with symptoms which may occur secondary to PTSD.
| Secondary symptom | Medication |
|---|---|
| depression | nefazodone; phenelzine |
| dream content distortions | nefazodone |
| relapse of symptoms | carbamazepine; |
| self-mutilation | clonidine; buprenorphine |
| sexual function reduction | nefazodone |
| sleep hours reduction | nefazodone |
Medication and self-medication issues and risks with PTSD
Alcohol abuseAlcohol abuse
Alcohol abuse, as described in the DSM-IV, is a psychiatric diagnosis describing the recurring use of alcoholic beverages despite negative consequences. Alcohol abuse eventually progresses to alcoholism, a condition in which an individual becomes dependent on alcoholic beverages in order to avoid...
and drug abuse
Drug abuse
Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance that is not considered dependent. The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in nonmedical contexts...
commonly co-occur with PTSD. Recovery from posttraumatic stress disorder or other anxiety disorders may be hindered, or the condition worsened, by medication or substance overuse, abuse, or dependence; resolving these problems can bring about a marked improvement in an individual's mental health status and anxiety levels.
Benzodiazepines are risky in several ways. They can be especially addictive when PTSD is present, and this is especially true with the fast-acting ones. Dis-inhibition upon initiation of treatment is another risk with this medication class. Finally, termination of the drug can be especially difficult. Recovery from benzodiazepine abuse or dependence tends to take a lot longer than recovery from alcohol abuse or dependence, but people can regain their previous good health. PTSD symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.
Yohimbine (not considered specifically appropriate for PTSD) increases arousal by increasing release of endogenous norepinephrine, and can worsen PTSD symptoms.
Epidemiology
There is debate over the rates of PTSD found in populations, but despite changes in diagnosis and the criteria used to define PTSD between 1997 and 2007, epidemiologicalEpidemiology
Epidemiology is the study of health-event, health-characteristic, or health-determinant patterns in a population. It is the cornerstone method of public health research, and helps inform policy decisions and evidence-based medicine by identifying risk factors for disease and targets for preventive...
rates have not changed significantly.
International PTSD rates
The United Nations' World Health Organization publishes estimates of PTSD impact for each of its member states; the latest data available are for 2004. Considering only the 25 most populated countries, ranked by overall age-standardizedAge adjustment
In epidemiology and demography, age adjustment, also called age standardisation, is a technique used to better allow populations to be compared when the age profiles of the populations are quite different....
Disability-Adjusted Life Year (DALY) rate, the top half of the ranked list is dominated by Asian/Pacific countries, the USA, and Egypt. Ranking the countries by the male-only or female-only rates produces much the same result, but with less meaningfulness, as the score range in the single sex rankings is much reduced (4 for women, 3 for men, as compared with 14 for the overall score range), suggesting that the differences between female and male rates, within each country, is what drives the distinctions between the countries.
| Region | Country | PTSD DALY rate, overall | PTSD DALY rate, females | PTSD DALY rate, males |
|---|---|---|---|---|
| Asia / Pacific | Thailand | 59 | 86 | 30 |
| Asia / Pacific | Indonesia | 58 | 86 | 30 |
| Asia / Pacific | Philippines | 58 | 86 | 30 |
| Americas | USA | 58 | 86 | 30 |
| Asia / Pacific | Bangladesh | 57 | 85 | 29 |
| Africa | Egypt | 56 | 83 | 30 |
| Asia / Pacific | India | 56 | 85 | 29 |
| Asia / Pacific | Iran | 56 | 83 | 30 |
| Asia / Pacific | Pakistan | 56 | 85 | 29 |
| Asia / Pacific | Japan | 55 | 80 | 31 |
| Asia / Pacific | Myanmar | 55 | 81 | 30 |
| Europe | Turkey | 55 | 81 | 30 |
| Asia / Pacific | Vietnam | 55 | 80 | 30 |
| Europe | France | 54 | 80 | 28 |
| Europe | Germany | 54 | 80 | 28 |
| Europe | Italy | 54 | 80 | 28 |
| Asia / Pacific | Russian Federation | 54 | 78 | 30 |
| Europe | United Kingdom | 54 | 80 | 28 |
| Africa | Nigeria | 53 | 76 | 29 |
| Africa | Dem. Republ. of Congo | 52 | 76 | 28 |
| Africa | Ethiopia | 52 | 76 | 28 |
| Africa | South Africa | 52 | 76 | 28 |
| Asia / Pacific | China | 51 | 76 | 28 |
| Americas | Mexico | 46 | 60 | 30 |
| Americas | Brazil | 45 | 60 | 30 |
United States
The National Comorbidity Survey has estimated that the lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.The United States Department of Veterans Affairs
United States Department of Veterans Affairs
The United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense...
estimates that 830,000 Vietnam War veterans suffered symptoms of PTSD. The National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5% of female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was 30.9% for males and 26.9% for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans suffered from PTSD symptoms (but not the disorder itself). Four out of five reported recent symptoms when interviewed 20–25 years after Vietnam.
