The Patient with Posttraumatic Stress Disorder

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Although the effects of natural calamities and their aftermaths have been recognized since the time of ancient Greece, it is only since 1980 that the American Psychiatric Association included post-traumatic stress disorder (PTSD) in its handbook of psychiatric disorders, the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III). One of the first descriptions of PTSD was made by the Greek historian Herodotus. In 490 bce, he described an Athenian soldier who suffered no injury in the Battle of Marathon but became permanently blind after witnessing the death of a fellow soldier. Health-care providers are only beginning to recognize the enormous toll that trauma can take in personal suffering and functional impairment. PTSD may also have an impact on future generations through effects on parental (or guardian) behavior and competence.

For many years, PTSD was considered only a wartime affliction. During World War I, PTSD was called ''shell shock,'' and during World War II, it was referred to as ''combat fatigue.'' After the Vietnam War, it was often mistakenly called the ''post-Vietnam syndrome.'' It has been estimated that 15% of 500,000 veterans of the Vietnam War are affected with PTSD. These patients have a variety of symptoms, including nightmares, sleep disturbances, avoidance reactions, guilt, intrusive memories, and dissociative flashbacks. In addition, as much as 9% to 10% of the U.S. population may have some form of PTSD. Almost 18% of 10 million women who were victims of physical assault have PTSD. Studies have shown that PTSD develops in 2% of people exposed to any type of accident, 30% of those exposed to a community disaster, 25% of those who have experienced traumatic bereavement, 65% of those experiencing nonsexual assault, 85% of battered women in shelters, and 50% to 90% of those who were raped. Of all psychiatric disorders, PTSD poses one of the greatest challenges to the health-care provider because of its complexity and variability of signs and symptoms.

In 1987, the revised DSM-III (DSM-III-R) defined PTSD as including traumatic events that were ''outside the range of usual human experience and that would be markedly distressing to almost anyone.'' PTSD is a normal reaction to an abnormal amount of stress. Although trauma is usually considered as an injury to a body part, it may be even more devastating to the psyche. Wounding of emotions, spirit, the will to live, dignity, and the sense of security can be traumatic. Some traumatic events may go on for months or years, whereas others may occur in a few seconds and have the same lasting effects as longer events. In minutes, a person's sense of self and sense of the world as a secure place can be shattered.

One problem with the DSM-III-R description is that it fails to recognize the importance of the subjective appraisal of the event;this includes the ethnocultural aspects of PTSD. The 1994 edition, DSM-IV, lists PTSD as the only diagnosis that identifies the origin of symptoms from external events rather than from within the individual. All the following DSM-IV criteria must be met to make a diagnosis of PTSD:

Experience of a traumatic event Experience of the trauma

Evidence of numbing or other avoidance behavior Exhibition of signs of hyperarousal Evidence of symptoms for at least 1 month

Experience of difficulties at home, work, or in other important areas of life as a result of the symptoms

Life is filled with many crises, such as losing a parent or being robbed. Although these events can be stressful, they are not considered ''traumatic.'' A traumatic event is defined as an unusual occurrence that is not part of normal human experience and that evokes extreme helplessness, fear, and despair. Examples of traumatic events include a natural catastrophe, such as a tornado, hurricane, volcano, earthquake, fire, landslide, or flood; a human catastrophe, such as war, concentration camps, refugee camps, sexual assault, physical assault, or other forms of victimization; witnessing a death, rape, torture, or beating; a suicide of a family member or close friend; and any exposure to danger of one's own safety and life.

Experiencing the trauma can take many forms, including dreams, flashbacks, or situations that remind the person of the traumatic event. While dreaming, the person may shout, shake, or thrash about the bed. Although the person may awake suddenly, he or she may not remember the nightmare, but the intense emotion may persist for long periods.

Psychic or emotional numbing is a form of self-protection against unbearable emotional pain. After the event, the individual may experience periods of feeling emotionally dead or numb. That person may have great difficulty in expressing tenderness or loving feelings. Avoidance behavior is another important aspect of PTSD. People with PTSD often feel alienated and apart from others. They may lose interest in activities that once gave them pleasure. Others are unable to remember certain aspects of the traumatic event.

Hyperarousal symptoms include difficulty in falling or staying asleep, irritability, outbursts of anger, difficulty in concentration, overprotectiveness of oneself or others, and an exaggerated startle response. People who were abused in a bed commonly experience insomnia. People with an exaggerated startle response may jump at loud noises or if someone touches them on the back.

Duration of symptoms is variable, but according to the official diagnostic criteria for PTSD, the symptoms must endure at least 1 month.

The last criterion relates to the impact of the psychic trauma on lifestyle. Survivors of human-engendered catastrophes, in general, suffer longer than survivors of natural catastrophes. In addition, the devastating effects of emotional trauma may be influenced by exposure of the individual to one or more traumatic events. Rape is traumatic, but multiple rapes are even more traumatic. Do the person's symptoms interfere with his or her ability to work, study, socialize, or maintain healthy familial relationships?

