A severe anxiety reaction that occurs in some people exposed to a traumatic event involving witness to, threat of, or experience of death or serious harm; it often affects war veterans. The traumatic event is re-experienced in the form of images or thoughts (‘flashbacks’), accompanied by sweating, a rapid heart beat, and a feeling of fear. Flashbacks are often precipitated by cues that resemble the original event, and stimuli that are associated with the trauma are avoided, which may substantially disrupt normal life. The condition also predisposes to depression and addiction. It may be prevented by offering counselling or other psychiatric interventions to people who have experienced extremely stressful situations.
(Discuss) Post-traumatic stress disorderClassifications and external resources
| ICD-10 | F43.1 |
|---|---|
| ICD-9 | 309.81 |
Post-traumatic stress disorder (PTSD) is a term for certain psychological consequences of exposure to, or confrontation with, stressful experiences that the person experiences as highly traumatic.
It is possible for individuals to experience traumatic stress without manifesting Post-Traumatic Stress Disorder, as indicated in the Diagnostic and Statistical Manual of Mental Disorders.
Symptoms of PTSD can include the following: nightmares, flashbacks, emotional detachment or numbing of feelings (emotional self-mortification or dissociation), insomnia, avoidance of reminders and extreme distress when exposed to the reminders ("triggers"), irritability, hypervigilance, memory loss, and excessive startle response, clinical depression and anxiety, loss of appetite. Most people who experience traumatic events will not develop PTSD - PTSD is thought to be primarily an anxiety disorder and should not be confused with normal grief and adjustment after traumatic events. PTSD may have a delayed onset of months, years or even decades and may be triggered by an external factor or factors.
Background
The first case of psychological distress was reported in 1900 BCE, Egypt by an Egyptian physician who described "hysterical" reaction to trauma (Veith 1965).
Hippocrates utilized a homeostasis theory to explain illness and stress is often defined as the reaction to a situation that threatens the balance or homeostasis of a system (Antonovsky 1981).
However, PTSD in and of itself is a relatively recent diagnosis in psychiatric nosology, first appearing in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. It has been said that development of the PTSD concept has, in part, socio-economic and political implications (Mezey & War veterans are the most publicly-recognised victims of PTSD; This situation has changed during the last two decades and PTSD is now one of several psychiatric diagnoses for which a veteran can receive compensation, such as a war veteran indemnity pension, in the U.S. (see below: Mezey & Robbins 2001)
Diagnostic criteria
The diagnostic criteria for PTSD, according to Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), are stressors listed from A to F. The current diagnostic criteria for the PTSD published in the Diagnostic and Statistical Manual of Mental Disorders may be found DSM-IV-TR here.
Symptoms and their possible explanations
Symptoms can include general restlessness, insomnia, aggressiveness, depression, dissociation, emotional detachment and nightmares. Young children suffering from PTSD will often re-enact aspects of the trauma through their play and may often have nightmares that lack any recognizable content.
One patho-psychological way of explaining PTSD is by viewing the condition as secondary to deficient emotional or cognitive processing of a trauma (Cordova 2001). This view also helps to explain the three symptom clusters of the disorder (Shalev 2001):
Intrusion: Since the sufferer is unable to process the extreme emotions brought about by the trauma, they are plagued by recurrent nightmares or daytime flashbacks, during which they graphically re-experience the trauma. These re-experiences are characterized by high anxiety levels and make up one part of the PTSD symptom cluster triad called intrusive symptoms.
Hyperarousal: PTSD is also characterized by a state of nervousness with the patient being prepared for "fight or flight". The typical hyperactive startle reaction, characterized by "jumpiness" in connection with high sounds or fast motions, is typical for another part of the PTSD cluster called hyperarousal symptoms and could also be secondary to an incomplete processing.
Avoidance: The hyperarousal and the intrusive symptoms are eventually so distressing that the individual strives to avoid contact with everything and everyone, even their own thoughts, which may arouse memories of the trauma and thus provoke the intrusive and hyperarousal states. This avoidance behavior is the third part of the symptom triad that makes up the PTSD criteria.
Dissociation: Dissociation is another "defense" that includes a variety of symptoms including feelings of depersonalization and derealization, disconnection between memory and affect so that the person is "in another world," and, in extreme forms can involve apparent multiple personalities and acting without any memory ("losing time").
Biology of PTSD
Neurochemistry
PTSD displays biochemical changes in the brain and body, which are different from other psychiatric disorders such as major depression.
In PTSD patients, the dexamethasone cortisol suppression is strong, while it is weak in patients with major depression. In most PTSD patients the urine secretion of cortisol is low, at the same time as the catecholamine secretion is high, and the norepinephrine/cortisol ratio is increased.