In other species
There have been reports of captive and wild elephantElephant
Elephants are large land mammals in two extant genera of the family Elephantidae: Elephas and Loxodonta, with the third genus Mammuthus extinct...
s suffering from posttraumatic stress reactions, the latter from seeing members of their herd shot by hunters. Service dogs used overseas in the military have been said to develop posttraumatic stress after witnessing war.
Earliest reports
Reports of battle-associated stress reactions appear as early as the 6th century BC/BCE. One of the first descriptions of PTSD was made by the Greek historian HerodotusHerodotus
Herodotus was an ancient Greek historian who was born in Halicarnassus, Caria and lived in the 5th century BC . He has been called the "Father of History", and was the first historian known to collect his materials systematically, test their accuracy to a certain extent and arrange them in a...
. In 490 BC/BCE he described, during the Battle of Marathon
Battle of Marathon
The Battle of Marathon took place in 490 BC, during the first Persian invasion of Greece. It was fought between the citizens of Athens, aided by Plataea, and a Persian force commanded by Datis and Artaphernes. It was the culmination of the first attempt by Persia, under King Darius I, to subjugate...
, an Athenian soldier who suffered no injury from war but became permanently blind after witnessing the death of a fellow soldier.
Modern recognition in military settings
In the early 19th century military medical doctors started diagnosing soldiers with "exhaustion" after the stress of battle. This "exhaustion" was characterized by mental shutdown due to individual or group trauma. Soldiers during the 19th century were not supposed to be scared or show any fear in the midst of battle. The only treatment for this "exhaustion" was to bring the afflicted to the back for a bit then send them back into battle. During the intense and frequently repeated stress, the soldiers became fatigued as a part of their body's natural shock reaction.According to Stéphane Audoin-Rouzeau and Annette Becker, "One-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and after thirty-five days of uninterrupted combat, 98% of them manifested psychiatric disturbances in varying degrees."
Although PTSD-like symptoms have also been recognized in combat veterans of many military conflicts since, the modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by US military veterans of the war in Vietnam
Vietnam War
The Vietnam War was a Cold War-era military conflict that occurred in Vietnam, Laos, and Cambodia from 1 November 1955 to the fall of Saigon on 30 April 1975. This war followed the First Indochina War and was fought between North Vietnam, supported by its communist allies, and the government of...
.
Previous diagnoses now considered historical equivalents of PTSD include railway spine
Railway spine
Railway spine was a nineteenth-century diagnosis for the post-traumatic symptoms of passengers involved in railroad accidents.The first full length medical study of the condition was John Eric Erichsen's classic book, On Railway and Other Injuries of the Nervous System...
, stress syndrome, shell shock
Shell Shock
Shell Shock, also known as 82nd Marines Attack was a 1964 film by B-movie director John Hayes. The film takes place in Italy during World War II, and tells the story of a sergeant with his group of soldiers....
, battle fatigue, or traumatic war neurosis.
Terminology
The term post-traumatic stress disorder (PTSD) was coined in the mid 1970s, in part through the efforts of anti-Vietnam War activists and the anti war group Vietnam Veterans Against the WarVietnam Veterans Against the War
Vietnam Veterans Against the War is a tax-exempt non-profit organization and corporation, originally created to oppose the Vietnam War. VVAW describes itself as a national veterans' organization that campaigns for peace, justice, and the rights of all United States military veterans...
and Chaim F. Shatan
Chaim F. Shatan
Chaim F. Shatan was a Canadian psychiatrist born in Włocławek, Poland.Shatan's parents moved to Canada when he was two. He received his MDCM degree from McGill University in Montreal, Canada...
, who worked with them and coined the term post-Vietnam Syndrome; the condition was added to the DSM-III as posttraumatic stress disorder.
Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders. The term was formally recognized in 1980. (In the DSM-IV, the spelling "posttraumatic stress disorder" is used, while in the ICD-10
ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
the spelling is "post-traumatic...". Elsewhere, especially in less formal writing, the term may be rendered as two words — "post traumatic stress disorder".)
See also
External links
- Management of PTSD in adults and children by the National Institute for Health and Clinical ExcellenceNational Institute for Health and Clinical ExcellenceThe National Institute for Health and Clinical Excellence is a special health authority of the English National Health Service , serving both English NHS and the Welsh NHS...
(UKUnited KingdomThe United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
) - Practice guidelines from the American Psychiatric AssociationAmerican Psychiatric AssociationThe American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
- Post Traumatic Stress Disorder Information Resource from The University of Queensland School of Medicine
- Resources for Parents of Children with PTSD from The Children's Hospital of Philadelphia