Post Traumatic Stress Disorder
 

 

 

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Post-Traumatic Stress Disorder

 

Course Objectives

Upon completion of this course material, the health care professional will be able to:                       

1.  Assess a patient for the most common symptoms of Post-Traumatic Stress Disorder

2.  Evaluate the patient's level of pathology

3.  Describe the medications used to treat PTSD

4.  Describe how cognitive behavioral therapy is used with victims of trauma

5.  Describe the symptoms of PTSD in children

 

What is Post-Traumatic Stress Disorder?

 

Posttraumatic Stress Disorder, or PTSD, is a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair the person's daily life.

PTSD is marked by clear biological changes as well as psychological symptoms. PTSD is complicated by the fact that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health. The disorder is also associated with impairment of the person's ability to function in social or family life, including occupational instability, marital problems and divorces, family discord, and difficulties in parenting.

Understanding PTSD

PTSD is not a new disorder. There are written accounts of similar symptoms that go back to ancient times, and there is clear documentation in the historical medical literature starting with the Civil War, when a PTSD-like disorder was known as "Da Costa's Syndrome." There are particularly good descriptions of posttraumatic stress symptoms in the medical literature on combat veterans of World War II and on Holocaust survivors.

Careful research and documentation of PTSD began in earnest after the Vietnam War. The National Vietnam Veterans Readjustment Study estimated in 1988 that the prevalence of PTSD in that group was 15.2% at that time and that 30% had experienced the disorder at some point since returning from Vietnam.

PTSD has subsequently been observed in all veteran populations that have been studied, including World War II, Korean conflict, and Persian Gulf populations, and in United Nations peacekeeping forces deployed to other war zones around the world. There are remarkably similar findings of PTSD in military veterans in other countries. For example, Australian Vietnam veterans experience many of the same symptoms that American Vietnam veterans experience.

PTSD is not only a problem for veterans, however. Although there are unique cultural- and gender-based aspects of the disorder, it occurs in men and women, adults and children, Western and non-Western cultural groups, and all socioeconomic strata. A national study of American civilians conducted in 1995 estimated that the lifetime prevalence of PTSD was 5% in men and 10% in women.

 

How does PTSD develop?

 

Most people who are exposed to a traumatic, stressful event experience some of the symptoms of PTSD in the days and weeks following exposure. Available data suggest that about 8% of men and 20% of women go on to develop PTSD, and roughly 30% of these individuals develop a chronic form that persists throughout their lifetimes.

The course of chronic PTSD usually involves periods of symptom increase followed by remission or decrease, although some individuals may experience symptoms that are unremitting and severe. Some older veterans, who report a lifetime of only mild symptoms, experience significant increases in symptoms following retirement, severe medical illness in themselves or their spouses, or reminders of their military service (such as reunions or media broadcasts of the anniversaries of war events).

 

How is PTSD assessed?

In recent years, a great deal of research has been aimed at developing and testing reliable assessment tools. It is generally thought that the best way to diagnose PTSD-or any psychiatric disorder, for that matter-is to combine findings from structured interviews and questionnaires with physiological assessments. A multi-method approach especially helps address concerns that some patients might be either denying or exaggerating their symptoms.

 

How common is PTSD?

An estimated 7.8 percent of Americans will experience PTSD at some point in their lives, with women (10.4%) twice as likely as men (5%) to develop PTSD. About 3.6 percent of U.S. adults aged 18 to 54 (5.2 million people) have PTSD during the course of a given year. This represents a small portion of those who have experienced at least one traumatic event; 60.7% of men and 51.2% of women reported at least one traumatic event. The traumatic events most often associated with PTSD for men are rape, combat exposure, childhood neglect, and childhood physical abuse. The most traumatic events for women are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.

About 30 percent of the men and women who have spent time in war zones experience PTSD. An additional 20 to 25 percent have had partial PTSD at some point in their lives. More than half of all male Vietnam veterans and almost half of all female Vietnam veterans have experienced "clinically serious stress reaction symptoms." PTSD has also been detected among veterans of the Gulf War, with some estimates running as high as 8 percent.

 

Who is most likely to develop PTSD?

1. Those who experience greater stressor magnitude and intensity, unpredictability, uncontrollability, sexual (as opposed to nonsexual) victimization, real or perceived responsibility, and betrayal

2. Those with prior vulnerability factors such as genetics, early age of onset and longer-lasting childhood trauma, lack of functional social support, and concurrent stressful life events

3. Those who report greater perceived threat or danger, suffering, upset, terror, and horror or fear

4. Those with a social environment that produces shame, guilt, stigmatization, or self-hatred.

 

What are the consequences associated with PTSD?

 

PTSD is associated with a number of distinctive neurobiological and physiological changes. PTSD may be associated with stable neurobiological alterations in both the central and autonomic nervous systems, such as altered brainwave activity, decreased volume of the hippocampus, and abnormal activation of the amygdala. Both the hippocampus and the amygdala are involved in the processing and integration of memory. The amygdala has also been found to be involved in coordinating the body's fear response.

Psychophysiological alterations associated with PTSD include hyper-arousal of the sympathetic nervous system, increased sensitivity of the startle reflex, and sleep abnormalities.

