Post-Traumatic Stress Disorder (PTSD)
We know that every time people recall memories and talk about them, they can modify the content of those memories.
-Dr. Karim Nader
What is PTSD?
Post-traumatic stress disorder (PTSD) is a psychiatric condition that is diagnosed clinically, that is, by consulting a mental health professional and giving an account of what you are experiencing. Although the diagnostic criteria in the DSM (Diagnostic and Statistics Manual of Mental Disorders) is more detailed, the spirit of the disorder is marked by the presence of the following symptoms still persisting at least one month after an exposure to a traumatic event:
Hyperarousal
E.g., a war veteran hears a traffic helicopter and starts to panic. Common symptoms of hyperarousal include Irritability, recklessness, hypervigilance, an exaggerated startle response, problems in concentration, sleep issue, etc.
Avoidance
E.g., a patient who had been in a car accident doesn’t want to get back in the car or doesn’t want to see anything that is reminding of the accident; or, internally, patients can just detach themselves from social groups and numb their feelings in an attempt to be ‘impervious’ to it all.
Re-experiencing
This refers to the intrusive uncomfortable thoughts, emotions and physical sensations that are consequent to the trauma. They can take the form of:
- Flashbacks or a dissociative reaction where one sort of blanks out and involuntarily disconnects one’s attention from what is going on
- Nightmares
- Emotions that tally with the emotions of the trauma
- Sensory perceptions that tally with those experienced in the trauma (e.g., a lighting pattern, a sound, etc.). These can be frustrating as people can develop seemingly ‘strange’ associations that don’t seem immediately logical, e.g., a route into work may expose one to a pattern of light that flickers through the trees in a pattern that tallies with sensations one experienced at the time of the trauma leading to symptoms of hyperarousal
- Memories (recurrent, involuntary and intrusive)
- Intense and prolonged reaction after an exposure to direct or indirect reminder to a trauma
Mood
Negative changes in cognition and mood like:
- Inability to recall key features of traumatic events
- Persistent – and often distorted – negative beliefs and expectations about oneself or the world, e.g., “it’s all my fault”, “the world is a dangerous place”
- Feeling alienated
- Decreased interest in things you used to enjoy
- An affect that is flatter, like you were wearing a mask
- Depersonalization – feeling like you’re not your self
- Derealization – feeling like the world is not normal
- Feeling ashamed
- Feeling guilty
What trauma is sufficient to elicit PTSD?
A traumatic event has to contain real or threatened emotional and/or physical harm/danger. In some instances, the patient can suffer from PTSD on just hearing about the trauma if it affects them intimately, e.g., hearing about a trauma that occurred to a child can trigger PTSD in a parent. Some people have latent (i.e., not clinically manifest) trauma lingering from the past, even from as far back as when they were pre-verbal (i.e., before the age of 2). And, although these traumas never developed into clinical PTSD, they can set the stage for being more susceptible to PTSD. Those traumas may have been influential in setting up our fear structure (see “Why does PTSD happen?”) or core beliefs about ourselves. In this context, a subsequent trauma may hit a sore spot leading to a negative appraisal of the event: “I shouldn’t have put myself in that situation in the first place”, “The world is a dangerous place”, etc. As such, it should be noted that an event that causes PTSD in one patient may not do so in another. In fact, fortunately, most traumatic events experienced by people do not lead to PTSD.
An analysis from a survey of a large, representative community-based sample in 24 countries estimated the chance of developing of PTSD based on the type of trauma one faces (Kessler et al., 2014):
- Sexual relationship violence – 33 percent (e.g., rape, childhood sexual abuse, intimate partner violence).
- Interpersonal-network traumatic experiences – 30 percent (e.g., unexpected death of a loved one, life-threatening illness of a child, other traumatic event of a loved one).
- Interpersonal violence – 12 percent (e.g., childhood physical abuse or witnessing interpersonal violence, physical assault, or being threatened by violence).
- Exposure to organized violence – 3 percent (e.g., refugee, kidnapped, civilian in war zone).
- Participation in organized violence – 11 percent (e.g., combat exposure, witnessing death/serious injury or discovered dead bodies, accidentally or purposefully caused death or serious injury).
- Other life-threatening traumatic events – 12 percent (e.g., life-threatening motor vehicle collision, natural disaster, toxic chemical exposure).
Does everyone who experiences trauma develop PTSD?
Prospective studies indicate that PTSD symptoms are almost universal in the immediate aftermath of trauma (Rothbaum et al., 1992). The majority of individuals have symptoms of re-experiencing, avoidance, and hyperarousal following a severely traumatic event. For most individuals, these symptoms steadily resolve over time, while those who meet diagnostic criteria for PTSD continue to experience the symptoms. PTSD can thus be viewed as a failure of recovery caused in part by a failure of the fear phasing out (Rothbaum et al., 2003).
Another misunderstanding is that the further you get away from the trauma, the less likely you are to get PTSD. Technically, one will not be said to have PTSD unless the symptoms are still there one month after a trauma. However, people can continue to develop PTSD even years after the trauma. Delayed onset of PTSD can occur when something that happens after the trauma gives the trauma a more threatening meaning. Most individuals who develop PTSD experience its onset within a few months of the traumatic event. However, epidemiological studies have found that approximately 25 percent experience a delayed onset after six months or more (Smid et al., 2009).
Risk factors for developing PTSD include being female; younger age at trauma; lower education; lower socioeconomic status; being separated, divorced, or widowed; previous trauma; general childhood adversity; personal and family psychiatric history; reported childhood abuse; poor social support; and initial severity of reaction to the traumatic event (Van Ameringen et al., 2008; Vieweg et al., 2006 ; Liebschutz et al., 2007; Bisson et al., 2015; Brewin et al., 2000).