The response to stress in PTSD is abnormal with long-term high levels of norepinephrine, at the same time as cortisol levels are low, a pattern associated with facilitated learning in animals. Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response (Yehuda 2002). With this deduction follows that the clinical picture of hyperreactivity and hyperresponsiveness in PTSD is consistent with the sensitive HPA-axis.
Swedish United Nations soldiers serving in Bosnia 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 (Aardal-Eriksson 2001).
Another possible factor in PTSD is that a persistence of depressive symptoms may be caused by an underlying biochemical disorder, associated with insulin resistance (dysglycemia), that can be treated by a hypoglycemic diet.
It is important to note that you may find seemingly contradictory information concerning physiological processes of PTSD as there is considerable controversy within the medical community regarding the biology of PTSD.
Neuroanatomy
In animal research as well as 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.
Prevalence
PTSD may be experienced following any traumatic experience, or series of experiences which satisfy the criteria and that do not allow the victim to readily recuperate from the detrimental effects of stress. It is believed that of those exposed to traumatic conditions between 5% and 80% will develop PTSD depending on the severity of the trauma and personal vulnerability.
According to recent epidemiologic studies, between 10% and 14% of the population at any given time has PTSD (Sandro Galea). Additionally, about one third of the population will have experienced some form of PTSD in their lifetime.
In recent history, the Indian Ocean Tsunami Disaster, which took place December 26, 2004 and took hundreds of thousands of lives, as well as the September 11, 2001 attacks on the World Trade Center and The Pentagon, may have caused PTSD in many survivors and rescue workers.
Other informaion concerning prevalence of PTSD is that females have a higher rate of PTSD than do males, and Hispanics have higher rates of PTSD than do other ethnicities.
Veterans and PTSD politics
The practice of providing compensation for veterans with PTSD is under review in the United States. In 2005, the US Department of Veterans Affairs Veterans Benefits Administration began a review of claims after it noted a reported 30% increase in PTSD claims in recent years.
However the feeling of reprieve experienced by some veterans and veteran advocates was short-lived. Soon thereafter, the Department of Veterans Affairs announced that it had contracted with the Institute of Medicine (IOM) to conduct a study on PTSD. The committee will review and comment on the objective measures used in the diagnosis of PTSD and known risk factors for the development of PTSD. The committee will also "review the literature on various treatment modalities (including pharmacotherapy and psychotherapy) and treatment goals for individuals with PTSD [and] ... comment on the prognosis of individuals diagnosed with PTSD and existing comorbidities." The institute organized a recent meeting to discuss PTSD among veterans.
In some, the diagnosis is highly controversial because of the strong connection with compensation seeking behavior and efforts and the uncertainty about the effect of this on objective diagnosis of those who may have been subjected to trauma. See recent article at
While PTSD-like symptoms were recognized in combat veterans following many historical conflicts, the modern understanding of the condition dates to the 1980s. Reported OEF/OIF cases of combat-PTSD incidents are currently being compiled in ePluribus Media's PTSD Timeline
Cancer as PTSD-trauma
PTSD is normally associated with trauma such as violent crimes, rape, and war experience. However, there have been a growing number of reports of PTSD among cancer survivors and their relatives (Smith 1999, Kangas 2002). There is yet disagreement on whether the traumas associated with different stressful events relating to cancer diagnosis and treatment actually qualify as PTSD stressors (Green 1998).
Treatment
Early intervention after a traumatic incident, known as Critical Incident Stress Management (CISM) is often used to reduce traumatic effects of an incident, and potentially prevent a full-blown occurrence of PTSD.
There have been scores of treatments suggested for the treatment of PTSD. The most researched (non-medical) psychotherapeutic method, specifically targeted at the disorder PTSD, is Eye Movement Desensitization and Reprocessing (EMDR) . The treatment of complex trauma often requires a multi-modal approach
PTSD is commonly treated using a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and psychotropic drug therapy (antidepressant or atypical antipsychotics, e.g. According to some studies, the most effective psychotherapeutic treatment for PTSD is Eye Movement Desensitization and Reprocessing (EMDR) q.v.
Basic counseling for PTSD includes education about the condition and provision of safety and support (Foa 1997).
Dr. Jan Bastiaans of the Netherlands has developed a form of psychedelic psychotherapy involving LSD, with which he has successfully treated concentration camp survivors who suffer from PTSD.
PTSD is often co-morbid with other psychiatric disorders such as depression and substance abuse. This is a variant of PTSD that includes the breakthrough of Borderline Personality traits.
Law
If the acts and omissions of an individual suffering from PTSD result in consequences that breach the criminal law, there may be levels of confusion that prevent the formation of the relevant mens rea (Latin for "guilty mind") so mistake or reasonable excuse may be a defence. For a detailed discussion of a sometimes related condition, see battered woman syndrome and, more generally, the abuse defense in the U.S.
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