People with PTSD tend to have abnormal levels of key hormones involved in the body's response to stress. Thyroid function also seems to be enhanced in people with PTSD. Some studies have shown that cortisol levels in those with PTSD are lower than normal and epinephrine and norepinephrine levels are higher than normal. People with PTSD also continue to produce higher than normal levels of natural opiates after the trauma has passed. An important finding is that the neurohormonal changes seen in PTSD are distinct from, and actually opposite to, those seen in major depression. The distinctive profile associated with PTSD is also seen in individuals who have both PTSD and depression.

Co-occurring Psychiatric Disorders

PTSD is associated with the increased likelihood of co-occurring psychiatric disorders. In a large-scale study, 88 percent of men and 79 percent of women with PTSD met criteria for another psychiatric disorder. The co-occurring disorders most prevalent for men with PTSD were alcohol abuse or dependence (51.9 percent), major depressive episodes (47.9 percent), conduct disorders (43.3 percent), and drug abuse and dependence (34.5 percent). The disorders most frequently comorbid with PTSD among women were major depressive disorders (48.5 percent), simple phobias (29 percent), social phobias (28.4 percent), and alcohol abuse/dependence (27.9 percent).

PTSD also significantly impacts psychosocial functioning, independent of comorbid conditions. For instance, Vietnam veterans with PTSD were found to have profound and pervasive problems in their daily lives. These included problems in family and other interpersonal relationships, problems with employment, and involvement with the criminal justice system.

Headaches, gastrointestinal complaints, immune system problems, dizziness, chest pain, and discomfort in other parts of the body are common in people with PTSD. Often, medical doctors treat the symptoms without being aware that they stem from PTSD.

 

How is PTSD treated?

 

PTSD is treated by a variety of forms of psychotherapy and drug therapy. There is no definitive treatment, and no cure, but some treatments appear to be quite promising, especially cognitive-behavioral therapy, group therapy, and exposure therapy.

Exposure therapy involves having the patient repeatedly relive the frightening experience under controlled conditions to help him or her work through the trauma. Studies have also shown that medications help ease associated symptoms of depression and anxiety and help with sleep. The most widely used drug treatments for PTSD are the selective serotonin reuptake inhibitors, such as Prozac and Zoloft. At present, cognitive-behavioral therapy appears to be somewhat more effective than drug therapy. However, it would be premature to conclude that drug therapy is less effective overall since drug trials for PTSD are at a very early stage. Drug therapy appears to be highly effective for some individuals and is helpful for many more. In addition, the recent findings on the biological changes associated with PTSD have spurred new research into drugs that target these biological changes, which may lead to much increased efficacy.

Treatment of PTSD

This fact sheet describes elements common to many treatment modalities for PTSD, including education, exposure, exploration of feelings and beliefs, and coping skills training. Additionally, the most common treatment modalities are discussed, including cognitive-behavioral treatment, pharmacotherapy, EMDR, group treatment, and psychodynamic treatment.

Common Components of PTSD Treatment:

Treatment for PTSD typically begins with a detailed evaluation, and development of a treatment plan that meets the unique needs of the survivor. Generally, PTSD-specific-treatment is begun only when the survivor is safely removed from a crisis situation. For instance, if currently exposed to trauma (such as by ongoing domestic or community violence, abuse, or homelessness), severely depressed or suicidal, experiencing extreme panic or disorganized thinking, or in need of drug or alcohol detoxification, addressing these crisis problems becomes part of the first treatment phase.

Educating trauma survivors and their families about how persons get PTSD, how PTSD affects survivors and their loved ones, and other problems that commonly come along with PTSD symptoms. Understanding that PTSD is a medically recognized anxiety disorder that occurs in normal individuals under extremely stressful conditions is essential for effective treatment.

Exposure to the event via imagery allows the survivor to reexperience the event in a safe, controlled environment, while also carefully examining their reactions and beliefs in relation to that event.  Examining and resolving strong feelings such as anger, shame, or guilt, which are common among survivors of trauma.

Teaching the survivor to cope with post-traumatic memories, reminders, reactions, and feelings without becoming overwhelmed or emotionally numb is essential. Trauma memories usually do not go away entirely as a result of therapy, but become manageable with new coping skills.

Therapeutic Approaches Commonly Used to Treat PTSD:

Cognitive-behavioral therapy (CBT) involves working with cognitions to change emotions, thoughts, and behaviors. Exposure therapy, is one form of CBT unique to trauma treatment which uses careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled context, to help the survivor face and gain control of the fear and distress that was overwhelming in the trauma. In some cases, trauma memories or reminders can be confronted all at once ("flooding"). For other individuals or traumas it is preferable to work gradually up to the most severe trauma by using relaxation techniques and either starting with less upsetting life stresses or by taking the trauma one piece at a time ("desensitization").

Along with exposure, CBT for trauma includes learning skills for coping with anxiety (such as breathing retraining or biofeedback) and negative thoughts ("cognitive restructuring"), managing anger, preparing for stress reactions ("stress inoculation"), handling future trauma symptoms, as well as addressing urges to use alcohol or drugs when they occur ("relapse prevention"), and communicating and relating effectively with people ("social skills" or marital therapy).

