Post-Traumatic Stress Disorder – Causes, Symptoms and Treatment

Post-Traumatic Stress Disorder (PTSD) is a diagnosis frequently made for patients who have survived a serious traumatic event, but it is also a diagnosis that is greatly misunderstood.

While PTSD has been commonly associated with veterans returning home from combat zones, 8% of the general population in the United States is believed to have suffered from PTSD at some point in their lives. (1)   In comparison, 13.8% of veterans returning from Iraq and Afghanistan reportedly suffer from PTSD. (2)  Enlisted personnel are twice as likely to suffer from PTSD as officers. (3)

There is no doubt that physical trauma caused by armed conflict, assaults, motor vehicle crashes, falls, burns, or loss of a limb can, and often does, result in significant pain and emotional traumatic injury.  However, the mere presence of psychological distress related to traumatic injury does not necessarily mean the patient has post-traumatic stress disorder.

It is now accepted in the health care community based on a growing body of scientific literature that persistent and profound changes in some of the body’s physiologic systems occur in individuals with PTSD.  Researchers have found evidence of damage to the physical systems associated with PTSD such as increased sympathetic nervous system activity, alterations in stress hormones secretion, memory processing and limbic system abnormalities in brain imaging studies of traumatized patients.

In order for a psychological injury to rise to the level of a diagnosis of PTSD, it must meet all of the specific diagnostic criteria of the DSM-IV (Diagnostic and Statistical Manual — 4th edition) published by the American Psychological Association, including the following:

• Exposure to a traumatic event in which “the person experienced, witnessed, or was confronted with . . . actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” The patient must also have experienced the event with “intense fear, helplessness, or horror.”

• The traumatic event is persistently re-experienced “by distressing recollections of the event, distressing dreams, reliving of the event, or intense psychological or physical distress at exposure to cues that remind the patient of the trauma.”

• Persistent avoidance of stimuli associated with the trauma or “numbing” of the senses. Examples include: avoiding thoughts of the event; avoiding activities, places, or people that arouse memories of the event; inability to recall important aspects of the trauma; diminished interest or participation in life activities; feelings of detachment; reduced range of emotional expression; or a lack of a sense of future.

• Persistent symptoms of increased arousal. Examples are: insomnia, irritability, difficulty concentrating, or an exaggerated startle response.

• A duration of more than one month, with a disturbance in the person’s social and work life. (1)

In the area of motor vehicle crashes, there are characteristics that make for a greater risk of PTSD or related psychological symptoms, including:

1. The event is completely out of the individual’s control, much like an unprovoked and completely unexpected physical attack.

2. The event causing the traumatic injury involves feelings of helplessness and fear; the victim was unable to do anything to avoid or prevent it.

3. Phobias.  Fear of driving or fear of the traumatic event’s location.

4. Injuries can be very painful.  PTSD has been associated not only with the physical trauma of a violent event, but also arising from intense pain experienced by the patient separate from the traumatic event itself.  Prolonged and severe pain experienced immediately after a traumatic injury, but before the intervention of care, can be the traumatic experience itself leading to PTSD symptoms.

5. Cognitive disorders can increase PTSD symptoms. Cognitive disorders following trauma are often not diagnosed early on.  This can have a very negative psychological impact on those who experience further fear, anxiety, or depression because real symptoms are not believed or validated by the treatment provider.  This can lead to the exacerbation of PTSD symptoms.

Treatment of PTSD

The most successful treatment for PTSD has been the use of cognitive-behavioral therapy, often in conjunction with medication. (5)  The medications Sertraline (Zoloft) and Paroxetine (Paxil) are Selective Serotonin Re-uptake inhibitors (SSRI) that are the first medications to have received FDA approval as indicated treatments for PTSD. (5)   In addition to cognitive-behavioral therapy and medications, group therapy is also frequently used for mildly to moderately affected PTSD patients.  (5)  In the group setting, the PTSD patient can discuss traumatic memories, PTSD symptoms, and functional deficits with others who have had similar experiences. This approach has been most successful with war Veterans, rape/incest victims, and natural disaster survivors. (5)

PTSD and Traumatic Brain Injury

PTSD and Traumatic Brain Injury (TBI) have several symptoms in common.  Among these are irritability, concentration deficits, amnesia for the causal event, reduced cognitive processing ability, and sleeping disturbances.  The overlap of symptoms of PTSD with traumatic brain injury can make diagnosing more challenging for a healthcare professional not well versed in both conditions. (6)

Treatments for PTSD, TBI and other co-morbidities are typically symptom-focused and evidence based.  For example, early data shows that the treatments that have worked well in Veterans with PTSD alone, such as cognitive processing therapy, prolonged exposure or SSRI’s, can also work well for Veterans who have suffered a mild traumatic brain injury as well as emotional trauma.  (7)  Memory aids can also be useful in this population.  Patients can also benefit from occupational rehabilitation and case management, depending on the severity of their injuries. Patient should be referred to consultants, such as neurologists, neuropsychologists, and substance abuse or other specialized treatment as needed. (7)

References

1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Liebowitz, Michael R, Barlow, David H., Ballenger, James C., Davidson, Johnathan, Foa, Edna, Fyer, Abby.
2. Gradus, Jaimie L. Epidemiology of PTSD, National Center for PTSD.
3. The History of Post Traumatic Stress Disorder, PsychiatricDisorders.com
4. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General—Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
5. Friedman, Matthew J.  PTSD History and Overview, National Center for PTSD.
6. Glaesser, J.et al. (2004).  Posttraumatic Stress Disorder in patients with traumatic brain injury.  BMC Psychiatry. 2004; 4: 5.)
7. Summerall, E. Lanier.  Traumatic Brain Injury and PTSD, National Center for PTSD.