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POSTTRAUMATIC STRESS DISORDER

John 1. Kluck, M.D.
1. What is posttraumatic stress disorder (PTSD)?
PTSD is caused by experiencing severe psychic trauma. Psychic trauma is defined as an inescapable event that overwhelms an individuals existing coping mechanisms. The seven cardinal features of PTSD are: The trauma must be of life-threatening magnitude, and the person must respond with intense fear, helplessness, or horror. The person may either personally experience or witness the trauma. The trauma is reexperienced in the following ways: Frequent intrusive memories of the event (the patient complains that he or she cannot stop thinking about the trauma) Frequent nightmares concerning the event The person acts or feels that the event is recurring; for example, Reliving the event Flashbacks Any reminders of the event are persistently avoided, and general responsiveness is numbed by: Avoidance of all conversations, places, people, or events that might remind the person of the event Feeling detached from others, being emotionally restricted, or having a sense of a foreshortened future The person experiences persistent and intense autonomic arousal, including hypervigilance and an exaggerated startle response. Symptoms must last more than 1 month. Symptoms must cause significant distress and impairment in major areas of human functioning.

2. What are the subtypes of PTSD? There are three subtypes: Acute PTSD has been present 1-3 months. Chronic PTSD symptoms have been present > 3 months. With delayed onset, the symptoms appear > 6 months after the trauma.

3. List associated features of PTSD. Survivors guilt Disturbed interpersonal relationships Impaired ability to modulate feelings Self-destructive behavior Impulsive behavior

Dissociative symptoms Somatic complaints Shame Social withdrawal Changes in personality characteristics

4. List disorders often associated with PTSD. There may be an increased risk of the following disorders: Panic disorder Agoraphobia Obsessive-compulsive disorder Social phobia Major depression or bipolar disorder Somatization disorder
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Substance-related disorders Dissociative identity disorder and other dissociative disorders Borderline personality disorder

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5. Do young children present differently from adults? The symptoms of PTSD for young children differ from adults in the following ways: Adults Young Children Respond to trauma with intense fear, Respond to trauma with disorganized helplessness, or horror or agitated behavior Reexperience the trauma with intrusive Engage in repetitive play in which themes or images, thoughts, and perceptions aspects of trauma are expressed Have recurrent distressing dreams of Have nonspecific nightmares; e.g., the trauma monsters Act or feel as if trauma were recurring Reenact the trauma

6. What are some associated features in children?

The younger the child, the more vulnerable they are, and the fewer psychic resources they have. Children develop pessimistic expectations for the future, including a foreshortened life span. A childs developmental phase contributes to their specific presentation. Younger children tend to withdraw and may even become mute. Latency-age children may use obsessive defenses to repetitively discuss the trauma, but with isolation of affect. Latency-age children can use fantasy; i.e., to fantasize what they might have done. Adolescents develop a syndrome more like adults. Adolescents are more prone to act out, through truancy, sexual behavior, substance abuse, or delinquency.

7. What is the differential diagnosis of PTSD? In adjustment disorder, the stressor can be of any severity. Diagnose adjustment disorder when there is insufficient criteria to diagnose PTSD and the stress is not extreme, but the patients symptoms meet the criteria for PTSD. Acute stress disorder is distinguished from PTSD because it must resolve in a 4-week period. In obsessive-compulsivedisorder, recurrent, intrusive thoughts are experienced as inappropriate and are not related to a specific trauma. Flashbacks in PTSD must be distinguished from illusions and hallucinations found in psychotic disorders, such as schizophrenia, mood disorders with psychotic features, other psychotic disorders, delirium, substance use disorders, and psychotic disorders due to a general medical condition. Consider malingering whenever there is a significant secondary gain, such as avoiding prosecution, avoiding work, and getting financial remuneration.
8. Is PTSD a normal response to a horrible event? PTSD has long been thought of as a normal response to a severe stressor that continues long after the stressor has resolved. There are two major problems with this hypothesis. Most survivors of even horrific trauma, such as combat, the Holocaust, or torture, do not develop long-lasting PTSD. Further, several recent studies have shown that PTSD can result from mild stressors that commonly occur, such as motor vehicle accidents, medical procedures, and myocardial infarcts.