The percentage of people that go on to develop PTSD after a traumatic event is influenced by the patient’s characteristics and the details surrounding the inciting event (Yehuda et al., 2015). Women are four times more likely to develop PTSD than men, after adjusting for exposure to traumatic events (Vieweg et al., 2005). The rates of PTSD are similar among men and women after events such as accidents (6.3 versus 8.8 percent), natural disasters (3.7 versus 5.4 percent), and sudden death of a loved one (12.6 versus 16.2 percent).
Why does PTSD happen?
PTSD only occurs if people process the event or its consequences in a way that makes them feel like they are still under threat. Some patients can have beliefs or values that makes it more likely to appraise an event in a negative light, or more negatively than others. Some people may have a different recollection of how things went down; we all see the world through a lens that takes the shade of things we either liked or disliked in our past.
Unlike anxiety in which people fear the unknown, in PTSD, patients fear something that already happened. In other words, patients are afraid of their memories, and they are acting as if they are back there, although they may be in a safe place like in the comfort of their living rooms. Sometimes patients are not consciously aware of the link between their symptoms and their triggers. Common triggers are events, thoughts, images, memories, flashbacks, emotions, behaviours and physiological sensations.
How common is PTSD?
The chance of getting PTSD in a lifetime ranges from 6.1 to 9.2 percent in national samples of the general adult population in the United States and Canada (Kessler et al., 2005; Van Ameringen et al., 2008; Koenen et al., 2017; Goldstein et al., 2016). Any given year, about 3.5 to 4.7 percent have PTSD (Goldstein et al., 2016; Kessler et al., 2005).
The impact of PTSD
PTSD is a serious mental health condition that can have many negative consequences. Some consequences of untreated PTSD are:
Suicide
As with any mental health disorder, suicide remains a significant concern.
Chronicity
PTSD is commonly a chronic condition, with only one-third of patients recovering at one-year follow-up and one-third still symptomatic ten years after the exposure to the trauma (Kessler et al., 1996).
Co-occurring mental health conditions
Disability can endure for a long period of time and one can develop other overlapping mental health issues. The National Comorbidity Survey data suggest that 16 percent of PTSD patients have one coexisting psychiatric disorder, 17 percent have two psychiatric disorders, and 50 percent have three or more (Kessler et al., 1996). Depressive disorders, anxiety disorders, and substance abuse are two to four times more prevalent in patients with PTSD; substance abuse is often due to the patient’s attempts to self-medicate symptoms (Kessler et al., 1996). Approximately 20 percent of people with PTSD have reported use of alcohol or other substances to reduce tension (Leeies et al., 2010).
Co-occurring “physical” health conditions
Research evidence suggests that exposure to traumatic events and PTSD are associated with a range of physical health conditions including bone and joint, neurological, cardiovascular, respiratory, autoimmune and metabolic disease.
What are the treatment options for PTSD?
There are several treatments for PTSD. Psychotherapy remains first line before medication. Medication does not help process the trauma; it may help manage the symptoms of PTSD. There are several psychotherapeutic approaches to PTSD. Majority of psychotherapists (e.g., psychiatrists, psychologists, social workers, etc.) practice an eclectic or integrative form of psychotherapy. Eclectic therapists employ many different techniques including dynamic, cognitive, and behavioral approaches (Palmer et al., 1999). Some common forms of psychotherapy that can be integrated in these approaches are Acceptance and Commitment Therapy (ACT), psychodynamic therapy, eye movement desensitization and reprocessing (EMDR) and interpersonal psychotherapy. It is uncertain how effective these therapies are for PTSD in some cases, and in others some have been shown to be effective. However, the two most evidence-based approaches are Exposure therapy and Cognitive Processing Therapy (CPT).
Exposure Therapy.
Emotional processing theory holds that PTSD emerges due to the development of a fear network in memory that causes people to start avoiding many things in life out of fear. Exposure therapy assists patients in confronting their feared memories and situations in a therapeutic manner. Re-experiencing the trauma through exposure allows it to be emotionally processed so that it can become less painful (Foa et al., 1986, 1989). There are many protocols in exposure therapy stemming from Dr. Joseph Wolpe’s systematic desensitization on the work of such as Imaginal exposure, Prolonged Exposure and Gradual Exposure.
Cognitive Processing Therapy (CPT)
Our YouTube Channel has videos introducing you to this line of therapy designed for PTSD. CPT is basically a structured 12-step CBT program that is focused on identifying your thinking in situations where you get stuck, choked up or in a rut, and evaluating from where they come. Then on the touchstone of reason, thoughts underlying these stuck points are tested to see if they are actually valid or useful. It’s aim is to help you process the trauma so that it no longer weighs you down and you can move on with your life. Generally, the areas processed include:
- What the traumatic event meant to you on emotional, cognitive and behavioural levels
- Learning to connect the dots between your thoughts and feelings
- Processing the the difference between the event and the event’s memory
- Processing several emotions like guilt and blame
- Identifying thoughts that get us stuck in PTSD (i.e., stuck points) and learning to process them so we can get unstuck.
- Identifying and correcting cognitive distortions (problematic thinking)
- Rebuilding a sense of safety, trust and self-esteem
- Fostering power and control to live your life again
- Honouring our sense of intimacy.
Ultimately, the main goal is to process the memories of the event. Although many patients avoid memories of the event, ultimately, the memories need to be processed and integrated and to not be made to not feel conspicuous like a mustard stain on a white shirt. The irony about this is that many patients have a hard time remembering details of the trauma (i.e., avoidance strategy) but they have a high incidence of intrusive memories, emotions, sensory impressions spawned by the trauma. Just talking about the memory in unemotional contexts doesn’t help integrate it, e.g., I had a bad childhood, I was in a car accident, etc.
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