Post-Traumatic Stress Disorder ... Anxiety, Depression, Stress

Posttraumatic stress disorder (commonly referred to by its acronym, PTSD) is a severe anxiety disorder that can develop after exposure to any event which 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 psychological defenses.

PTSD is a less frequent and more enduring consequence of psychological trauma than the more frequently seen acute stress response. PTSD has also been recognized in the past as railway spine, stress syndrome, shell shock, battle fatigue, traumatic war neurosis, or post-traumatic stress syndrome.

Diagnostic symptoms include re-experiencing original trauma(s), by means of flashbacks or nightmares; 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 and ICD-9) require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and/or relationships).

Signs and symptoms
PTSD can cause many symptoms. These symptoms can be grouped into three categories[4]. However, emerging factor analytic research suggests that symptoms are best described as falling into four clusters.

Re-experiencing
Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
Bad dreams
Frightening thoughts.
Re-experiencing symptoms may cause problems in a person’s everyday routine. They can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing.

Avoidance
Staying away from places, events, or objects that are reminders of the experience
Feeling emotionally numb
Feeling strong guilt, depression, or worry
Losing interest in activities that were enjoyable in the past
Having trouble remembering the dangerous event.
Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.

Hyperarousal
Being easily startled
Feeling tense or "on edge"
Having difficulty sleeping, and/or having angry outbursts.
Hyperarousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic event. They can make the person feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

It is natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a few weeks and become an ongoing problem, they might be PTSD. Some people with PTSD show no symptoms for weeks or months, and people with it will have certain trigger words which will trigger an anger outbreak.

Emotional numbing or dysphoria
Currently, Diagnostic and Statistical Manual of Mental Disorders divides diagnostic criteria for PTSD into these three clusters: re-experiencing, avoidance, hyperarousal symptoms. However, a number of studies using factor analysis have consistently found that PTSD symptoms are better represented by a four-factor model. 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).[6] 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).

Diagnosis

The diagnostic criteria for PTSD, per the Diagnostic and Statistical Manual of Mental Disorders IV (Text Revision) (DSM-IV-TR), may be summarized as:

A. Exposure to a traumatic event
B. Persistent reexperience (e.g. flashbacks, nightmares)
C. Persistent avoidance of stimuli associated with the trauma (e.g. avoidance of experiences that they fear will trigger flashbacks and reexperiencing of symptoms fear of losing control)
D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep, anger and hypervigilance)
E. Duration of symptoms for more than 1 month
F. Significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and relationships.)
Notably, criterion A requires that "the person’s response involved intense fear, helplessness, or horror." 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."

Since the introduction of DSM-IV, the number of possible PTSD traumas has increased and one study suggests that the increase is around 50%. Various scales exist to measure the severity and frequency of PTSD symptoms.

Prevention
In recent history, catastrophes (by human means or not) such as the Indian Ocean Tsunami Disaster 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 post-traumatic stress disorder.

The diagnosis of PTSD 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.

Management

Early interventions
Some benefit has been found from early access to cognitive behavioral therapy, as well as from some medications such as propranolol. Effects of all these prevention strategies is modest.

Critical incident stress management
(CISM) has been used to attempt to reduce effects of a potentially traumatic incident, and to attempt to prevent a full-blown occurrence of PTSD. However, recent studies regarding CISM seem to indicate iatrogenic effects.[63][64] Six studies have formally looked at the effect of CISM, four finding no benefit for preventing PTSD, and the other two studies indicating that CISM actually made things worse. Hence this is not a recommended treatment.

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, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and many combinations of these procedures.

The British Journal of Psychiatry has recommended EMDR or trauma-specific cognitive behavioral therapy as first-line treatments for trauma victims. A meta-analytic comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in terms of effectiveness in treating PTSD.

Cognitive behavioral therapy
Cognitive Behavioral Therapy (CBT) is a psychotherapeutic approach that aims to change the patterns of thinking and/or behavior that are responsible for a trauma victim’s negative emotions and, in doing so, change the way they feel and act. CBT has been proven to be an effective treatment for PTSD, and is currently considered the standard of care for PTSD by the Department of Defense. 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 trauma cause stress and make symptoms worse.

Eye movement desensitization and reprocessing
Eye Movement Desensitization and Reprocessing (EMDR) is specifically targeted as a treatment for PTSD. Based on the evidence of controlled research, the American Psychiatric Association and the U.S. 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.

Exposure therapy
Exposure involves assisting trauma survivors to therapeutically confront 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.

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.

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 comparing interpersonal psychotherapy, prolonged exposure therapy, and relaxation therapy.

Medication
Medications have shown benefit in reducing PTSD symptoms, but "there is no clear drug treatment for PTSD". Standard medication therapy useful in treating PTSD includes SSRIs (selective serotonin reuptake inhibitors) and TCAs (tricyclic antidepressants). Positive symptoms (re-experiencing, hypervigilance, increased arousal) generally respond better to medication than negative symptoms (avoidance, withdrawal).

Tricyclics tend to be associated with greater side effects and lesser improvement of the three PTSD symptom clusters than SSRIs. SSRIs for which there are data to support use include: citalopram, escitalopram,[85] fluvoxamine, paroxetine, and sertraline. SSRIs are considered to be a first-line drug treatment.

There are data to support the use of "autonomic medicines" such as propranolol (beta blocker) and clonidine (alpha-adrenergic agonist) if there are significant symptoms of "over-arousal". These may inhibit the formation of traumatic memories by blocking adrenaline's effects on the amygdala, has been used in an attempt to reduce the impact of traumatic events, or they may simply demonstrate to an individual that the symptoms can be controlled thereby assisting with "self efficacy" and helping the person remain calmer.

There are also data to support the use of mood-stabilizers such lithium carbonate and carbamazepine if there is significant uncontrolled mood or aggression. Risperidone can be used to help with dissociation, mood and aggression and benzodiazepines can be used with caution for short-term anxiety relief. While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD or of effectiveness in the treatment of post traumatic stress disorder.

Recently the anticonvulsant lamotrigine has been reported to be useful in treating some people with PTSD.

There is some evidence suggesting that administering glucocorticoids 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. 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.[102] The neurodegenerative effects of the glucocorticoids, however, may prove this treatment counterproductive.

Combination therapies
PTSD is commonly treated using a combination of psychotherapy and medications.

Clinical trials evaluating methylenedioxymethamphetamine (MDMA, "Ecstasy") in conjunction with psychotherapy are being conducted in Switzerland and Israel. A clinical trial is also examining the efficacy of hydrocortisone in conjunction with exposure therapy for PTSD symptoms.

Substance dependence as an inhibitor of recovery
Recovery from posttraumatic stress disorder or other anxiety disorders may be hindered, or the conditions worsened, by alcohol or benzodiazepine dependence. Treating accompanying substance dependences (particularly alcohol or benzodiazepine dependence) can bring about a marked improvement in an individuals mental health status and anxiety levels. Recovery from benzodiazepines tends to take a lot longer than recovery from alcohol but people can regain their previous good health. Symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.

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