9. Discuss the psychophysiology of PTSD.

First and foremost, PTSD is a physical experience. Extremely intense, simultaneous stimuli of auditory, visual, olfactory, gustatory, and kinesthetic origin can overwhelm the brains ability to integrate them into a meaningful experience; i.e., the construction of a story of the trauma that integrates the trauma with the self, and integrates the trauma with pre-existing schema. All layers of the brain, brainstemhypothalamus, limbic system, and neocortex usually are affected. There is considerable evidence that neurons can be physically and permanently changed.

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There are at least four lasting psychobiological abnormalities in PTSD: Psychophysiologicaleffects Extreme autonomic responses to stimuli reminiscent of the trauma Hyperarousal to intense but neutral stimuli (loss of stimulus discrimination) Neurohormonal effects Elevated catecholamines (NE) Decreased glucocorticoid levels Decreased serotonin activity Increased opioid response to stimuli reminiscent of trauma Neuroanatomical effects Decreased hippocampal volume Activation of the amygdala (implicated in evaluating the emotional meaning of incoming stimuli) and right visual cortex during flashbacks Decreased activation of Brocas area during flashbacks (possibly explaining why the PTSD patient has difficulty putting the experience into words) Marked right-hemispheric lateralization Decreased immunological response
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10. What are the risk factors for developing PTSD? Pretrauma vulnerability: Genetic biological, and environmental factors can influence vulnerability to PTSD. Examples include family history of mental disorders, especially alcoholism; history of child abuse; early separation from parents; parental poverty; lower education; and previous traumatization by a similar event. Age: Children are much more susceptible to the effects of trauma than adults. Magnitude of the stressor: In general, the more intense and threatening the trauma is (serious injury or death), and the longer the duration or the more repetitive the trauma is, the greater the risk of developing PTSD. Green has proposed seven categories of generic traumas that cut across different types of traumatic events: 1. Threat to ones life and body integrity 2. Severe physical harm or injury 3. Receipt of intentional injuryham 4. Exposure to the grotesque 5. Witnessing or learning of violence to loved ones 6. Learning of exposure to a noxious agent 7. Causing death or severe harm to another Preparation for the event: The less the preparation, the higher the risk of developing PTSD. Immediate and short-term responses: The likelihood of developing PTSD can be correlated to the individuals response to a trauma, or peritraumatic response. Predictive of the development of PTSD are dissociation, freezinghrrender, disorganization, agitation, and severe anxiety and panic. Coping styles also have been found to be predictive of PTSD in one study, but not another. Intuitively, one would expect that the more successful a person is in coping, such as taking some action to lessen the effects of the stressor, the less likely he or she would be to develop PTSD. Posttrauma responses: Nearly all victims of severe trauma demonstrate distress immediately following the trauma. PTSD-like symptoms are so frequent that their presence alone is not a good predictor of developing PTSD. While the literature is mixed concerning what factors are good predictors, in general, the more a victims behavior and cognition are adaptive following a trauma, and the more they are able to assimilate and or accommodate the trauma into their experience, the le5s likely they are to develop PTSD.
11. Discuss the role of memory in PTSD. The person with PTSD usually cannot construct a full, coherent story of the trauma because: Too much happened too fast to record memories Dissociative phenomena

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The brain has a fundamental difficulty integrating the trauma with other past life events. Ordinary declarative memories (the conscious awareness of past events) fade in intensity with time. Traumatic memories retain their intensity, even after many years, as if the event always just happened yesterday. Thus, the trauma seems to be a recent experience, rather than an event from the past. Reminders or triggers of the trauma can precipitate the spectrum of intrusive symptoms, flashbacks, intrusive thoughts, and nightmares. Sometimes, the trigger is only remotely related to or symbolic of the trauma. With the passage of time, the person with PTSD can activate intrusive phenomena with a neutral stimulus. When there has been more than one unresolved trauma, the activation of PTSD memories of one may activate memories of the other. This is especially true for people with histories of child abuse. For instance, the helplessness felt in an automobile accident may activate memories of helplessness during childhood sexual or physical abuse.

