Post-Traumatic Stress Disorder - PTSD

Post-traumatic stress disorder can occur after a person has been exposed to severe trauma such as violence or abuse. It is a form of self-defense. Survivors of trauma often respond by mentally shutting down and avoiding their emotions as a way of avoiding their pain.

Avoidance is a short-term coping strategy that allows survivors to function. But over the long-run, avoidance becomes an obstacle to healthy functioning and can turn post-traumatic stress into a disorder. The suppressed emotions have to come out somehow, and they often come out in the form of anxiety, panic attacks, depression, nightmares, and rage.

The chances of developing PTSD vary greatly depending on the person and the nature of the trauma.

• Approximately 7 to 9 percent of people exposed to significant trauma in an urban setting will develop post-traumatic stress disorder.[1]
• Up to 38 percent of combat veterans will develop PTSD.[2, 3, 4]

Table of Contents

1. Symptoms of PTSD
2. Definition and Diagnosis of PTSD
3. PTSD Tests
4. PTSD Risk Factors
5. PTSD Treatment
6. Family Support
7. Links and Find Help

Five Symptoms of PTSD

• Reliving the trauma. You may frequently re-experience the trauma in your dreams or flashbacks. When you relive the trauma, you feel as if you're caught in the traumatic event again. You may feel intense anxiety when you see or hear about people or places that symbolize the trauma.
• Avoiding triggers. You probably work hard to avoid people, places, thoughts, feelings, conversations, or anything that can trigger memories of the trauma. You may have difficulty remembering some important aspect of the trauma.
• Feeling on guard. You may feel constantly on guard. For example, you may startle easily, feel irritable or hypervigilant, have difficulty falling or staying asleep, and have difficulty concentrating.
• Feeling detached. You may feel detached, numb, or estranged from others. You may enjoy things less than you did before.
• Diminished sense of the future. You may be less interested in the future than you were before, or feel more hopeless about the future.

Trying to self-diagnose PTSD can trigger memories that you may not be able to handle on your own. If you feel you have some of these symptoms, you should speak to your doctor or a specialist on PTSD. Making the diagnosis of PTSD can be the first step to recovery.

Definition of PTSD

Post-traumatic stress disorder criteria based on the DSM-5.[5] There are five separate criteria.

• Directly exposed
• Witnessed the trauma
• Learned that a relative or close friend was exposed to the trauma
• Indirectly exposed to details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

• Unwanted and/or upsetting memories
• Nightmares
• Flashbacks
• Emotional distress after exposure to traumatic reminders
• Physical distress after exposure to traumatic reminders (chest tightness, difficulty breathing, racing heart, tremors, nausea, sweating)

• You try to avoid distressing thoughts or feelings about the trauma
• You try to avoid external reminders of the trauma (people, places, things, conversations)

• Hard to recall key features of the trauma
• Negative mood
• Decreased interest in activities
• Feel detached or isolated
• Difficulty experiencing positive emotions
• Overly negative thoughts about yourself or the world
• Exaggerated blame of yourself or others for causing the trauma

• Hypervigilant
• Heightened startle response
• Difficulty concentrating
• Difficulty sleeping
• Irritable or aggressive
• Risky or self-destructive behavior

• Have you had these symptoms for at least one month?
• Have your symptoms had a significant negative impact on your life (relationships, work, social, or emotional life)?
• Your symptoms are not due to medication, substance abuse, or any other medical condition.
• Your symptoms are not due to another mental health condition such as generalized anxiety disorder, panic disorder, depression, or obsessive-compulsive disorder.

If you answered yes to all of the above criteria, you may meet the DSM definition of post-traumatic stress disorder.
The five criteria make up the acronym ARENA: Avoidance, Reliving, Exposure, Negativity, and Adrenaline.

PTSD Tests

Test for PTSD based on the DSM criteria:

Post-Traumatic Stress Disorder-PTSD Test - DSM Criteria (pdf)

There are a number of screening tests for PTSD.[6] One of the most studied is the Primary Care PTSD Screen, which is a 5-item screen designed to identify individuals with possible PTSD.[7] This is not a definitive diagnosis. It is a general screening.

Post-Traumatic Stress Disorder-PTSD Screening Test – PC-PTSD-5 (pdf)

Risk Factors and Protective Factors for PTSD

Not everyone who lives through a dangerous event develops PTSD. Here are some of the factors that increase and decrease the risk.

