Post Traumatic Stress Disorder

For some people merely recalling a traumatic event feels just like going through it all over again. Psychotherapy and some other strategies can help.

At some time in life, at least half of us will live through a terrifying event in which we experience, are threatened by, or witness grave physical harm. Obviously, 100% of police officers and firefighters will have such an experience. The stress of a life-threatening trauma takes time to ease.

Most people recover with the support of family, friends, and co workers but some develop post-traumatic stress disorder (PTSD), an anxiety disorder that may last a lifetime if appropriate help is not available.

Who develops PTSD?

Many unwelcome and unanticipated life events, such as a spouse’s betrayal or the loss of a job, can cause distressing emotional reactions, but most such events don’t lead to PTSD. Under the current official definition, PTSD is diagnosed only if you have been exposed to actual or threatened death or serious injury and responded with fear, helplessness, or horror.

However, the definition of PTSD is broadening, as mental health professionals gain more experience with the disorder. Individual traits and circumstances help determine how an event is perceived and how emotionally overwhelming it is. In making a diagnosis of PTSD, a mental health professional considers both the type of trauma and the individual’s reaction. The point in a person’s life when a trauma occurs may also predict his or her likelihood of developing the disorder.

The traumatic event does not have to be experienced directly. Public safety and health care workers confronted with the aftermath of violence or natural disaster can also develop PTSD.

What are the symptoms?

Mental health professionals divide the symptoms of PTSD into three types:

Intrusion: Re-experiencing the trauma in nightmares, day-time flashbacks, unwanted memories, thoughts, images, or sensations. Cues resembling some aspect of the event can cause intense emotional and physical distress, and the person may feel and act as if the event is recurring.

Avoidance: Avoiding thoughts, feelings, activities, places, and people associated with the trauma. This may result in social withdrawal and becoming numb to positive as well as negative emotions.

Arousal: Being constantly on guard, resulting in insomnia, irritability, outbursts of anger, difficulty concentrating, or being easily startled. Some people have panic attacks.

After a trauma, it is normal to experience many of these symptoms temporarily. If your symptoms worsen or interfere with your ability to function after a month or more, you may be given a diagnosis of acute stress disorder. Symptoms lasting more than three months are considered chronic PTSD. Occasionally, someone develops “delayed PTSD” six months later or more, following a reminder of the event.

The disorder can also occur in combination with other psychological difficulties. People with certain mental illnesses and those who have experienced PTSD in the past are at increased risk. If a loved one dies unexpectedly or traumatically, PTSD can mingle with bereavement, making recovery more difficult. People with PTSD may try to ease their symptoms with drugs or alcohol. If the underlying PTSD is not addressed, treatment for substance abuse will likely be unsuccessful.

How PTSD occurs

Using imaging techniques, researchers have begun to construct a picture of the brain under the influence of PTSD. The body responds to a traumatic event by releasing adrenaline, a stress hormone that prepares the body to flee or fight. In the brain, adrenaline and the brain chemical norepinephrine stimulate the amygdale, a deep brain structure that spurs the formation of vivid, emotional memories of the threat. In evolutionary terms, that is a good survival strategy – for example, putting a hunter on high alert if he later nears the same cave where an animal attacked him. In PTSD; however, the system goes overboard. Memories and environmental cues provoke out-of proportion fear responses to ordinary situations, thus intervening with normal functioning.

Researchers are investigating the contributions of both brain structure and previous experiences to vulnerability to PTSD.

Getting help

If symptoms last more than a month, if they are severe, or if you would like professional help, consult a mental health care provider experienced in working with trauma. Remember that treatment is not about forgetting a trauma or feeling as if it never happened. The goal is to eliminate or reduce its ability to disrupt your life.

Psychotherapy is the centerpiece of most PTSD treatment. The most specific is a cognitive behavioral approach called exposure therapy, which provides a safe environment for you to confront a situation that your fear. People with PTSD often feel that the only way to reduce their anxiety is to avoid anything that stirs their memories of the trauma. But gradual and repeated exposure can reduce symptoms and help change how you respond to the triggering situations. This approach would be difficult for many public safety traumatic incidents.

The particulars of the trauma and personal history influence not only the likelihood of developing PTSD but also the effectiveness of therapy.

If several weeks of psychotherapy do not resolve symptoms (or if additional help is needed), medications may be prescribed, although not all clinical trials have shown medication to work better than a placebo.

Although medication and psychotherapy have not been directly compared, a combination of the two seems to work better than medication alone.

Can PTSD be prevented?

If everyone received some treatment soon after a trauma, could they be spared PTSD? Both psychological and medical approaches have been considered.

A model called “critical incident stress debriefing” has been introduced into many settings. The idea is that providing a little treatment early on – encouraging people to talk about the traumatic event and educating them about common stress reactions – might help prevent PTSD down the road. Unfortunately, it does not seem to help. An expert review of studies by the international nonprofit Cochrane Collaboration concluded that it may interfere with natural recovery from trauma and should not be compulsory for any trauma victims. Although workplaces and schools offer counseling following many types of loss, current research argues against any program that requires graphic recounting of trauma details or explicitly labels certain reactions as normal or pathological.

What you can do?

Social support is one of the most important factors that distinguish those who recover from trauma from those who develop PTSD. But providing support to a friend or relative does not mean you have to become an amateur therapist.

“Just be a good listener,” says Ellen Blumenthal, M.D., a psychiatrist at Massachusetts General Hospital. “Help them process the event in their own way. Don’t insist that they talk about the event or tell them to put it out of their mind.”

Just as you do not necessarily expect someone to function well in the first few months after a death in the family, recognize that people may not act like themselves after a serious trauma. On the other hand, do not regard traumatized persons solely as victims. Encourage them and give them opportunities to reengage in enjoyable activities.

If a person become increasingly withdrawn, it is likely that professional help is needed. Warning signs include increasing efforts to avoid people, places or activities associated with trauma; detachment from family and friends; drinking or using drugs to feel better; out-of-control anger; and constantly being on the lookout for danger. If a friend or co worker shows any of these behaviors or seems to be getting worse rather than better, encourage them to consult a mental health professional.

Adapted from Harvard Women’s Health Watch – March 2005

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