Eye Movement Desensitization and Reprocessing

(EMDR) is a relatively new treatment of traumatic memories which involves elements of exposure therapy and cognitive behavioral therapy, combined with techniques (eye movements, hand taps, sounds) which create an alteration of attention back and forth across the person's midline. While the theory and research are still evolving with this form of treatment, there is some evidence that the therapeutic element unique to EMDR, attentional alteration, may facilitate accessing and processing traumatic material.

Group treatment is often an ideal therapeutic setting because trauma survivors are able to risk sharing traumatic material with the safety, cohesion, and empathy provided by other survivors. As group members achieve greater understanding and resolution of their trauma, they often feel more confident and able to trust. As they discuss and share coping of trauma-related shame, guilt, rage, fear, doubt, and self-condemnation, they prepare themselves to focus on the present rather than the past. Telling one's story (the "trauma narrative") and directly facing the grief, anxiety, and guilt related to trauma enables many survivors to cope with their symptoms, memories, and other aspects of their lives.

Brief psychodynamic psychotherapy focuses on the emotional conflicts caused by the traumatic event, particularly as they relate to early life experiences. Through the retelling of the traumatic event to a calm, empathic, compassionate and non-judgmental therapist, the survivor achieves a greater sense of self-esteem, develops effective ways of thinking and coping, and more successfully deals with the intense emotions that emerge during therapy. The therapist helps the survivor identify current life situations that set off traumatic memories and worsen PTSD symptoms.

Psychiatric disorders commonly co-occurring with PTSD

 

Psychiatric disorders commonly co-occurring with PTSD include: depression, alcohol/substance abuse, panic disorder, and other anxiety disorders. Although crises that threaten the safety of the survivor or others must be addressed first, the best treatment results are achieved when both PTSD and the other disorder(s) are treated together rather than one after the other. This is especially true for PTSD and alcohol/substance abuse.

Complex PTSD

Complex PTSD (sometimes called "Disorder of Extreme Stress") is found among individuals who have been exposed to prolonged traumatic circumstances, especially during childhood, such as childhood sexual abuse. Developmental research is revealing that many brain and hormonal changes may occur as a result of early, prolonged trauma, and contribute to difficulties with memory, learning, and regulating impulses and emotions. Combined with a disruptive, abusive home environment which does not foster healthy interaction, these brain and hormonal changes may contribute to severe behavioral difficulties (such as impulsivity, aggression, sexual acting out, eating disorders, alcohol/drug abuse, and self-destructive actions), emotional regulation difficulties (such as intense rage, depression, or panic) and mental difficulties (such as extremely scattered thoughts, dissociation, and amnesia). As adults, these individuals often are diagnosed with depressive disorders, personality disorders or dissociative disorders. Treatment often takes much longer, may progress at a much slower rate, and requires a sensitive and structured treatment program delivered by a trauma specialist.

The National Vietnam Veterans Readjustment Survey (NVVRS) report provided the following information about PTSD among Vietnam War veterans:

  • The estimated lifetime prevalence of PTSD among American Vietnam theater veterans is 30.9% for men and 26.9% for women. An additional 22.5% of men and 21.2% of women have had partial PTSD at some point in their lives. Thus, more than half of all male Vietnam veterans and almost half of all female Vietnam veterans-about 1,700,000 Vietnam veterans in all-have experienced "clinically serious stress reaction symptoms."
  • 15.2% of all male Vietnam theater veterans (479,000 out of 3,140,000 men who served in Vietnam) and 8.1% of all female Vietnam theater veterans (610 out of 7,200 women who served in Vietnam) are currently diagnosed with PTSD. ("Currently" means 1986-88 when the survey was conducted.)
  • The NVVRS report also contains these figures on other problems of Vietnam veterans:
  • Forty percent of Vietnam theater veteran men have been divorced at least once (10% had two or more divorces), 14.1% report high levels of marital problems, and 23.1% have high levels of parenting problems.
  • Almost half of all male Vietnam theater veterans currently suffering from PTSD had been arrested or in jail at least once-34.2% more than once-and 11.5% had been convicted of a felony.
  • The estimated lifetime prevalence of alcohol abuse or dependence among male theater veterans is 39.2%, and the estimate for current alcohol abuse or dependence is 11.2%. The estimated lifetime prevalence of drug abuse or dependence among male theater veterans is 5.7%, and the estimate for current drug abuse or dependence is 1.8%.

 

PTSD in Children and Adolescents

The diagnosis of Posttraumatic Stress Disorder (PTSD) was formally recognized as a psychiatric diagnosis in 1980. At that time, little was known about what PTSD looked like in children and adolescents. Today, we know children and adolescents are susceptible to developing PTSD, and we know that PTSD has different age-specific features. In addition, we are beginning to develop child-focused interventions. This fact sheet provides information regarding what events cause PTSD in children, how many children develop PTSD, risk factors associated with PTSD, what PTSD looks like in children, other effects of trauma on children, treatment for PTSD, and what you can do for your child.

 

What events cause PTSD in children?