Risk Factors that Increase the Risk of PTSD[8, 9]

• Previous trauma, childhood abuse
• Childhood adversity (economic deprivation, family dysfunction, parental separation or death)
• History of anxiety, depression, alcohol or drug abuse
• Family history of psychiatric problems
• Stressful life events (divorce, financial stress)
• Little or no social support after the event

Specific Risk Factors for Combat Veterans[4]

• Non-officer rank
• High number of deployments
• Long cumulative length of deployments
• Lack of post-deployment support

Protective Factors that Decrease the Risk of PTSD

• Professional support after the traumatic event
• Social support from friends and family
• Using a self-help support group after a traumatic event
• Believing that you can cope with the results of a disaster, and that you will get better

Accumulated Traumatic Stress Disorder

Sometimes people develop post-traumatic stress disorder, not after one overwhelming trauma, but after many accumulated smaller traumas. If you don’t know how to let go of stress, many repeated traumas can have the same effect as one big trauma.[10]
This is supported by the fact that adults who develop post-traumatic stress disorder often had painful or traumatic childhoods. In their case the final trauma is just the top layer of many accumulated traumas. Past traumas become interconnected so that one triggers another, and older traumas intensify newer ones.

Therefore, it can be helpful to think of post-traumatic stress as accumulated traumatic stress disorder. This emphasizes that the treatment involves dealing with layers of trauma not just the last trauma.

PTSD Treatment

Five Things You Can Do About Your PTSD

1. Take care of yourself. Get enough rest, eat well, exercise, and take time to relax.
2. Don't self-medicate. Alcohol, marijuana, opioids and other drugs temporarily numb your feelings, but they're not healthy coping skills. Drugs and alcohol prevent you from doing the work you need to do to overcome your symptoms. They are also brain depressants, which lead to more problems down the road.
3. Spend time with people. You don't have to talk about your trauma. Just reach out and spend time with supportive people. Make it clear that you just want to keep it light and you'll talk when you're ready. Connecting with people is healing.
4. Join a support group. Ask your health care professional about PTSD groups. Look them up in your local phone book or contact your community social services.
5. "The best way to get rid of your feelings is to feel them."[11] Seek professional help. Find a qualified professional or treatment program that has experience in dealing with PTSD.

Treatment for PTSD

The following therapies have been shown to be more effective for treating PTSD than other treatments.[12, 13, 14]

1. Trauma-focused cognitive behavioral therapies:
• Cognitive behavioral therapy (CBT)
• Cognitive processing therapy (CPT)
• Prolonged exposure therapy (PE, also called gradual exposure therapy)
2. 2. Stress management, meditation, and mindfulness
3. Eye movement desensitization and reprocessing (EMDR). EMDR involves gently reviewing the trauma while focusing on side-to-side eye movements, sounds, or hand-tapping. It is not clear how this works, but studies suggest that it is effective for treating PTSD.

Key Components of Trauma-Focused Psychotherapy:

• Education about trauma and its effects
• Learn about PTSD symptoms
• Identify your triggers
• Stress management, meditation, and mindfulness. The evidence is overwhelming that these are effective in treating a variety of mental health conditions including PTSD.
• Gently review your trauma memories, usually through writing or talking under the supervision of your therapist. This helps you gradually release the pressure that has built up inside. It will also help you develop coping skills as you practice managing your symptoms in a safe and controlled environment.
• Cognitive restructuring helps you make sense of your uncomfortable memories and emotions so that they have less power over you. It’s not uncommon for trauma survivors to feel guilt or shame about something that was not their fault and was beyond their control. Cognitive restructuring helps you change the way you think about the trauma so that you can begin to let it go.
• Practice integrating your skills into your everyday life. (Learn more about cognitive behavioral therapy and stress management)

Medications

Medication on its own cannot treat PTSD. But studies have shown that including antidepressants in PTSD treatment may help control the sadness, worry, anger, and feeling numb inside that can be part of PTSD.

Benefits of Self-Help Support Groups

This is one of the keys to recovery. Self-help groups are a source of understanding, hope, strength, safety, and guidance.

• You meet people who are going through the same thing. You feel that you’re not alone.
• You believe that recovery is possible. You see that other people are improving or have recovered from their PTSD, and you feel that you can too.
• You learn other people's recovery techniques. You can ask other people who've been in the same boat how they handled certain situations. You can ask them if what you're going through is normal.
• You won't be judged. Most trauma survivors have difficulty opening up, partly because they're afraid nobody will understand them. They bottle everything up inside. At a self-help group you get the chance to share, and you can do as much or as little as you like.
• You have a safe place to go. Self-help groups are a safe harbor where you can go if you're having a bad day. By the end of the meeting you'll almost certainly feel better and more motivated for recovery.

A Famous Sufferer

J.D. Salinger, author of Catcher in the Rye, was one of America’s most iconic authors and a sufferer of PTSD.