12. How are compulsivity and avoidance factors in PTSD? Victims with PTSD frequently demonstrate compulsive reexposure to the trauma through hurting others, hurting themselves, or placing themselves in a position to become revictimized. Violent criminals have a high incidence of childhood abuse. Self-destructive behaviors include cutting, burning, suicide attempts and completions, and starvation (anorexia). Rape victims are more likely to be raped again; victims of childhood physical abuse are more likely to be abused by a spouse; and victims of childhood sexual abuse are much more at risk to become prostitutes. Avoidance of triggers becomes the principal activity of the person, who would do anything to not remember the trauma and not have the associated feelings. But since, with time, the person becomes more and more sensitized to cues in the environment, they necessarily must avoid more and more events. The side effect of this process is that more time is spent thinking about the trauma and less time is spent thinking about present-day life. The more intense the emotions experienced during the trauma, the more emotional numbing takes place. All emotions shut down, positive and negative aiike. This leads to social isolation and detachment from loved ones, with resultant conflict and eventual disruption or ending of relationships. Alcohol and drugs may be used to assist in the numbing process, and they may become problems in their own right. 13. How are perceptions skewed by PTSD? The body of a person with PTSD is in a state of chronic hyperarousal of the autonomic nervous system. As in panic disorder, the brain and body are sending the message that there is a constant state of danger. Thus, the individual reacts with hypervigilance, an exaggerated startle response, and agitation. The most insignificant of stimuli can rapidly elicit intense negative emotions. The victims prior belief that the world is basically a safe place is shattered. Victims of PTSD are always on emotional overload; thus, they do not have the benefit of using emotions as signals and guides in relationships or to determine when and what action to take. Studies in adults and children reveal that fantasy tends to break down the harriers against remembering the trauma. Thus, elimination of fantasy is systematic. Since fantasy is necessary for planning and considering options, the PTSD victim has great difficulty with these functions in everyday life. This, in turn, leads to impulsivity and inflexibility. One common defense mechanism, especially in children, is to blame themselves for the trauma. Women frequently blame themselves for being raped. Feelings of helplessness are ovemdden with feelings of guilt, It is better to feel responsible and in control (even falsely) than to feel helpless. Vulnerability and humiliation usually are present in severe traumas. The victims self-confidence goes down, and he or she begins to feel defective and/or inadequate in all aspects of life. This produces profound shame and, if severe enough, may be dissociated away from consciousness. 14. What is the core psychological effect of trauma? Like everyone, trauma victims have developed their own theory about themselves, the world, and the relationship between themselves and the world. Within their reality are strongly held assumptions. These commonly include:

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Belief in their own personal invulnerability Perception of the world as meaningful and comprehensible View of themselves in a positive light. Whenever a person experiences a severe trauma, these unconscious assumptions are challenged. If the trauma cannot be assimilated into preexisting experience, then the person experiences severe anxiety. The stress response syndrome may be largely attributable to the shattering of basic assumptions about the self and the world.

15. Describe the general principles of treatment. The principle treatment modality for PTSD is some type of psychotherapy, such as supportive, psychodynamic, cognitive behavioral, and others, with medication used to augment the psychotherapy and help reduce symptoms. The goals of treatment are: To help patients regain a sense of being worthwhile To again feel in control of themselves and their lives (the opposite of the feelings of helplessness experienced in the trauma) To re-work their shattered assumptions.
16. How is treatment conducted? Many authors, such as Herman, Chu, Van Der Kolk, and others, use a phase-oriented model to conceptualize treatment. While there are differences, most have three phases: Phase I Establishing safety, stabilization, symptom reduction and the therapeutic alliance Phase I1 Dealing with the traumatic event; e.g., through remembering and abreaction, desensitization, deconditioning, mourning, etc. Phase 1 1 1 Restructuring personal schema and integrating the trauma into a meaningful life narrative; i.e., putting the trauma into perspective and moving forward in developing a positive life. The first phase is devoted to establishing safety-in the actual environment as well as in memories. For instance, if the patient with PTSD is living with the perpetrator of violence, plans should be made to ensure safety; i.e., developing a safety plan, arranging alternate housing, or learning how to avoid provoking the abuser. Encourage the patient to improve self care and to reduce self-destructive behaviors, e.g., by abstaining from alcohol and drugs of abuse. Educate early about the signs and symptoms of PTSD, and teach various coping mechanisms for mastering intrusive memories and flashbacks. Address social supports, and inform patients that important people in their lives also should learn about the symptoms of PTSD. Finally, encourage patients not to let their symptoms stop them from functioning in everyday life. In the second phase, the main task is story construction. Frequently, information is needed from collateral sources, such as other victims accounts, eye-witnesses, police records, hospital records, etc. Affects should be identified as they are attached to elements of the story. Many people have great difficulty talking about a trauma because the feelings are so intense, and Brocas area turns off during the trauma. Other approaches include desensitization to the trauma memories, controlled exposure and memory reactivation, and restructuring of trauma-related cognitive schemes. Patients must restructure their personal schema and integrate the trauma into a meaningful narrative within the continuum of their life, while putting the trauma into perspective. In the third phase of treatment, patients must assimilate the trauma(s) into their belief system, or accommodate their beliefs to better fit reality. Their basic assumptions about themselves and the world need to be re-thought. This will necessitate adjusting their sense of self and identity. They are forever changed, and as such need to re-negotiate relationships and make new ones. Patients need to become involved in activities that provide them with feelings of mastery and pleasure.