Many trauma-related disorders have been recognized and include brief reactive psychosis, multiple personality disorder, dissociative fugue, dissociative amnesia, conversion disorder, depersonalization disorder, dream anxiety disorder, summarization disorder, borderline personality disorder, and antisocial personality disorder. Many other trauma-related disorders have been postulated. These disorders and the trauma that may precede them are indicated as follows:

Brief reactive psychosis: any one or more events that would be stressful to anyone Multiple personality disorder: abuse or other childhood emotional trauma Dissociative fugue: severe psychologically stressful event such as marital quarrels, military conflict, natural disaster, or personal rejection

Dissociative amnesia: severe psychologically stressful event such as the tragic death of a loved one, abandonment, or a threat of personal injury

Conversion disorder: extreme psychologically stressful event such as warfare or a recent tragic death of a loved one

Depersonalization disorder: severe stressful event such as military combat or an automobile accident

Dream anxiety disorder: any major life stress, depression, substance abuse, or substance withdrawal

Somatization disorder: early childhood abuse Borderline personality disorder: early childhood trauma Antisocial personality disorder: early childhood abuse

Learned helplessness syndrome is a condition that is frequently seen in trauma survivors, commonly women and children; prisoners of war; concentration camp survivors; refugee camp survivors; or other tortured survivors. The name developed from animal experiments by Seligman (1967, 1975). Animals subjected to electric shocks and unable to escape despite their attempts would sink into listlessness and despair. Later, they were reshocked, but although trained to press a lever to stop the shocks, the animals made no effort to do so. The animals had learned to be helpless. It has been postulated that there is an adrenal neuro-transmitter problem in animals and humans exposed to severe, repeated traumatic events that may serve as the biologic basis for the hyperarousal and numbing phases of PTSD.

Although almost any symptom can result from PTSD, some of the more common ones are as follows:

Eating disorders

Anger or rage





Suicidal thoughts

Homicidal thoughts



Chronic gastrointestinal problems • Worsening or activation of chronic medical problems (e.g., diabetes, hypertension) Drug abuse Overworking Self-isolation

The Holocaust is a classic example of a tragic, traumatic event that inflicted significant, permanent changes in the victims' physical and psychological responses to stress. Holocaust survivors have complex problems that have affected their lives for more than 60 years. They are survivors; therefore, they never stopped fighting for survival. They are especially frightened of becoming sick because, in the past, to survive meant to be in good health; the alternative was to face doom. These patients are afraid of losing control of their lives, as well as losing their dignity.

Patients who are Holocaust survivors may have many psychosomatic complaints commonly related to the gastrointestinal tract. Chest pain, often relieved by belching, may be related to frequent air swallowing. These patients experience vivid dreams and nightmares. They are suspicious and do not trust people readily because they suffered so much in the past. The interviewer must be especially kind and understanding. The majority of the survivors of the Nazi concentration camps are now 85 to 90 years of age, and many suffer from PTSD. Many suffer from severe depression, panic attacks, and anxiety. The interviewer must be careful when asking about family history and background. Most survivors lost entire families; many lost their first spouse and children. The psychological wounds are deep, and anything can trigger an outpouring of grief. It is frequently difficult to find out anything about the family medical history because the patients' parents and grandparents might have been killed at early ages. These patients should be reassured that they will be treated gently and competently. They, like all patients with PTSD, must be assured of security. Feeling safe is the highest priority in their lives.

It has become clear that individuals need not be present at a catastrophic event to experience stress symptoms. The terrorist attacks that shook the United States on September 11, 2001, were immediately broadcast on television screens around the world. The events and their aftermath were shown in graphic detail repeatedly after the attacks.

Many Americans identified with the victims directly or perceived the unprecedented attacks as directed at themselves as well. Thus, even people who were nowhere near the location of the attacks experienced substantial stress responses.

In a study published in the New England Journal ofMedicine shortly after the attacks, 90% of the adults surveyed reported experiencing, to at least some degree, one or more symptoms of stress, and 44% of the adults reported a substantial level of at least one symptom of stress (Schuster et al, 2001). Although those closest to the sites of attack had the most substantial stress, respondents throughout the country, from large cities to small communities, reported stress symptoms: 36% of respondents more than 1000 miles from the World Trade Center reported substantial stress reactions, in comparison with 60% of those within 100 miles of the site. Among respondents who lived south of Canal Street in Manhattan (i.e., near the World Trade Center), the prevalence of PTSD was 20% after the attacks, in comparison with 4% before the tragic event. The article notes that more than 130,000 Manhattan citizens suffered from PTSD, depression, or anxiety after the attacks. Other studies have shown that children who were exposed solely through television to such horrifying events as these attacks, the Challenger disaster, the Oklahoma City bombing, and the Gulf Wars experienced trauma-related stress reactions.

Five to 8 weeks after the attack on the World Trade Center, a random telephone survey was conducted to estimate the prevalence of increased cigarette smoking, alcohol consumption, and marijuana use among residents of Manhattan (Vlahov et al, 2002). Among 988 persons included, 28.8% reported an increase in use of any of these three substances, 9.7% reported an increase in smoking, 24.6% reported an increase in alcohol consumption, and 3.2% reported an increase in marijuana use. Persons who increased smoking of cigarettes and marijuana were more likely to experience PTSD than were those who did not (24.2% vs. 5.6% for cigarettes; 36.0% vs. 6.6% for marijuana). The study was repeated 6 months later, and the increases were sustained, suggestive of potential long-term health consequences as a result of such disasters.

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