A diagnosis of PTSD means that an individual experienced an event that involved a threat to one's own or another's life or physical integrity and that this person responded with intense fear, helplessness, or horror. There are a number of traumatic events that have been shown to cause PTSD in children and adolescents. Children and adolescents may be diagnosed with PTSD if they have survived natural and man made disasters such as floods; violent crimes such as kidnapping, rape or murder of a parent, sniper fire, and school shootings; motor vehicle accidents such as automobile and plane crashes; severe burns; exposure to community violence; war; peer suicide; and sexual and physical abuse.

 

How many children develop PTSD?

A few studies of the general population have been conducted that examine rates of exposure and PTSD in children and adolescents . Results from these studies indicate that 15 to 43% of girls and 14 to 43% of boys have experienced at least one traumatic event in their lifetime. Of those children and adolescents who have experienced a trauma, 3 to 15% of girls and 1 to 6% of boys could be diagnosed with PTSD.

Rates of PTSD are much higher in children and adolescents recruited from at-risk samples. The rates of PTSD in these at-risk children and adolescents vary from 3 to 100%. For example, studies have shown that as many as 100% of children who witness a parental homicide or sexual assault develop PTSD. Similarly, 90% of sexually abused children, 77% of children exposed to a school shooting, and 35% of urban youth exposed to community violence develop PTSD.

 

What are the risk factors for PTSD?

There are three factors that have been shown to increase the likelihood that children will develop PTSD. These factors include the severity of the traumatic event, the parental reaction to the traumatic event, and the physical proximity to the traumatic event. In general, most studies find that children and adolescents who report experiencing the most severe traumas also report the highest levels of PTSD symptoms. Family support and parental coping have also been shown to affect PTSD symptoms in children. Studies show that children and adolescents with greater family support and less parental distress have lower levels of PTSD symptoms. Finally, children and adolescents who are farther away from the traumatic event report less distress.

There are several other factors that affect the occurrence and severity of PTSD. Research suggests that interpersonal traumas such as rape and assault are more likely to result in PTSD than other types of traumas. Additionally, if an individual has experienced a number of traumatic events in the past, those experiences increase the risk of developing PTSD. In terms of gender, several studies suggest that girls are more likely than boys to develop PTSD. A few studies have examined the connection between ethnicity and PTSD. While some studies find that minorities report higher levels of PTSD symptoms, researchers have shown that this is due to other factors such as differences in levels of exposure. It is not clear how a child’s age at the time of exposure to a traumatic event impacts the occurrence or severity of PTSD. While some studies find a relationship, others do not. Differences that do occur may be due to differences in the way PTSD is expressed in children and adolescents of different ages or developmental levels.

What does PTSD look like in children?

Researchers and clinicians are beginning to recognize that PTSD may not present itself in children the same way it does in adults.  Criteria for PTSD now include age-specific features for some symptoms.

Very young children may present with few PTSD symptoms. This may be because eight of the PTSD symptoms require a verbal description of one's feelings and experiences. Instead, young children may report more generalized fears such as stranger or separation anxiety, avoidance of situations that may or may not be related to the trauma, sleep disturbances, and a preoccupation with words or symbols that may or may not be related to the trauma. These children may also display posttraumatic play in which they repeat themes of the trauma. In addition, children may lose an acquired developmental skill (such as toilet training) as a result of experiencing a traumatic event.

Clinical reports suggest that elementary school-aged children may not experience visual flashbacks or amnesia for aspects of the trauma. However, they do experience "time skew" and "omen formation," which are not typically seen in adults. Time skew refers to a child mis-sequencing trauma related events when recalling the memory. Omen formation is a belief that there were warning signs that predicted the trauma. As a result, children often believe that if they are alert enough, they will recognize warning signs and avoid future traumas. School-aged children also reportedly exhibit posttraumatic play or reenactment of the trauma in play, drawings, or verbalizations. Posttraumatic play is different from reenactment in that posttraumatic play is a literal representation of the trauma, involves compulsively repeating some aspect of the trauma, and does not tend to relieve anxiety. An example of posttraumatic play is an increase in shooting games after exposure to a school shooting. Posttraumatic reenactment, on the other hand, is more flexible and involves behaviorally recreating aspects of the trauma (e.g., carrying a weapon after exposure to violence).

 

Besides PTSD, what are the other effects of trauma on children?

PTSD in adolescents may begin to more closely resemble PTSD in adults. However, there are a few features that have been shown to differ. As discussed above, children may engage in traumatic play following a trauma. Adolescents are more likely to engage in traumatic reenactment, in which they incorporate aspects of the trauma into their daily lives. In addition, adolescents are more likely than younger children or adults to exhibit impulsive and aggressive behaviors.

Besides PTSD, children and adolescents who have experienced traumatic events often exhibit other types of problems. Perhaps the best information available on the effects of traumas on children comes from a review of the literature on the effects of child sexual abuse. In this review, it was shown that sexually abused children often have problems with fear, anxiety, depression, anger and hostility, aggression, sexually inappropriate behavior, self-destructive behavior, feelings of isolation and stigma, poor self-esteem, difficulty in trusting others, and substance abuse. These problems are often seen in children and adolescents who have experienced other types of traumas as well. Children who have experienced traumas also often have relationship problems with peers and family members, problems with acting out, and problems with school performance.

