Post-traumatic Stress Disorder

Post-traumatic stress disorder is an anxiety disorder which results from a traumatic experience. Post-traumatic stress can result from an extreme situation, such as being involved in warfare, rape, hostage situations, or involvement in a serious accident. It can also result from long term (chronic) exposure to a severe stressor, for example soldiers who endure individual battles but cannot cope with an unceasing sequence of battles. The sufferer may experience flashbacks, avoidant behavior, and other symptoms.

Epidemiology

It is a severe and ongoing emotional reaction to an extreme psychological trauma. This stressor may involve someone's actual death or a threat to the patient's or someone else's life, serious physical injury, or threat to physical and/or psychological integrity, to a degree that usual psychological defenses are incapable of coping. In some cases it can also be from profound psychological and emotional trauma, apart from any actual physical harm. Often, however, the two are combined.

PTSD is a condition distinct from traumatic stress, which is of less intensity and duration, and combat stress reaction, which is transitory. PTSD has also been recognized in the past as shell shock, traumatic war neurosis, or post-traumatic stress syndrome (PTSS).

PTSD may be experienced following any traumatic experience, or series of experiences that satisfy the criteria and that do not allow the victim to readily recuperate from the detrimental effects of stress. The National Comorbidity Survey Report provided the following information about PTSD in the general adult population: The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.

The National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5 of female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was 30.9 for males and 26.9 for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans suffered from PTSD-symptoms. Four out of five reported recent symptoms when interviewed 20-25 years after Vietnam.

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.

There is debate over the rates of PTSD found in populations, but despite changes in diagnosis and the criteria used to define PTSD between 1997 and 2007, epidemiological rates have not changed significantly.

DSM-IV Diagnostic Criteria

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. inability to talk about things even related to the experience. Avoidance of things and discussions that trigger flashbacks and reexperiencing 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 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 (the "stressor") consists of two parts, both of which must apply for a diagnosis of PTSD. The first (A1) requires that "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others." The second (A2) 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%

Research on Possible Risk Factors for PTSD

Currently, many scientists are focusing on genes that play a role in creating fear memories. Understanding how fear memories are created may help to refine or find new interventions for reducing the symptoms of PTSD. For example, PTSD researchers have pinpointed genes that make:

Stathmin, a protein needed to form fear memories. In one study, mice that did not make stathmin were less likely than normal mice to "freeze" a natural, protective response to danger, after being exposed to a fearful experience. They also showed less innate fear by exploring open spaces more willingly than normal mice.
GRP (gastrin-releasing peptide), a signaling chemical in the brain released during emotional events. In mice, GRP seems to help control the fear response, and lack of GRP may lead to the creation of greater and more lasting memories of fear.

Researchers have also found a version of the 5-HTTLPR gene, which controls levels of serotonin - a brain chemical related to mood-that appears to fuel the fear response. Like other mental disorders, it is likely that many genes with small effects are at work in PTSD.

Studying parts of the brain involved in dealing with fear and stress also helps researchers to better understand possible causes of PTSD. One such brain structure is the amygdala, known for its role in emotion, learning, and memory. The amygdala appears to be active in fear acquisition, or learning to fear an event (such as touching a hot stove), as well as in the early stages of fear extinction, or learning not to fear.

Storing extinction memories and dampening the original fear response appears to involve the prefrontal cortex (PFC) area of the brain, involved in tasks such as decision-making, problem-solving, and judgment. Certain areas of the PFC play slightly different roles. For example, when it deems a source of stress controllable, the medial PFC suppresses the amygdala an alarm center deep in the brainstem and controls the stress response. The ventromedial PFC helps sustain long-term extinction of fearful memories, and the size of this brain area may affect its ability to do so.

Individual differences in these genes or brain areas may only set the stage for PTSD without actually causing symptoms. Environmental factors, such as childhood trauma, head injury, or a history of mental illness, may further increase a person's risk by affecting the early growth of the brain. Also, personality and cognitive factors, such as optimism and the tendency to view challenges in a positive or negative way, as well as social factors, such as the availability and use of social support, appear to influence how people adjust to trauma. More research may show what combinations of these or perhaps other factors could be used someday to predict who will develop PTSD following a traumatic event.

Research on Treating PTSD

Currently, people with PTSD may be treated with psychotherapy ("talk" therapy), medications, or a combination of the two.

Psychotherapy

Cognitive behavioral therapy (CBT) teaches different ways of thinking and reacting to the frightening events that trigger PTSD symptoms and can help bring those symptoms under control. There are several types of CBT, including

exposure therapy - uses mental imagery, writing, or visiting the scene of a trauma to help survivors face and gain control of overwhelming fear and distress
cognitive restructuring - encourages survivors to talk about upsetting (often incorrect) thoughts about the trauma, question those thoughts, and replace them with more balanced and correct ones.
stress inoculation training - teaches anxiety reduction techniques and coping skills to reduce PTSD symptosm, and helps correct inaccurate thoughts related to the trauma.

Researchers is currently studying how the brain responds to CBT compared to sertraline (Zoloft), one of the two medications recommended and approved by the U.S. Food and Drug Administration (FDA) for treating PTSD. This research may help clarify why some people respond well to medication and others to psychotherapy

Medications

In a small study, NIMH researchers recently found that for people already taking a bedtime dose of the medication prazosin (Minipress), adding a daytime dose helped to reduce overall PTSD symptom severity, as well as stressful responses to trauma reminders.

Another medication of interest is D-cycloserine (Seromycin), which boosts the activity of a brain chemical called NMDA, which is needed for fear extinction. In a study of 28 people with a fear of heights, scientists found that those treated with D-cycloserine before exposure therapy showed reduced fear during the therapy sessions compared to those who did not receive the drug. Researchers are currently studying the effects of using D-cycloserine with therapy to treat PTSD.

Propranolol (Inderal), a type of medicine called a beta-blocker, is also being studied to see if it may help reduce stress following a traumatic event and interrupt the creation of fearful memories. Early studies have successfully reduced or seemingly prevented PTSD in small numbers of trauma victims.

Treatment After Mass Trauma

Researchers are testing creative approaches to making CBT widely available, such as with Internet-based self-help therapy and telephone-assisted therapy. Less formal treatments for those experiencing acute stress reactions are also being explored to reduce chances of developing full blown PTSD

For example, in one preliminary study, researchers created a self-help website using concepts of stress inoculation training. People with PTSD first met face-to-face with a therapist. After this meeting, participants could log onto the website to find more information about PTSD and ways to cope, and their therapists could also log on to give advice or coaching as needed. Overall, the scientists found delivering therapy this way to be a promising method for reaching a large number of people suffering with PTSD symptoms.

Researchers are also working to improve methods of screening, providing early treatment, and tracking mass trauma survivors; and approaches for guiding survivors through self-evaluation/screening and prompting referral to mental health care providers based on need.

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