17. How are medications used to treat PTSD? The principal reasons for using medications are to: Reduce PTSD specific symptoms

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Frequency and/or severity of intrusive symptoms Interpreting incoming stimuli as recurrences of the trauma Developing hyperarousal to stimuli reminiscent of the trauma, as well as in generalized hyperarousal Becoming avoidant Developing numbing Treat depression and/or mood swings Treat anxiety Reduce psychotic or dissociative symptoms Reduce impulsivity and aggression against self and others. Although almost every class of psychiatric medication has been used to treat PTSD, very few medications have been systematically studied. Additionally, the findings of most studies may not be applicable, because they have been done with male combat victims with chronic PTSD. Antidepressants such as fluoxetine, amitriptyline, desipramine, and phenelzine may decrease symptoms of PTSD in addition to their benefits for depressive disorder. Anticonvulsants such as carbamazepine and valproic acid also could be beneficial in treating chronic PTSD. Propanolol and benzodiazepines such as alprazelam and clonazepam appear to decrease the autonomical arousal associated with PTSD. Finally, clonidine, an Alpha,-adrenergic agonist, may be useful in treating PTSD symptoms. Lithium, neuroleptics, and cyproheptadine have been studied only sparsely. Perhaps the best approach is to choose a medication based on the more problematic target symptoms. This may require a combination of medications, e.g., an SSRI to decrease numbing and depression, and a benzodiazepine and a beta blocker to decrease autonomic hyperarousal.
BIBLIOGRAPHY
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

Washington, DC, American Psychiatric Association, 1994. 2. Chu JA: Rebuilding Shattered Lives: The Responsible Treatment of Complex Posttraumatic and Dissociative Disorders. New York, John Wiley & Sons, Inc., 1998. 3. Eth S, Pynoos RS: Developmental perspective on psychic trauma in childhood. In Figley CR (ed): Trauma and Its Wake, Volume I. New York, Brunnerhlazel, 1985. 4. Herman JL: Trauma and Recovery. New York, Harper-Collins, 1992. 5. Janoff-Bulman R: The aftermath of victimization: Rebuilding shattered assumptions. In Figley CR (ed): Trauma and Its Wake, Volume I. New York, Brunnerhlazel, 1985. 6. Pynoos RS, Steinberg AM, Goenjian A: Traumatic stress in childhood and adolescence: Recent developments and current controversies. In van der Kolk BA, McFarlane AC, Weisaeth L (eds): Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, The Guilford Press, 1996. 7. Shalev AY: Stress versus traumatic stress: From acute homeostatic reactions to chronic psychopathology. In van der Kolk BA, McFarlane AC, Weisaeth L (eds): Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, The Guilford Press, 1996. 8. van der Kolk BA: The body keeps score: Approaches to the psychobiology of posttraumatic stress disorder. In van der Kolk BA, McFarlane AC, Weisaeth L (eds): Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, The Guilford Press, 1996. 9. van der Kolk BA, McFarlane AC, van der Hart 0: A general approach to treatment of posttraumatic stress disorder. In van der Kolk BA, McFarlane AC, Weisaeth L (eds): Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society, New York, The Guilford Press, 1996. 10. van der Kolk BA, McFarlane AC: The black hole of trauma. In van der Kolk BA, McFarlane AC, Weisaeth L (eds): Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society, New York, The Guilford Press, 1996. 11. van der Kolk BA, van der Hart 0, Marmar CR: Dissociation and information processing in posttraumatic stress disorder. In van der Kolk BA, McFarlane AC, Weisaeth L (eds): Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society, New York, The Guilford Press, 1996.