Along with associated symptoms, there are a number of psychiatric disorders that are commonly found in children and adolescents who have been traumatized. One commonly co-occurring disorder is major depression. Other disorders include substance abuse; other anxiety disorders such as separation anxiety, panic disorder, and generalized anxiety disorder; and externalizing disorders such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder.

 

How is PTSD treated in children and adolescents?

Although some children show a natural remission in PTSD symptoms over a period of a few months, a significant number of children continue to exhibit symptoms for years if untreated. Few treatment studies have examined which treatments are most effective for children and adolescents. A review of the adult treatment studies of PTSD shows that Cognitive-Behavioral Therapy (CBT) is the most effective approach. CBT for children generally includes the child directly discussing the traumatic event (exposure), anxiety management techniques such as relaxation and assertiveness training, and correction of inaccurate or distorted trauma related thoughts. Although there is some controversy regarding exposing children to the events that scare them, exposure-based treatments seem to be most relevant when memories or reminders of the trauma distress the child. Children can be exposed gradually and taught relaxation so that they can learn to relax while recalling their experiences. Through this procedure, they learn that they do not have to be afraid of their memories. CBT also involves challenging children's false beliefs such as, "the world is totally unsafe." The majority of studies have found that it is safe and effective to use CBT for children with PTSD.

CBT is often accompanied by psycho-education and parental involvement. Psycho-education is education about PTSD symptoms and their effects. It is as important for parents and caregivers to understand the effects of PTSD as it is for children. Research shows that the better parents cope with the trauma, and the more they support their children, the better their children will function. Therefore, it is important for parents to seek treatment for themselves in order to develop the necessary coping skills that will help their children.

Several other types of therapy have been suggested for PTSD in children and adolescents. Play therapy can be used to treat young children with PTSD who are not able to deal with the trauma more directly. The therapist uses games, drawings, and other techniques to help the children process their traumatic memories.

Psychological first aid has been prescribed for children exposed to community violence and can be used in schools and traditional settings. Psychological first aid involves clarifying trauma related facts, normalizing the children's PTSD reactions, encouraging the expression of feelings, teaching problem solving skills, and referring the most symptomatic children for additional treatment. Twelve Step approaches have been prescribed for adolescents with substance abuse problems and PTSD. Another therapy, Eye Movement Desensitization and Reprocessing (EMDR), combines cognitive therapy with directed eye movements. While EMDR has been shown to be effective in treating both children and adults with PTSD, studies indicate that it is the cognitive intervention rather than the eye movements that accounts for the change. Medications have also been prescribed for some children with PTSD.Ê However, due to the lack of research in this area, it is too early to evaluate the effectiveness of medication therapy.

Finally, specialized interventions may be necessary for children exhibiting particularly problematic behaviors or PTSD symptoms. For example, a specialized intervention might be required for inappropriate sexual behavior or extreme behavioral problems.

Motor Vehicle Accidents

Researchers are looking more closely at motor vehicle accidents (MVAs) as a common cause of traumatic stress. In one large study, accidents were shown to be the traumatic event most frequently experienced by males (25%) and the second most frequent traumatic event experienced by females (13%) in the United States. Over 100 billion dollars are spent every year to take care of the damage caused by auto accidents. Survivors of MVAs often also experience emotional distress as a result of such accidents. Mental-health difficulties such as posttraumatic stress, depression, and anxiety are problems survivors of severe MVAs may exhibit. This fact sheet addresses important issues related to MVAs, including how many people experience serious MVAs, how many people develop MVA-related Posttraumatic Stress Disorder (PTSD) and other psychological reactions, what the risk factors are for MVA-related PTSD, and what kind of treatments help MVA-related PTSD.

How many people experience serious motor vehicle accidents?

One unfortunate consequence of the high volume of commuter and personal travel in the U.S. is the number of accidents that result in personal injury and fatalities. In any given year, approximately 1% of the U.S. population will be injured in motor vehicle accidents. Thus, MVAs account for over 3 million injuries annually and are one of the most common traumas individuals experience.

How many people develop MVA-related PTSD and other psychological reactions?

Research on individuals seeking treatment and individuals in the general population suggests that the majority of those who survive a serious MVA do not develop mental-health problems that warrant professional treatment. However, a substantial minority of MVA survivors suffer from mental-health problems, the most common of which are Posttraumatic Stress Disorder (PTSD), Major Depression, and Anxiety Disorders.

Studies of the general population have found that approximately 9% of MVA survivors develop PTSD. Rates are significantly higher in samples of MVA survivors who seek mental-health treatment. Studies show that between 14% and 100% of MVA survivors who seek mental-health treatment have PTSD, with an average of 60% across studies. In addition, between 3% and 53% of MVA survivors who seek treatment and have PTSD also have a mood disorder such as Major Depression. Finally, in one large study of MVA survivors who sought treatment, 27% had an anxiety disorder in addition to their PTSD, and 15% reported a phobia of driving

What are the risk factors for MVA-related PTSD?

Recent research has identified variables that have predictive value when trying to determine who might experience PTSD after a serious accident. The use of such research allows clinicians to identify individuals at risk for long-term mental-health problems secondary to their accident.

The research focusing on identifying at risk individuals has been directed at three sets of variables: characteristics about the individual that were present prior to the MVA, accident-related variables, and post accident variables.

