Definition

Post-traumatic stress disorder (PTSD) is a debilitating psychological condition triggered by a major traumatic event, such as rape, war, a terrorist act, death of a loved one, a natural disaster, or a catastrophic accident. It is marked by upsetting memories or thoughts of the ordeal, "blunting" of emotions, increased arousal, and sometimes severe personality changes.

Description

Officially termed post-traumatic stress disorder since 1980, PTSD was once known as shell shock or battle fatigue because of its more common manifestation in war veterans. However in the past 20 years, PTSD has been diagnosed in rape victims and victims of violent crime; survivors of natural disasters; the families of loved ones lost in the downing of Flight 103 over Lockerbie, Scotland; and survivors of the 1993 World Trade Center bombing, the 1995 Oklahoma City bombing, the random school and workplace shootings, and the release of poisonous gas in a Japanese subway; and, most recently, in the September 11, 2001, World Trade Center and Pentagon terrorist attacks. PTSD can affect adults of all ages. Statistics gathered from past events indicate that the risk of PTSD increases in order of the following factors.

• female gender
• middle-aged (40 to 60 years old)
• little or no experience coping with traumatic events
• ethnic minority
• lower socioeconomic status (SES)
• children in the home
• women with spouses exhibiting PTSD symptoms
• pre-existing psychiatric conditions
• primary exposure to the event including injury, life-threatening situation, and loss
• living in traumatized community

For example, over a third of the Oklahoma City bombing survivors developed PTSD and over half showed signs of anxiety, depression, and alcohol abuse. Over one year later, Oklahomans in general had a increased use of alcohol and tobacco products, as well as PTSD symptoms.

Children are also susceptible to PTSD and their risk is increased exponentially as their exposure to the event increases. Children experiencing abuse, the death of a parent, or those located in a community suffering a traumatic event can develop PTSD. Two years after the Oklahoma City bombing, 16% of children in a 100 mile radius of Oklahoma City with no direct exposure to the bombing had increased symptoms of PTSD. Weak parental response to the event, having a parent suffering from PTSD symptoms, and increased exposure to the event via the media all increase the possibility of the child developing PTSD symptoms.

Causes and symptoms

Specific causes for the onset of PTSD following a trauma aren't clearly defined, although experts suspect it may be influenced both by the severity of the event, by the person's personality and genetic make-up, and by whether or not the trauma was expected. First response emergency personnel and individuals directly involved in the event or those children and families who have lost loved ones are more likely to experience PTSD. Natural disasters account for about a 5% rate of PTSD, while there is a 50% rate of PTSD among rape and Holocaust survivors.

Media coverage plays a new role in both adult and pediatric onset of PTSD symptoms. The heightened level of news footage of actual traumatic events, such as the Oklahoma City bombing and the terrorist attack on the World Trade Center and the Pentagon, increases the exposure to the violence, injury, and death associated with the event and may reinforce PTSD symptoms in individuals, especially young children who cannot distinguish between the actual event and the repeated viewing of the event in the media.

PTSD symptoms are distinct and prolonged stress reactions that naturally occur during a highly stressful event. Common symptoms are:

• hyperalertness
• fear and anxiety
• nightmares and flashbacks
• sight, sound, and smell recollection
• avoidance of recall situations
• anger and irritability
• guilt
• depression
• increased substance abuse
• negative world view
• decreased sexual activity

Symptoms usually begin within three months of the trauma, although sometimes PTSD doesn't develop until years after the initial trauma occurred. Once the symptoms begin, they may fade away again within six months. Others suffer with the symptoms for far longer and in some cases, the problem may become chronic.

Among the most troubling symptoms of PTSD are flashbacks, which can be triggered by sounds, smells, feelings, or images. During a flashback, the person relives the traumatic event and may completely lose touch with reality, suffering through the trauma for minutes or hours at a time, believing that the traumatizing event is actually happening all over again.

For a diagnosis of PTSD, symptoms must include at least one of the following so-called "intrusive" symptoms:

• flashbacks
• sleep disorders: nightmares or night terrors
• intense distress when exposed to events that are associated with the trauma

In addition, the person must have at least three of the following "avoidance" symptoms that affect interactions with others:

• trying to avoid thinking or feeling about the trauma
• inability to remember the event
• inability to experience emotion, as well as a loss of interest in former pleasures (psychic numbing or blunting)
• a sense of a shortened future

Finally, there must be evidence of increased arousal, including at least two of the following:

• problems falling asleep
• startle reactions: hyperalertness and strong reactions to unexpected noises
• memory problems
• concentration problems
• moodiness
• violence

In addition to the above symptoms, children with PTSD may experience learning disabilities and memory or attention problems. They may become more dependent, anxious, or even self-abusing.

Recovery may be slowed by injuries, damage to property, loss of employment, or other major problems in the community due to disaster.

Diagnosis

Treatment

Several factors have shown to be important in the treatment of post-traumatic stress. These include proximity of the treatment to the site of the event, immediate intervention of therapy as soon as possible, and the expectation that the individual will eventually return to more normal functions. The most helpful treatment of prolonged PTSD appears to be a combination of medication along with supportive and cognitive-behavioral therapies.

Emergency care

Immediate intervention is important for individuals directly affected by the traumatic event. Emergency care workers focus on achieving the following during the hours and days following the trauma.

