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POST-TRAUMATIC STRESS DISORDER (Military; Environmental & Natural Disasters; Occupational; Physical Injury; Domestic Violence; Divorce)

POST-TRAUMATIC STRESS DISORDER (Military; Environmental & Natural Disasters; Occupational; Physical Injury; Domestic Violence; Divorce)

  Post-traumatic Stress Disorder (PTSD) has only been recognized as a formal diagnosis since the early 1980's. However, the cluster of symptoms (of what we know as PTSD today) were recognized by different names as early as the American Civil War. The term for emotional distress associated with battlefield participation was coined "soldiers heart." In World War I, emotional problems consistent with this syndrome were referred to as "combat fatigue." Soldiers who developed psychological symptoms in World War II were said to be suffering from "gross stress reaction," and many troops in Vietnam who had symptoms of what is now clinically known to be PTSD were assessed as having "post-Vietnam syndrome." Despite the fact that PTSD has also been labeled "battle fatigue" and "shell shock," there seemed to be little sympathy for the diagnosis by the Veteran's Administration and many veterans went without treatment. 


   Yet, in 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM5) and added a broader range of symptomatology to allow for a qualified and eligible diagnosis of PTSD It also broadened the definition to cover a wide range of populations affected by the symptoms that had previously been overlooked, and included a preschool subtype of PTSD for children ages six years and younger as well as specific criteria for adults, adolescents, and children older than six years that had nothing to do with combat exposure or military experience. Below is a brief overview of the categories used to identify the diagnosis of PTSD:


Criterion A relates to the type of trauma exposure: (death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence); whether or not there was direct or indirect exposure; if the event involved actual or threatened death; whether it had been violent or accidental. Note, it does not include indirect non-professional exposure through electronic media, television, movies, or pictures.


Criterion B defines recurring symptoms including: intrusive memories; traumatic nightmares; dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness; intense or prolonged distress after exposure to traumatic reminders; and marked physiologic reactivity after exposure to trauma-related stimuli. This DSM version also outlines specific criteria for children that differs from symptoms for adults. 


Criterion C delineates avoidance behaviors that include: persistent evasion of distressing trauma-related stimuli after the event; trauma-related thoughts or feelings; trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations.


Criterion D outlines the negative alterations in cognitions and mood including: worsening of cognition after the traumatic event; inability to recall key features of the traumatic event; dissociative amnesia (not due to head injury, alcohol, or drugs); persistent (and often distorted) negative beliefs and expectations about oneself or the world; persistent distorted blame of self or others for causing the traumatic event or for resulting consequences; persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame); diminished interest in (pre-traumatic) significant activities; feeling alienated from others (e.g., detachment or estrangement); constricted affect and a persistent inability to experience positive emotions.


Criterion E symptoms are associated with alterations in arousal and reactivity. They may include: trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event; irritable or aggressive behavior; self-destructive or reckless behavior; hyper-vigilance; exaggerated startle response; problems in concentration; and sleep disturbance.


Criterion F pertains to the duration of symptoms.


Criterion G relates to symptom-related distress or functional impairment (e.g., social, occupational).


Criterion H summarizes exclusion criteria; the disturbance is not due to medication, substance use, or other illness. Full diagnosis is not met for PTSD until at least six months after the trauma(s), although onset of symptoms may occur immediately. A full explanation of all of the diagnostic categories can be found in the American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders, (5th ed.). Washington, DC: Author.


    Although not all individuals who have been traumatized develop PTSD, there can be significant physical consequences of being traumatized. For example, research indicates that people who have been exposed to an extreme stressor sometimes have a smaller hippocampus (found on MRI imaging studies) than people who have not been exposed to trauma. This finding is significant in understanding the effects of trauma since this part of the brain that is thought to have an important role in developing new memories about life events. 


     Although PTSD symptoms may be identified, not everyone seeks treatment for same. Unfortunately, untreated PTSD can have devastating and far-reaching consequences on intimate relationships, family dynamics, work environments, and for society as a whole. Complications of PTSD in women who are pregnant can include having other types of emotional problems and memory problems as well. Research has also demonstrated that women who were sexually abused at earlier ages are more likely to develop complex PTSD and personality disorders (that disrupt her life and those around her) than her cohorts that were not abused. Also, individuals who suffer from this illness are at a greater risk of having more medical problems that the average public. In children and teens, PTSD can have significantly negative effects on their social and emotional development, as well as on their ability to absorb and learn new information. It can also have significant economic consequences for the individual, his/her family, and society. 


   Interventions for PTSD usually include psychological and medical interventions. Education about the illness and learning about ways to manage symptoms of PTSD, are key components to treatment. Patient education also reinforces the notion that PTSD is caused by extraordinary stress and life circumstances rather than personal weakness which thereby helps to reduce the shame and stigma that have been previously associated with having a diagnosis of PTSD. Families of PTSD individuals, may benefit from family therapy, couples counseling, parenting classes, and conflict-resolution education as well.