Pre-accident variables such as poor ability to cope in reaction to previous traumatic events, the presence of a pre-accident mental-health problem (e.g., depression), and poor social support have all been linked to the development of PTSD following severe MVAs.

With respect to accident-related variables, the amount of physical injury, potential life-threat, and loss of significant others have been predictive of the development of mental-health problems such as PTSD. That is, as the amount of physical injury and fear of dying increase, the chance of developing PTSD also increases.

Post accident variables that are predictive of PTSD following MVAs are: the rate of physical recovery from injury, the level of social support from friends and family, and the level of active reengagement in both work and social activities. To the extent that physical limitations will allow, survivors of MVAs should be encouraged to maintain as much of their pre-accident lifestyle as possible, with as much support from family and friends as possible. Such coping strategies appear to be linked with positive mental-health outcomes.

What treatments are available for MVA-related PTSD?

One aspect of MVA-related PTSD that is different from PTSD caused by other traumas is the increased likelihood of being injured or developing a chronic pain condition following the trauma. As a result, many people who have been in an MVA present first to their primary care physicians for treatment and do not consider psychological treatment for some time. Unfortunately, studies have shown that of the people who develop PTSD and do not seek psychological treatment, approximately half continue to have symptoms for more than six months or a year. Therefore, it is important to identify the symptoms early on and seek appropriate psychological treatment.

A number of different treatment approaches have proven effective for MVA-related PTSD. Treatments include behavior therapy, cognitive therapy, and medications. In addition, it may be useful to work with a chronic pain specialist to help manage the physical pain caused by the injury. Sometimes these treatments are provided in conjunction with one another.

How do PTSD and alcohol use affect each other and make problems worse?

 

  • PTSD and alcohol problems often occur together. People with PTSD are more likely than others with similar backgrounds to have alcohol use disorders both before and after being diagnosed with PTSD, and people with alcohol use disorders often also have PTSD.  Being diagnosed with PTSD increases the risk of developing an alcohol use disorder.
  • Women exposed to trauma show an increased risk for an alcohol use disorder even if they are not experiencing PTSD. Women with problematic alcohol use are more likely than other women to have been sexually abused at some point in their lives.
  • Men and women reporting sexual abuse have higher rates of alcohol and drug use disorders than other men and women.
  • Twenty-five to seventy-five percent of those who have survived abusive or violent trauma also report problems with alcohol use.
  • Ten to thirty-three percent of survivors of accidental, illness, or disaster trauma report problematic alcohol use, especially if they are troubled by persistent health problems or pain.
  • Sixty to eighty percent of Vietnam veterans seeking PTSD treatment have alcohol use disorders. Veterans over the age of 65 with PTSD are at increased risk for attempted suicide if they also experience problematic alcohol use or depression. War veterans diagnosed with PTSD and alcohol use tend to be binge drinkers. Binges may be in reaction to memories or reminders of trauma.
  • Alcohol problems often lead to trauma and disrupt relationships.
  • Persons with alcohol use disorders are more likely than others with similar backgrounds to experience psychological trauma. They also experience problems with conflict and intimacy in relationships.
  • Problematic alcohol use is associated with a chaotic lifestyle, which reduces family emotional closeness, increases family conflict, and reduces parenting abilities.
  • PTSD symptoms often are worsened by alcohol use.
  • Although alcohol can provide a temporary feeling of distraction and relief, it also reduces the ability to concentrate, enjoy life, and be productive.
  • Excessive alcohol use can impair one's ability to sleep restfully and to cope with trauma memories and stress.
  • Alcohol use and intoxication also increase emotional numbing, social isolation, anger and irritability, depression, and the feeling of needing to be on guard (hyper-vigilance).
  • Alcohol use disorders reduce the effectiveness of PTSD treatment.
  • Many individuals with PTSD experience sleep disturbances (trouble falling asleep or problems with waking up frequently after falling asleep). When a person with PTSD experiences sleep disturbances, using alcohol as a way to self-medicate becomes a double-edged sword. Alcohol use may appear to help symptoms of PTSD because the alcohol may decrease the severity and number of frightening nightmares commonly experienced in PTSD. However, alcohol use may, on the other hand, continue the cycle of avoidance found in PTSD, making it ultimately much more difficult to treat PTSD because the client's avoidance behavior prolongs the problems being addressed in treatment. Also, when a person withdraws from alcohol, nightmares often increase.
  • Individuals with a combination of PTSD and alcohol use problems often have additional mental or physical health problems. As many as 10-50% of adults with alcohol use disorders and PTSD also have one or more of the following serious disorders:
  • Anxiety disorders (such as panic attacks, phobias, incapacitating worry, or compulsions)
  • Mood disorders (such as major depression or a dysthymic disorder)
  • Disruptive behavior disorders (such as attention deficit or antisocial personality disorder)
  • Addictive disorders (such as addiction to or abuse of street or prescription drugs)
  • Chronic physical illness (such as diabetes, heart disease, or liver disease)
  • Chronic physical pain due to physical injury/illness or due to no clear physical cause

What are the most effective treatment patterns?

