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Post-traumatic stress disorder (PTSD) is a term for certain severe psychological consequences of exposure to, or confrontation with, stressful events that the person experiences as highly traumatic.[1] Clinically, such events involve actual or threatened death, serious physical injury, or a threat to physical and/or psychological integrity, to a degree that usual psychological defenses are incapable of coping with the impact. It is occasionally called post-traumatic stress reaction to emphasize that it is a result of traumatic experience rather than a manifestation of a pre-existing psychological weakness. The presence of a PTSD response is influenced by the intensity of the experience, its duration, and the individual person involved. It is possible for individuals to experience traumatic stress without manifesting Post-Traumatic Stress Disorder, as indicated in the Diagnostic and Statistical Manual of Mental Disorders, and also for people to experience traumatic situations and not develop PTSD. In fact, most people who experience traumatic events will not develop PTSD. For most people, the emotional effects of traumatic events tend to subside after several months. PTSD is thought to be primarily an anxiety disorder (possibly closely related to panic disorder) and should not be confused with normal grief and adjustment after traumatic events.
Symptoms that appear within the first month of the trauma are called Acute stress disorder, not PTSD according to DSM-IV. If there is no improvement of symptoms after this period of time, PTSD is diagnosed. PTSD has three subforms: Acute PTSD subsides after a duration of three months. If the symptoms persist, the diagnosis is changed to chronic PTSD. The third subform is referred to as delayed onset PTSD which may occur months, years, or even decades after the event.
Historical backgroundThe first case of psychological distress was reported in 1900 BCE, Egypt by an Egyptian physician who described a "hysterical" reaction to trauma (Veith 1965). Railway spine was a nineteenth-century diagnosis for the post-traumatic symptoms of passengers involved in railroad accidents. The first full length medical study of the condition was John Eric Erichsen's On Railway and Other Injuries of the Nervous System, published in 1864. For this reason, railway spine is often known as "Erichsen's disease". Many physicians thought that the symptoms were due to the "excessive speeds" (about 30 mph) of the trains, and that the human body could not cope with speeds that fast. It was later found to be purely psychological in origin, and no longer exists as a valid disorder.[2][3]
Hysteria was also related to "traumatic reminiscences" a century ago (Janet 1901). At that time, Sigmund Freud's pupil, Kardiner, was the first to describe what later became known as symptoms of post-traumatic stress disorder (Lamprecht & Sack 2002). Stress is often defined as the reaction to a situation that threatens the balance or homeostasis[9] of a system (Antonovsky 1981). The situation causing the stress reaction is defined as the "stressor", but the stress reaction and not the stressor is what jeopardizes the homeostasis (Aardal-Eriksson 2002). Post-traumatic stress can thus be seen as a chemical imbalance of neurotransmitters, according to stress theory. However, PTSD in and of itself is a relatively recent diagnosis in psychiatric nosology, first appearing in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. It has been said that development of the PTSD concept has, in part, socio-economic and political implications (Mezey & Robbins 2001). War veterans are the most publicly-recognized victims of PTSD; long-term psychiatric illness was formally observed in World War I veterans. The syndrome entered wide public consciousness after the Vietnam War. PTSD patients had difficulties receiving veterans' disability benefits because there was no psychiatric diagnosis available by which veterans could claim indemnity. This situation has changed during the last two decades and PTSD is now one of several psychiatric diagnoses for which a veteran can receive compensation, such as a war veteran indemnity pension, in the U.S. (see below: Mezey & Robbins 2001) PTSD has also been recognized as a problem for marginalized groups within societies. One such group is Australian Aboriginal peoples, and other Indigenous peoples around the world. In these cases the repeated history of childhood and adult trauma, removal of children from their families, interpersonal violence and substance abuse, and early death, results in generations of people with high levels of PTSD.[10][11] Clinical aspects of PTSDExperiences which may induce the condition