This is what the New York Times said about Salinger in his obituary on Jan. 28, 2010: “J.D. Salinger, who was thought at one time to be the most important American writer to emerge since World War II … died on Wednesday at his home in Cornish, N.H., where he had lived in seclusion for more than 50 years. He was 91…Mr. Salinger had been drafted. He served with the Counter-Intelligence Corps of the Fourth Infantry Division, whose job was to interview Nazi deserters and sympathizers… On June 6, 1944, he landed at Utah Beach, and he later saw action during the Battle of the Bulge. In 1945 he was hospitalized for ‘battle fatigue ’… and after recovering he stayed on in Europe past the end of the war, chasing Nazi functionaries.”

Salinger never got help, never talked about his experience, and died a recluse. We know better now. You can get better. There are people who can help.

Family Support

Post-traumatic stress disorder reaches beyond the individual to affect a broad circle of people. Family and friends need to learn what helps when supporting someone with PTSD, what doesn’t help, and the importance of taking care of oneself. Understand that it’s normal to have some negative feelings when helping someone with PTSD.

What Family Members Need to Know

• Let the individual set the pace. Do not work harder than the person you’re trying to help. This is the most important guideline in family support. It helps you gage how much or how little help you can offer at any time.
• Working harder than the other person and pushing for faster progress will only exhaust you and could make them resent your efforts.
• Loving someone with a mental health condition is not always easy. You also need time to recover and take care of yourself.
• If the individual doesn’t want to do anything right now, you can still be helpful by being an example of balance and self-care.
• Avoid self-blame. You can’t control another person’s decisions, and you can’t force them to change when they are not ready. Understand that there is only so much you can do.
• Ask for help. Talk to a professional. Go to a support group. You need as much support as they do.
• Helping someone with PTSD

How Does PTSD Affect Relationships?

PTSD can be hard on relationships. One of the short-term mechanisms for dealing with trauma is to stop feeling emotions. You may feel detached, numb, or estranged from others. This is usually not conscious, but a subconscious defense mechanism. You may find it difficult to emotionally connect with loved ones.

Another consequence of emotionally shutting down is that you may feel depressed and find little joy in things that you enjoyed before. Your friends and loved ones can feel shut out.

If you don’t seek treatment or follow through on treatment suggestions, you will bottle up your emotions. Suppressed emotions must come out eventually, and they often come out as hair-trigger anger.

Post-traumatic stress disorder is treatable. The most important step you can take is reaching out and asking for help. You can change your life.

References

1. Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., et al., Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry, 1998. 55(7): p. 626-32.
2. Dohrenwend, B. P., Turner, J. B., Turse, N. A., Adams, B. G., et al., The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods. Science, 2006. 313(5789): p. 979-82. 1584215.
3. Sareen, J., Belik, S. L., Afifi, T. O., Asmundson, G. J., et al., Canadian military personnel's population attributable fractions of mental disorders and mental health service use associated with combat and peacekeeping operations. Am J Public Health, 2008. 98(12): p. 2191-8. 2636534.
4. Xue, C., Ge, Y., Tang, B., Liu, Y., et al., A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PLoS One, 2015. 10(3): p. e0120270. PMC4368749.
5. American Psychiatric Association, DSM-5 The Diagnostic and Statistical Manual of Mental Disorders. 5 ed, ed. D. Kupfer: American Psychiatric Association.
6. Brewin, C. R., Systematic review of screening instruments for adults at risk of PTSD. J Trauma Stress, 2005. 18(1): p. 53-62.
7. Prins, A., Bovin, M. J., Smolenski, D. J., Marx, B. P., et al., The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample. J Gen Intern Med, 2016. 31(10): p. 1206-11. PMC5023594.
8. Brewin, C. R., Andrews, B., & Valentine, J. D., Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol, 2000. 68(5): p. 748-66.
9. DiGangi, J. A., Gomez, D., Mendoza, L., Jason, L. A., et al., Pretrauma risk factors for posttraumatic stress disorder: a systematic review of the literature. Clin Psychol Rev, 2013. 33(6): p. 728-44.
10. Grenier, J., Greenman, P.S., Farmanova, E., Atchessi, N., et al., Scoping Review of Risk Factors of Anxiety Disorders and Post-Traumatic Stress Disorder: A Public Health Perspective. Annals of Depression and Anxiety, 2015. 2(7): p. 1068.
11. Manville, Bill, Cool, Hip & Sober: 88 ways to beat booze and drugs: Forge, 2003. p. 228.
12. American Psychological Association, Clinical Practice Guidelines for the Treatment of PTSD. 2017: p. 1-139.
13. Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., et al., Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis. Br J Psychiatry, 2007. 190: p. 97-104.