Post-Traumatic 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, where a
PTSD-like disorder was known as "Da Costa’s Syndrome." There
are particularly good descriptions of post-traumatic 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 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, and in United Nations peacekeeping forces deployed to other war
zones around the world. PTSD also appears in military veterans in other
countries with remarkably similar findings – that is, Australian Vietnam
veterans experience much the same symptoms as American Vietnam veterans.
PTSD is not only a problem for veterans, however. Although there are
unique cultural- and gender-based aspects to the disorder, it occurs in
both 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 for some individuals symptoms
may be unremitting and severe. Some older veterans who report a lifetime
of only mild symptoms have experienced significant increases 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 development
and testing of 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 is especially
helpful to 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
have PTSD. About 3.6 percent of U.S. adults ages 18 to 54 (5.2 million
people) have PTSD during the course of a given year. This represents a
small proportion of those who have experienced a traumatic event at some
point in their lives, for 60.7% of men and 51.2% of women reported at
least one traumatic event. The traumatic events most often associated with
PTSD are: for men: rape, combat exposure, childhood neglect, and childhood
physical abuse. For women: 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. Thus 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
or being upset, terror, and horror or fear.
4. Those with a social environment which 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 of these brain structures 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
hyperarousal 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 response to stress. Thyroid function seems to be enhanced in people
with PTSD. Some studies have shown that cortisol levels are lower than
normal and epinephrine and norepinephrine 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; also, the distinctive profile
associated with PTSD is seen in individuals who have both PTSD and
depression.
PTSD is associated with 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 episode (47.9
percent), conduct disorder (43.3 percent), and drug abuse and dependence
(34.5 percent). The disorders most frequently comorbid with PTSD among
women were major depressive disorder (48.5 percent), simple phobia (29
percent), social phobia (28.4 percent) and alcohol abuse/dependence (27.9
percent).
PTSD also makes a significant impact on psychosocial functioning,
independent of comorbid conditions. For instance, Vietnam veterans with
PTSD were found to have profound and pervasive problems in their daily
lives. This included problems in family and other interpersonal
relationships, employment, and involvement with the criminal justice
system.
Headaches, gastrointestinal complaints, immune system problems,
dizziness, chest pain, or 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.
What is the Course of PTSD?
Most people who are exposed to a traumatic stressor experience some of
the symptoms of PTSD in the days and weeks following exposure. Available
data suggest that among individuals who go on to develop PTSD, roughly 30
percent develop a chronic form that persists throughout an individual’s
lifetime. The course of chronic PTSD usually has periods of symptom
exacerbation and remission or decrease, although for some individuals
symptoms may persist at an unremitting, severe level. Some older veterans
who report a lifetime of no or only mild symptoms have experienced symptom
exacerbations following retirement, severe medical illness in themselves
or their spouses, or exposure to reminders of their military service (such
as reunions or media broadcasts of the anniversaries of war events).
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, in which the patient
repeatedly relives the frightening experience under controlled conditions
to help him or her work throughout the trauma. Studies have also shown
that medications help ease associated symptoms of depression and anxiety
and help ease 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, but 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 definitely appears to be highly effective
for some individuals and is helpful for many more. Also, 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.
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