Because the existence of both PTSD and an alcohol use disorder in an individual makes both problems worse, alcohol use problems often must be addressed in PTSD treatment. When alcohol use is (or has been) a problem in addition to PTSD, it is best to seek treatment from a PTSD specialist who also has expertise in treating alcohol (addictive) disorders. In any PTSD treatment, several precautions related to alcohol use and alcohol disorders are advised:

The initial interview and questionnaire assessment should include questions that sensitively and thoroughly identify patterns of past and current alcohol and drug use. Treatment planning should include a discussion between the professional and the client about the possible effects of alcohol use problems on PTSD, sleep, anger and irritability, anxiety, depression, and work or relationship difficulties.

Treatment should include education, therapy, and support groups that help the client address alcohol use problems in a manner acceptable to the client. Treatment for PTSD and alcohol use problems should be designed as a single consistent plan that addresses both sources of difficulty together. Although there may be separate meetings or clinicians devoted primarily to PTSD or to alcohol problems, PTSD issues should be included in alcohol treatment, and alcohol use ("addiction" or "sobriety") issues should be included in PTSD treatment.

Relapse prevention must prepare the newly sober individual to cope with PTSD symptoms, which often seem to worsen or become more pronounced with abstinence.

Sleep Disturbances

Many people suffer from problems with their sleep. This can be especially true for those who have witnessed or experienced one or more traumatic events such as rape, military combat, natural disasters, beatings, or neighborhood violence.  It is well known that a problem with sleep is one of many problems for those with PTSD.

Sleep problems, such as difficulty falling asleep, waking frequently, and having distressing dreams or nightmares, are common to those with PTSD. In fact, sleep disturbance can be a normal response to past trauma or anticipated threat.

What are the major reasons why people have problems with sleep?

 Severe psychological or physical trauma can cause changes in a person’s basic biological functioning. As a result of being traumatized, a person with PTSD may be constantly hyper-vigilant, or "on the lookout," to protect him- or herself from danger. It is difficult to have restful sleep when you feel the need to be always alert.

What are some sleep problems commonly associated with PTSD?

Basic Biological Changes: Actual biological changes may occur as a result of trauma, making it difficult to fall asleep. In addition, a continued state of hyper-arousal or watchfulness is usually present. It is very hard for people to fall asleep if they think and feel that they need to stay awake and alert to protect themselves (and possibly others) from danger.

Medical Problems: There are medical conditions commonly associated with PTSD. They can make going to sleep difficult. Such problems include: chronic pain, stomach and intestinal problems, and pelvic-area problems (in women).

Thoughts: A person’s thoughts can also contribute to problems with sleep. For example, thinking about the traumatic event, thinking about general worries and problems, or just thinking, "Here we go again, another night, another terrible night’s sleep," may make it difficult to fall asleep.

Use of Drugs or Alcohol: These substances are often associated with difficulty going to sleep.

Difficulty staying asleep

Distressing Dreams or Nightmares: Nightmares are typical for people with PTSD. Usually, the nightmares tend to be about the traumatic event or some aspect of it. For example, in Vietnam veterans, nightmares are usually about traumatic things that happened in combat. In dreams, the person with PTSD may also attempt to express the dominant emotions of the traumatic event; these are usually fear and terror. For example, it is not uncommon to dream about being overwhelmed by a tidal wave or swept up by a whirlwind.

Night Terrors: These are events such as screaming or shaking while asleep. The person may appear awake to an observer, but he or she is not responsive.

Thrashing Movements:  Because of overall hyper-arousal, active movements of the arms or legs during bad dreams or nightmares may cause awakening. For example, if one were having a dream about fleeing an aggressor, one might wake up because of the physical movements of trying to run away.

Anxiety (Panic) Attacks: Attacks of anxiety or outright panic may interrupt sleep. Symptoms of such attacks may include: Feeling the heart beating very fast; Feeling that the heart "skipping a beat";  Feeling lightheaded or dizzy; Having difficulty breathing (e.g., tight chest, pressure on chest); Sweating;  Feeling really hot ("hot flashes"); Feeling really cold (cold sweat); Feeling fearful; Feeling disoriented or confused; Fearing that you may die (as a result of these symptoms); Thinking and feeling that you may be "going crazy"; Thinking and feeling that you may "lose control".

Nightmares:

After a traumatic event, many people experience one or two nightmares that relate to the trauma. For some people, however, these nightmares recur several times. Such repetitive nightmares are one of the main hallmarks of PTSD.

PTSD nightmares are often confused with night terrors and ordinary nightmares. These other sleep phenomena need to be distinguished from nightmares related to trauma.

Night terrors occur during deep non-REM sleep early in the sleep period and involve considerable body movement. Night terrors usually awaken the dreamer, who does not remember the content of the dream.

Ordinary nightmares, which are experienced occasionally by non-traumatized persons, are also different from PTSD nightmares. They tend to differ from one nightmare to the next, although they often feature the dreamer being chased or threatened by a hostile attacker(s).

PTSD nightmares, in contrast, usually involve "reliving" the past or a situation related to a past event. During PTSD nightmares, people often experience the same strong emotions that they felt during the trauma, such as fear or rage. Often the emotion is one that would have been appropriate to express during the original trauma.

Common themes of recurrent nightmares experienced by veterans are combat, being trapped, being pursued, being paralyzed and unable to act, or witnessing the death or mutilation of others. They can occur during any stage of sleep or during waking.

