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Understanding PTSD has progressed from early recognition of psychological responses to traumatic experiences such as shell-shock. PTSD is a complex disorder with previous trauma or vicarious experience increasing risk that can now be successfully treated.

Introduction to PTSD

Post-traumatic stress disorder (PTSD) is an anxiety disorder which develops after being involved in, or witnessing, traumatic events. Accounts of psychological reactions to combat (military) trauma date back to ancient Greek and Roman historians' accounts. However it first came into common parlance after the First World War when soldiers were considered to be suffering from "shell shock"; although it's aetiology (cause) was thought to be mechanical, rather than psychological (damage to the brain caused by the explosion of artillery shells). Subsequently, in the Second World War, the shell-shock diagnosis was replaced with Combat Stress Reaction (CSR), also known as "battle fatigue."

In 1952, the first Diagnostic and Statistical Manual of Mental Disorders (DSM-I), included "gross stress reaction." which was aimed at those who were exhibiting symptoms following traumatic experiences such as disaster or combat. In the early 1980s, the term Post Traumatic Stress Disorder (PTSD) was added to the DSM and over time it has been revised and understanding developed as a result of continued research.

Nowadays, PTSD is diagnosed in the presence of the following DSM (Version 5) criteria:

  • Exposure to a stressor

  • Persistent re-experiencing of the event

  • Avoidance of related triggers or reminders after the event

  • Negative thoughts or feelings that being or worsen following the event

  • Presence of trauma-related "arousal" or heightened emotional states.

  • Present for more than one month

  • Must have a significant impact on daily life either due to distress or impairment

  • Is not a result of substances, medication or illness.

Causes and risks/associations of PTSD

People differ in what they experience as traumatic and their longer-term reactions also vary widely. There are a wide array of events now acknowledged as possibly causing PTSD, which go beyond the original concept which was restricted to combat experiences. There is also now recognition of notions such as vicarious trauma or secondary traumatic stress which concerns the impact of indirect exposure to traumatic events. It is essentially the experience of witnessing or experiencing a harmful or life-threatening event.

Common Events Associated with PTSD include:

  • Sexual assault

  • Childhood sexual abuse

  • Physical assault or violent threats of harm

  • Vehicle accidents

  • Natural disasters

  • Medical events (including death and childbirth) or medical diagnoses

  • "Acts of terror" such as terrorist attacks.

Those at increased risk of PTSD include:

  • Children in the care system, especially those in foster care

  • The Armed Forces or Military

  • Those in the helping/caring professions, including the Police.

  • Hormones may also increase risk. Recent research suggests that hormone levels during stress or trauma may have an impact upon the person's reaction to the experience and increase the likelihood of developing subsequent disorders. For example, more negative flashbacks were reported by women who experienced a traumatic event during a high hormonal menstrual phase and those women who took emergency contraception (which suppresses hormones) following sexual assault reported that they experienced less post-traumatic reactions in comparison with those who did not.

  • Genetics may also play a part as there is often a family history of PTSD

  • Age: middle-aged women in their 50s are more likely to experience PTSD

  • Experience of previous trauma (which often leads to presentations of complex PTSD)

  • Mental health history and personality type.

Symptoms of PTSD

The key symptoms of PTSD fall into the following three categories:

  • Re-experiencing the event by frequent intrusive recollections, "flashbacks", and also nightmares.

  • Emotional numbness and avoidance of reminders of the trauma. This could be people, places, activities, for example.

  • Increased arousal such as insomnia, difficulty concentrating, exaggerated startle response (feeling at unease or very "jumpy"), and emotional lability such as being irritable or quick to anger.

Diagnosis of PTSD

Diagnosis is based upon the aforementioned criteria and the assessment process consists of an interview, interview checklists and self-report measures (such as The Impact of Events Scale). Interestingly, although brain-scanning is not part of the diagnosis process, research shows that the experience of trauma causes lasting changes to the brain including a volume of certain areas as well as increased and/or decreased functions in others. Brain imaging studies show altered circuitry in many areas, but the amygdala, hippocampus, and prefrontal cortex seem to be particularly involved in the stress response; as do neuro-chemicals such as cortisol and norepinephrine.

Treatment of PTSD

The primary treatment offered for PTSD is psychotherapy, but it can also include medication, which will be symptom-specific, rather than for the disorder as a whole.

Psychotherapy approaches include:

  • Trauma-focused CBT (cognitive behavioral therapy)

  • Cognitive processing therapy

  • Eye movement and desensitization reprocessing

  • Cognitive therapy

  • Exposure therapy

  • Narrative exposure therapy

  • Brief eclectic psychotherapy.

A recent study found that traditional psychotherapy approaches such as CBT can be augmented by the use of neurofeedback training. In PTSD there is accentuated amygdala action and this approach employing a "reality-checking reappraisal technique", at the same time as providing visual feedback about amygdala activity, showed promising benefits in terms of down-regulation of the amygdala. 

Psychotherapy approaches differ in emphasis but the goal is to enable the person to revisit the event to reprocess or re-evaluate it in some way and to develop new coping skills in relation to their symptoms. All of the approaches are intensive and so require the individual to have a degree of stability in their life; therefore being homeless or using substances or having some other lifestyle factor that might mean they are continually exposed to new stressors/trauma can be problematic.

Self-Care when you have PTSD

There is a lot you can do to help yourself recover from this disorder and accelerate the psychotherapy process:

  • Learn about your triggers and learn how to recognize them
  • Learn breathing strategies to manage flashbacks
  • Carry an object that helps to 'ground you' and bring you back to the present when experiencing a flashback
  • Engage in peer support
  • Look after your health, especially diet and sleep hygiene.  

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