• protect survivors from further danger
• treat immediate injuries
• provide food, shelter, fluids, and clothing
• provide safe zone
• locate separated loved ones
• reconnect loved ones
• provide normal social contact
• help reestablish routines
• help resolve transportation, housing, or other issues caused by disaster
• provide grief counseling, stress reduction, and other consultation to enable survivors and families to return to normal life

As well as providing care to others, emergency personnel often need the same support as the survivors. Operational debriefing is used to organize the emergency response and to disseminate information and sense of purpose to the first responders. Critical Incident Stress Debriefing (CISD) is a formal group invention designed to include various crisis intervention, such as information disbursement, one-on-one counseling, consultation, family crisis intervention, and referrals. CISD is not useful for survivors and is an interim support for first responders until they are able to receive therapy.

Medications

Medications used to reduce the symptoms of PTSD include anxiety-reducing medications and antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline HCl (Zoloft). In 2001, the U.S. Food and Drug Administration (FDA) approved Zoloft as a long-term treatment for PTSD. In a controlled study, Zoloft was effective in safely improving symptoms of PTSD over a period of 28 weeks and reducing the risk of relapse.

Sleep problems can be lessened with brief treatment with an anti-anxiety drug, such as a benzodiazepine like alprazolam (Xanax), but long-term usage can lead to disturbing side effects, such as increased anger, drug tolerance, dependency, and abuse.

Therapy

Several types of therapy may be useful and they are often combined in a multi-faceted approach to understand and treat this condition.

• Cognitive-behavioral therapy focuses on changing specific actions and thoughts through repetitive review of traumatic events, identification of negative behaviors and thoughts, and stress management.
• Group therapy has been useful in decreasing psychological distress, depression, and anxiety in some PTSD sufferers such as sexually abused women and war veterans.
• Psychological debriefing has been widely used to treat victims of natural disasters and other traumatic events such as bombings and workplace shootings, however, recent research shows that psychological debriefing may increase the stress response. Since this type of debriefing focuses on the emotional response of the survivor, it is not recommended for individuals experiencing an extreme level of grief.

Alternative treatment

Several means of alternative treatment may be helpful in combination with conventional therapy for reduction of the symptoms of post-traumatic stress disorder. These include relaxation training, breathing techniques, spiritual treatment, and drama therapy where the event is re-enacted.

Prognosis

The severity of the illness depends in part on whether the trauma was unexpected, the severity of the trauma, how chronic the trauma was (such as for victims of sexual abuse), and the person's readiness to embrace the recovery process. With appropriate medication, emotional support, counseling, and follow-up care, most people show significant improvement. However, prolonged exposure to severe trauma, such as experienced by victims of prolonged physical or sexual abuse and survivors of the Holocaust, may cause permanent psychological scars.

Prevention

More studies are needed to determine if PTSD can actually be prevented. Some measures that have been explored include controlling exposure to traumatic events through safety and security measures, psychological preparation for individuals who will be exposed to traumatic events (i.e. policemen, paramedics, soldiers), and stress inoculation training (rehearsal of the event with small doses of the stressful situation).

Resources:

Books:

• Fullerton, Carol and Robert Ursano, editors. Posttraumatic Stress Disorder: Acute and Long-term Responses to Trauma and Disaster. Washington, DC: American Psychiatric Press, 1997.
• O'Brien, Stephen. Traumatic Events and Mental Health. Cambridge University Press, 1998.

Periodicals:

• DiGiovanni, C. "Domestic Terrorism with Chemical or Biological Agents: Psychiatric Aspects." American Journal of Psychiatry 156 (1999): 1500-1505.
• North, C., S. Nixon, S. Hariat, S. Mallonee et al. "Psychiatric Disorders Among Survivors of the Oklahoma City Bombing." Journal of the American Medical Association 282 (1999): 755-762.
• Pfefferbaum, B., R. Gurwitch, N. McDonald et al. "Posttraumatic Stress Among Children After the Death of a Friend or Acquaintance in a Terrorist Bombing." Psychiatric Services 51 (2000): 386-388.
• "Sertraline HCl Approved for Long-Term Use." Women's Health Weekly (September 20, 2001).
• Sloan, M. "Response to Media Coverage of Terrorism" Journal of Conflict Resolution 44 (2000): 508-522.
• Smith, D, E. Christiansen, R. Vincent, and N. Hann. "Population Effects of the Bombing of Oklahoma City." Journal of Oklahoma State Medical Association 92 (1999): 193-198.

Organizations:

• American Psychiatric Association. 1400 K St., NW, Washington, DC 20005.
• Anxiety Disorders Association of America. 11900 Parklawn Dr., Ste. 100, Rockville, MD 20852. (301) 231-9350.
• Freedom From Fear. 308 Seaview Ave., Staten Island, NY 10305. (718) 351-1717.
• National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166.
• National Institute of Mental Health. Rm 15C-05, 5600 Fishers Lane, Rockville, MD 20857.
• Society for Traumatic Stress Studies, 60 Revere Dr., Ste. 500, Northbrook, IL 60062. (708) 480-9080.
• National Center for Post-Traumatic Stress Disorder. http://www.dartmouth.edu/dms/ptsd.

Reviewed: 01/2006