    Behavioral therapy interventions can also include exposure therapy (repeated exposure to a situation that triggers anxiety symptoms, and learns to resist the urge to perform the compulsion) and Thought stopping (learning to stop unwanted thoughts and focus attention on relieving anxiety). Psychoanalytically-oriented psychotherapy can be implemented in both short-term and long-term therapy depending on the treatment goal. Both frameworks focus on exploring unconscious drives and unresolved childhood conflicts that seem to continually resurface in adult life and prevent healthy attachment and intimacy with others. This mode of therapy is a process there may be times of great frustration along the way. But keep in mind that whether there was a sudden onset of PTSD symptoms or it took many years for the problems to develop, it will take time to understand and go through the healing process.

    Additionally, learning how to manage anger and anxiety, improve communication skills, and practice breathing techniques and other relaxation techniques can help individuals with PTSD gain a sense of mastery over frightening and overwhelming emotional and physical symptoms. Techniques might also include cognitive behavioral therapy and group therapy to aid in recognizing and adjusting destructive trauma-related thoughts and beliefs about the trauma and its impact, by educating individuals about the relationships between thoughts and feelings and developing alternative interpretations, and by practicing new ways of looking at situations and the normal dilemmas of everyday life.  


    Eye-movement desensitization and reprocessing (EMDR) is also another form of cognitive therapy that guides the person to talk about the trauma suffered and the negative feelings associated with the events, while focusing on the professional's rapidly moving finger. Research, however, is unclear about whether or not this form or therapy is any more effective than cognitive therapy that is done without EMDR.


    Occupational therapy (OT) is also another important treatment modality because it focuses on rehabilitation and recovery through participation in structured and supervised activities. Another potentially powerfully positive activity-based intervention for individuals with PTSD can be the use of a service dog because they have been found to improve PTSD suffers' sense of safety, responsibility, optimism, and self-awareness.


Finally, the Rapid Reduction Technique (RRT), developed by Dr. William Tollefson, can be used to help with intrusive memories and flashbacks In this video, he explains how intrusive memories can cripple and rob us from leading a fulfilling life and describes how the RRT can be a useful tool in helping to manage the triggers associated with painful memories


     Medications typically used to help PTSD sufferers may include serotonergic antidepressants (SSRIs), like fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) and medications that help decrease the symptoms associated with physical illness, like prazosin (Minipress), clonidine (Catapres), guanfacine (Tenex), and propranolol. SSRIs are the first group of medications that have received approval by the U.S. Food and Drug Administration (FDA) for the treatment of PTSD. Treatment guidelines provided by the American Psychiatric Association describe these medicines as being particularly helpful for people whose PTSD is the result of trauma that is not combat related. Research also shows that SSRI's tend to decrease anxiety, depression, and panic, and may also help reduce aggression, impulsivity, and suicidal thoughts that can be associated with this disorder. 


     For combat-related PTSD, there a growing body of evidence that prazosin can be particularly helpful in symptom reduction. Although other medications like duloxetine (Cymbalta), bupropion (Wellbutrin), venlafaxine (Effexor), and desvenlafaxine (Pristiq) have been used in the treatment of PTSD, there is very little scientific research that has studied their effectiveness in treating this illness. Other medications that have been tried in the treatment of PTSD include mood stabilizers like lamotrigine (Lamictal), tiagabine (Gabitril), and divalproex sodium (Depakote), as well as mood stabilizers that are also antipsychotics, like risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), asenapine (Saphris), and paliperidone (Invega). Antipsychotic prescriptions seem to be most useful for those who suffer from agitation, dissociation, hyper-vigilance, intense suspiciousness (paranoia), or brief breaks in being in touch with reality (brief psychotic reactions). Benzodiazepines, (tranquilizers) such as diazepam (Valium) and alprazolam (Xanax) can provide immediate relief from intrusive PTSD symptoms, but they present a number of complications like painful withdrawal symptoms, risks of overdose, psychological and physiological addiction, and have not been found to be significantly effective in helping individuals manage PTSD symptoms.


    Coping with symptoms of PTSD can seem daunting. However, there are ways for patients and their families to manage this illness. They include learning more about the disorder via the vast amount of information that is available on the internet, developing a buddy system (via friends, family, professionals) to rely on when the negative symptoms seem overwhelming, and finally, by joining a PTSD survivors group for support. Other helpful tips include: using relaxation techniques to cope with triggers (for example, breathing exercises, qigong, yoga); willingly and actively participating in treatment as prescribed by the treatment team; maintaining affirmative lifestyle practices (i.e., exercise, healthy eating, spiritual practices, volunteering your time or talents) that promote wellness and a sense of wellbeing; and minimizing negative activities (like substance abuse, social isolation, working to excess, gambling, and other self-destructive or suicidal behaviors) that can lead to feelings of helplessness and relapse.

    If you are a Veteran of any of the US armed forces, you can contact the following for more information about eligibility for treatment and locations of treatment centers. If you are a veteran (who wants treatment outside the VA system) or are a civilian who has suffered from PTSD and wish to explore treatment options, please feel free to call 954-779-2855 for the earliest appointment.

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