Dreamers often awaken feeling terrified, typically with physical signs of arousal such as sweating or labored breathing. They are often unable to return to sleep quickly and may go back to sleep only after several hours, or they may not go back to sleep for the remainder of the night.

Many veterans report that their recurrent nightmares are the single most distressing symptom of their PTSD. This is probably so because, through the nightmare, they continue to relive an experience in which they felt intense horror, fear, and helplessness.

 

Who is likely to suffer from PTSD nightmares?

 

Studies of combat veterans show that those who experience nightmares as part of their PTSD also have other similarities. Some studies have shown that, in comparison to veterans who do not experience nightmares, sufferers of PTSD nightmares tend to:

 

  • Have lost a combat buddy in the war
  • Be younger when the trauma occurred than those who didn't get nightmares. In one study of Vietnam era veterans, the nightmare sufferers were, on average, 17.4 years old when the trauma occurred.
  • Have had less experience with traumatic situations before entering combat
  • Avoid expressing anger or aggression

 

Why do PTSD nightmares tend to repeat?

Although not all scientists agree about why PTSD nightmares recur, it has been suggested that PTSD nightmares are a memory intrusion into dreams rather than an ordinary nightmare.

Both ordinary nightmares and typical dreams appear to connect recent events with memory paths from the past. Thus, they are said to integrate new information with old. However, because the PTSD nightmares occur repeatedly, they are thought to reflect an absence or failure of this connecting process. Rather than assimilating the traumatic events into the present, survivors experience the content of a PTSD nightmare as being "encapsulated" into itself. Unless a connection between the trauma and the present can be established, the dream will repeat.

What can be done to reduce nightmares?

Understandably, some veterans try to prevent their nightmares, sometimes by using alcohol or drugs to induce a (seemingly) dreamless sleep. Sometimes sufferers try to avoid sleep altogether. Both "solutions" usually create a number of new problems. These include substance dependence or all the symptoms characteristic of sleep deprivation: irritability, difficulty concentrating, poorer sleep, poorer memory, increased anxiety, and fatigue.

Addressing the nightmare directly in treatment can reduce the frequency and intensity of a recurring nightmare. Targeted, time-limited treatment of recurrent traumatic nightmares is available at many Veterans Affairs PTSD programs. Often the therapy is performed in dream work groups that treat PTSD nightmares.

During group therapy, the nightmare is "worked" by the group. Traumatic themes are identified and the group offers alternative perspectives on the dream that help "connect" the content with events from the past. With these new perspectives and perhaps some valuable insights into the dream, the dreamer leaves the group with an action plan to implement. Preliminary evidence suggests that dream work therapy for nightmares

What are the differences between the effects of short-term trauma and the effects of chronic trauma?

The diagnosis of PTSD accurately describes the symptoms that result when a person experiences a short-lived trauma. For example, car accidents, natural disasters, and rape are considered traumatic events of time-limited duration. However, chronic traumas continue for months or years at a time.

Clinicians and researchers have found that the current PTSD diagnosis often does not capture the severe psychological harm that occurs with such prolonged, repeated trauma. For example, ordinary, healthy people who experience chronic trauma can experience changes in their self-concept and the way they adapt to stressful events. Dr. Judith Herman of Harvard University suggests that a new diagnosis, called Complex PTSD, is needed to describe the symptoms of long-term trauma.

What are examples of captivity that are associated with chronic trauma?

Judith Herman notes that during long-term traumas, the victim is generally held in a state of captivity. In these situations the victim is under the control of the perpetrator and unable to flee.

Examples of captivity include:

  • Concentration camps
  • Prisoner of War camps
  • Prostitution brothels
  • Long-term domestic violence
  • Long-term, severe physical abuse
  • Child sexual abuse
  • Organized child exploitation rings

 

What are the symptoms of Complex PTSD?

  • The first requirement for the diagnosis is that the individual experienced a prolonged period (months to years) of total control by another. The other criteria are symptoms that tend to result from chronic victimization. Those symptoms include:
  • Alterations in emotional regulation, which may include symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger
  • Alterations in consciousness, such as forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body
  • Alterations in self-perception, which may include a sense of helplessness, shame, guilt, stigma, and a sense of being completely different than other human beings
  • Alterations in the perception of the perpetrator, such as attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge
  • Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer
  • Alterations in one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair

What other difficulties do those with Complex PTSD tend to experience?

Survivors may avoid thinking and talking about trauma-related topics because the feelings associated with the trauma are often overwhelming. Survivors may use alcohol and substance abuse as a way to avoid and numb feelings and thoughts related to the trauma.  Survivors may also engage in self-mutilation and other forms of self-harm. There is a tendency to blame the victim.

A person who has been abused repeatedly is sometimes mistaken as someone who has a "weak character."   Because of their chronic victimization, in the past, survivors have been misdiagnosed by mental-health providers as having Borderline, Dependent, or Masochistic Personality Disorder. When survivors are faulted for the symptoms they experience as a result of victimization, they are being unjustly blamed.

Researchers hope that a new diagnosis will prevent clinicians, the public, and those who suffer from trauma from mistakenly blaming survivors for their symptoms.