Cancer as PTSD-traumaPTSD is normally associated with trauma such as violent crimes, rape, and war experience. However, there have been a growing number of reports of PTSD among cancer survivors and their relatives (Smith 1999, Kangas 2002). Most studies deal with survivors of breast cancer (Green 1998, Cordova 2000, Amir & Ramati 2002), and cancer in children and their parents (Landolt 1998, Stuber 1998), and show prevalence figures of between five and 20%. Characteristic intrusive and avoidance symptoms have been described in cancer patients with traumatic memories of injury, treatment, and death (Brewin 1998). There is yet disagreement on whether the traumas associated with different stressful events relating to cancer diagnosis and treatment actually qualify as PTSD stressors (Green 1998). Cancer as trauma is multifaceted, includes multiple events that can cause distress, and like combat, is often characterized by extended duration with a potential for recurrence and a varying immediacy of life-threat (Smith 1999). Diagnostic criteriaThe diagnostic criteria for PTSD, according to Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), are stressors listed from A to F. The current diagnostic criteria for the PTSD published in the Diagnostic and Statistical Manual of Mental Disorders may be found DSM-IV-TR here. Notably, the stressor criterion A is divided into two parts. The first (A1) requires that "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others." The second (A2) requires that "the person’s response involved intense fear, helplessness, or horror." The DSM-IV A criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience." Since the introduction of DSM-IV, the number of possible PTSD-traumas has increased and one study suggests that the increase is around 50% (Breslau & Kessler 2001). Symptoms and their possible explanationsSymptoms can include general restlessness, insomnia, aggressiveness, depression, dissociation, emotional detachment, and nightmares. A potential symptom is memory loss about an aspect of the traumatic event. Amplification of other underlying psychological conditions may also occur. Young children suffering from PTSD will often re-enact aspects of the trauma through their play and may often have nightmares that lack any recognizable content. One patho-psychological way of explaining PTSD is by viewing the condition as secondary to deficient emotional or cognitive processing of a trauma.[12] This view also helps to explain the three symptom clusters of the disorder:[13] Intrusion: Since the sufferer is unable to process the extreme emotions brought about by the trauma, they are plagued by recurrent nightmares or daytime flashbacks, during which they graphically re-experience the trauma. These re-experiences are characterized by high anxiety levels and make up one part of the PTSD symptom cluster triad called intrusive symptoms. Hyperarousal: PTSD is also characterized by a state of nervousness with the patient being prepared for "fight or flight". The typical hyperactive startle reaction, characterized by "jumpiness" in connection with high sounds or fast motions, is typical for another part of the PTSD cluster called hyperarousal symptoms and could also be secondary to an incomplete processing. Avoidance: The hyperarousal and the intrusive symptoms are eventually so distressing that the individual strives to avoid contact with everything and everyone, even their own thoughts, which may arouse memories of the trauma and thus provoke the intrusive and hyperarousal states. The sufferer isolates themselves, becoming detached in their feelings with a restricted range of emotional response and can experience so-called emotional detachment ("numbing"). This avoidance behavior is the third part of the symptom triad that makes up the PTSD criteria. Dissociation: Dissociation is another "defense" that includes a variety of symptoms including feelings of depersonalization and derealization, disconnection between memory and affect so that the person is "in another world," and in extreme forms can involve apparent multiple personalities and acting without any memory ("losing time"). TreatmentEarly intervention after a traumatic incident, known as Critical Incident Stress Management (CISM) is often used to reduce traumatic effects of an incident, and potentially prevent a full-blown occurrence of PTSD. However recent studies regarding CISM seem to indicate iatrogenic effects (Carlier, Lamberts, van Uchelen & Gersons 1998) (Mayou, Ehlers & Hobbs 2000). There have been scores of treatments suggested for the treatment of PTSD. The most researched (non-medical) psychotherapeutic method, specifically targeted at the disorder PTSD, is Eye Movement Desensitization and Reprocessing (EMDR).