Post-traumatic stress disorder is generally perceived as a mental disorder that occurs in combat veterans who experience the trauma of war. The truth is that PTSD can occur in any adult or child exposed to any traumatic event such as a natural disaster, serious traffic accident or the violence of rape or other physical assault. A person need not be the actual victim of the traumatizing event; simply witnessing one can lead to the development of PTSD. Not surprisingly, veterans, rescue workers and emergency medical personnel–individuals whose work commonly entails exposure to disturbing events–are particularly susceptible to developing PTSD, as are children exposed to sexual abuse or domestic violence.
Fight or Flight
It is natural to feel afraid during a stressful situation—fear triggers instant changes in the brain that help humans defend against danger (fight) or avoid it (flight). The “fight or flight” response exists in virtually all living things to guard against injury or being killed. Stress reactions such as a pounding heartbeat, anxiety and panic help humans and other animals react to danger quickly to save themselves or confront the threat at hand. Once the emergency has ended, most people feel relief and, often, some lingering anxiety and fear that gradually fade away. But in patients with PTSD heightened stress responses linger and intensify, causing uncontrollable and emotionally crippling symptoms for many months or even years after the trauma occurs.
As mentioned, it is normal for a person exposed to traumatic events to have some lingering symptoms for a time, or even develop short-term acute stress disorder. In these cases, the symptoms will lessen and eventually resolve in a matter of weeks or months. A diagnosis of PTSD entails more enduring symptoms, including:
Re-experiencing: Reliving the trauma repeatedly in flashbacks, physical symptoms such as a racing heart and sweating, nightmares, and frightening thoughts and feelings. These re-experiencing symptoms can disrupt a patient’s daily routines and ability to function. Seemingly random words, objects or situations can trigger a re-experiencing event.
Avoidance: Patients with PTSD may show avoidance behaviors, such as keeping their distance from objects, experiences and places that remind them of the triggering event (for example, refusing to ride in/drive a car after exposure to a traffic accident). They might also avoid feelings or thoughts related to the event (for example, being unwilling to watch a movie featuring cars or driving).
Arousal and Reactivity: These symptoms in patients with PTSD involve being easily startled, feelings of being tense and edgy, difficulty sleeping and angry outbursts. The behavior is generally consistent rather than being triggered by a reminder of the traumatic episode. Arousal and reactivity symptoms interrupt daily activities such as sleeping, concentrating on routine tasks, and eating.
Cognition and Mood: Cognitive and mood symptoms typically include difficulty remembering the traumatic event, feelings of guilt or blame, loss of interest in activities that were previously enjoyable, and negative feelings about the world and oneself.
Patients may manifest all or most of the above symptoms, or just a few from each category. Regardless, the National Institute of Mental Health’s guidelines indicate that a diagnosis of PTSD requires, at minimum, the recurrent presence of 1 re-experiencing symptom, 1 avoidance symptom, 2 arousal symptoms and 2 cognition/mood symptoms.
PTSD: Psychology or Physiology?
Initially, PTSD was conceived as a purely psychological response to trauma. The American Psychiatric Association added PTSD to the DSMV III in 1980 in the wake of clinical studies and reports in the 70s on a cluster of symptoms specific to Vietnam combat troops. But the concept was not a new one; in 1915, the term “shell shock” was coined to describe similar symptoms in World War I servicemen, especially those who were subjected to repeated bombardment from enemy fire. But with advances in neurology and brain imaging, researchers have shown that brain function is altered in people with PTSD, within three main areas of the brain:
1.. The amygdala is an area of the brain key in regulating emotions, especially fear.
2.. The ventromedial prefrontal cortex (vmPFC) area controls higher functions, such as emotional processing and decision-making.
3.. The hippocampus, the largest area of the three discussed herein, is involved in memory—especially spatial memory of places.
In people with a normal response to dangerous cues from their environment–for example, seeing a shark in a tank at the aquarium–the amygdala becomes active, sending fight or flight messages to other areas of the brain. At that moment, the “higher thinking” vmPFC communicates to the amygdala that the shark is contained, no need to worry. The hippocampus supports the amygdala by providing context such as “you recognize this setting; you are at the aquarium.” These processes allow the vmPFC to inhibit the fearful impulses of the amygdala.
Conversely, in people with PTSD, brain imaging studies show that the vmPFC is underactive, which allows the unfettered amygdala to produce the uncontrollable and intense panic and anxiety so common in the disorder. The exact reason for this brain imbalance is not known. Research has shown, however, that extremely stressful events (war, witnessing terrible events, sexual assault) results in acute and chronic changes in neurochemical systems such as the stress response brain chemicals cortisol and norepinephrine. Changes in specific brain regions and chemistry result in alterations in the workings of brain circuits involved in reasoning, stress responses and memory.
The first task is to ascertain that your patient is indeed suffering from PTSD and not a different mental disorder (for information on PTDS and differential diagnosis, visit https://bit.ly/2J8jBwx). Screen for dual-diagnoses; many patients with PTSD will have a co-occurring condition such as substance use, depression and/or suicidal ideation (for a comprehensive list of diagnostic tools, visit https://bit.ly/2sjHR4D).
As is true of all behavioral health treatments, there is no single one-size-fits all approach to treating PTSD. Research shows, however, that the best evidence-based treatments for PTSD include psychotherapy, medications, or a combination of both, specifically:
Cognitive behavioral therapy, which can help to identify the events, situations and objects that trigger symptoms, and how to address these triggers. In addition, CBT can help educate patients about trauma and its effects; provide relaxation and anger-control skills; tips on improving diet, sleep and exercise habits; address feelings of guilt, shame and blame surrounding the traumatic event; and change reactions to PTSD symptoms.
CBT therapies may include exposure therapy/prolonged exposure therapy to help patients control the symptoms caused by fear. Employing mental imagery, writing exercises and revisiting the place where the trauma occurred can all help patients to overcome or tolerate distressing emotions and reminders.
Cognitive processing therapy can help patients gain control over disturbing thoughts and learn how their traumatic experience changed them and their world view. Doing so enables them to gain insight into their emotions and behavior.
The use of eye movement desensitization and reprocessing therapy (EMDR) makes use of rapid and rhythmic eye movements to stimulate the brain while revisiting the traumatic event. EMDR can unlock negative emotions to help patients develop coping mechanisms.
For children and adolescents, trauma-focused CBT (TF-CBT) is an effective approach for young people exposed to a wide-array of traumas, including war, domestic violence, traumatic loss and the complexities of surviving foster care. However, this type of therapy should only be provided by a TF-CBT certified therapist. For more on this approach, visit https://bit.ly/2xcP3F7.
A wide array of medications for patients with PTSD have been proven effective. Certain drugs can help them manage problems with addiction, sleep disturbances, depression, anger, anxiety, despair and loss of control. The National Institute of Mental Health’s comprehensive list of medications can be found at https://bit.ly/2lv5cLV.
Complimentary therapies often help patients with PTSD to recover, including family therapy, mindfulness training, meditation and yoga, companion dog and horse therapy, and self-expression through art or writing assist patients to find positive outlets for their emotions. Connecting with new and old friends, socializing with others who have experienced a similar trauma and volunteering create support networks and reconnection to their communities.
PTSD is a multi-faceted and debilitating condition that wreaks havoc on the psyche and the brain’s circuitry. With compassionate and evidence-based care provided by an experienced professional, however, people can and do recover every day.