[14] Relationship based treatments are also often used. Johnson, S., (2002). Emotionally Focused Couples Therapy with Trauma Survivors. NY: Guilford, is one example. These, and other approaches, such as Dyadic Developmental Psychotherapy[15][16] use attachment theory and an attachment model of treatment. The treatment of complex trauma often requires a multi-modal approach. PTSD is commonly treated using a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and psychotropic drug therapy (antidepressant or atypical antipsychotics, e.g. brand names such as Prozac (fluoxetine), Effexor (venlafaxin), Zoloft (sertraline), Remeron (mirtazapine), Zyprexa (olanzapine), or Seroquel (quetiapine)). Recently Lamotrigine has been reported to be useful in treating some people with PTSD.[17][18][19] According to some studies, the most effective psychotherapeutic treatment for PTSD is Eye Movement Desensitization and Reprocessing (EMDR) q.v.[20] Talk therapy may prove useful, but only insofar as the individual sufferer is enabled to come to terms with the trauma suffered and successfully integrate the experiences in a way that does not further damage the psyche. Forbes, et al, (2001)[21] have shown that a technique of "rewriting" the content of nightmares through imagery rehearsal so that they have a resolution can not only reduce the nightmares but also other symptoms. The US Food and Drug Administration (FDA) recently approved a clinical protocol that combines the drug MDMA ("Ecstasy") with talk therapy sessions.[22] Basic counseling for PTSD includes education about the condition and provision of safety and support (Foa 1997). Cognitive therapy shows good results (Resick 2002), and group therapy may be helpful in reducing isolation and Stigma (Foy 2002). Dr. Jan Bastiaans of the Netherlands has developed a form of psychedelic psychotherapy involving LSD, with which he has successfully treated concentration camp survivors who suffer from PTSD.[1] PTSD is often co-morbid with other psychiatric disorders such as depression and substance abuse. Currently under scrutiny is the inclusion of Complex Post Traumatic Stress in the 2006 revision of the DSM-IV-TR. This is a variant of PTSD that includes the breakthrough of Borderline Personality traits. James McGaugh is a pioneer in the neurobiology of learning and memory. He directs the Center for Neurobiology of Learning and Memory at the University of California at Irvine. For several decades, he has performed numerous animal and human experiments to understand the processes involved in memory consolidation. He believes strongly in the work being done to help people suffering from PTSD. An event becomes a strong memory, a traumatic memory, when emotions are high, he explains. Those emotions trigger a release of stress hormones like adrenaline, which act on a region of the brain called the amygdala -- and the memory is stored or "consolidated," explains McGaugh. Current studies have focused on a drug called propranolol, which is commonly prescribed for heart disease because it helps the heart relax, relieves high blood pressure, and prevents heart attacks. "Hundreds of thousands, millions of people take this drug now for heart disease," he tells WebMD. "We're not talking about some exotic substance." Studies have shown that "if we give a drug that blocks the action of one stress hormone, adrenaline, the memory of trauma is blunted," he says. The drug cannot make someone forget an event, McGaugh says. "The drug does not remove the memory -- it just makes the memory more normal. It prevents the excessively strong memory from developing, the memory that keeps you awake at night. The drug does something that our hormonal system does all the time -- regulating memory through the actions of hormones. We're removing the excess hormones."[23] Recently, the use of Virtual reality and Integrated reality experiences applied as a new type of exposure therapy methods to come types of PTSD (specifically military related patients) has been gaining recognition. Some of this work is done at the CAREN VR LAB at the SHEBA rehabilitation hospital in Israel. The ideas behind this methods is based on introducing PTSD causes in a gradual manner, inside a safe environment, the hope is that training in VR in this manner will reduce stress and transfer to daily reality. A similar system is recently installed at the BAMC (Brooke Army Medical Center ) In the USA. Biology of PTSDNeurochemistryPTSD displays biochemical changes in the brain and body, which are different from other psychiatric disorders such as major depression. In PTSD patients, the dexamethasone cortisol suppression is strong, while it is weak in patients with major depression. In most PTSD patients the urine secretion of cortisol is low, at the same time as the catecholamine secretion is high, and the norepinephrine/cortisol ratio is increased. Brain catecholamine levels are low, and corticotropin-releasing factor (CRF) concentrations are high. There is also an increased sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis, with a strong negative feedback of cortisol, due to a generally increased sensitivity of cortisol receptors (Yehuda, 2001). Studies found no clear connection to cortisol levelThe association of PTSD with cortisol levels is controversial within the medical community. Some researchers have associated the response to stress in PTSD with long-term high levels of norepinephrine, at the same time as cortisol levels are low, a pattern associated with facilitated learning in animals. Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response (Yehuda 2002). With this deduction follows that the clinical picture of hyperreactivity and hyperresponsiveness in PTSD is consistent with the sensitive HPA-axis. Low cortisol levels are also discussed as a possible pre-existing condition that neurochemically predisposes a person to PTSD. Swedish United Nations soldiers serving in Bosnia with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels (Aardal-Eriksson 2001). There is considerable controversy within the medical community regarding the neurobiology of PTSD. A review of existing studies on this subject showed no clear relation between cortisol levels and PTSD. For example, only a slight majority of studies have found a decrease in cortisol levels; many others have found no effect or even an increase.[24] NeuroanatomyIn animal research as well as human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. Neuroimaging studies in humans have revealed both morphological and functional aspects of PTSD. The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex and the hippocampus. Further animal and clinical research into the amygdala and fear conditioning may suggest additional treatments for the condition. PTSD and societyPrevalencePTSD may be experienced following any traumatic experience, or series of experiences which satisfy the criteria and that do not allow the victim to readily recuperate from the detrimental effects of stress. It is believed that of those exposed to traumatic conditions between 5% and 80% will develop PTSD depending on the severity of the trauma and personal vulnerability.[citation needed] The National Comorbidity Survey Report provided the following information about PTSD in the general adult population: The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.[2] In recent history, the Indian Ocean Tsunami Disaster, which took place December 26, 2004 and took hundreds of thousands of lives, the September 11, 2001 attacks on the World Trade Center and The Pentagon, and the impact and effects of Hurricane Katrina may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as The Red Cross and the Salvation Army provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder. Other agencies, such as the National Meditation Center for World Peace [3], have created similar special programs. The NMC trains agencies such as crisis centers NGOs and works with international agencies to prevent trauma to children. Veterans and PTSD politicsThe practice of providing compensation for veterans with PTSD is under review in the United States. In 2005, the US Department of Veterans Affairs Veterans Benefits Administration began a review of claims after it noted a reported 30% increase in PTSD claims in recent years. Because of the negative effect on the budget and the apparent inconsistency in the rate of rewards by different rating offices of the Department, they undertook this review. There was broad political backlash from veterans rights groups and some highly publicized suicides by veterans who feared loss of their benefits, which in some cases served as their only source of income. In response to these events, on November 10, 2005, the Secretary of the US Department of Veterans Affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for post-traumatic stress disorder..." However the feeling of reprieve experienced by some veterans and veteran advocates was short-lived. Soon thereafter, the Department of Veterans Affairs announced that it had contracted with the Institute of Medicine (IOM) to conduct a study on PTSD. The committee will review and comment on the objective measures used in the diagnosis of PTSD and known risk factors for the development of PTSD. It will also "review the utility and objectiveness of the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and will comment on the validity of current screening instruments and their predictive capacity for accurate diagnoses." The committee will also "review the literature on various treatment modalities (including pharmacotherapy and psychotherapy) and treatment goals for individuals with PTSD [and] ... comment on the prognosis of individuals diagnosed with PTSD and existing comorbidities." Some veteran advocates expressed concern that this was merely a back-door method of reducing benefits to veterans who have served and currently serve in Iraq and the Persian Gulf. On the other hand, conservatives such as psychiatrist Sally Satel, who is affiliated with the conservative American Enterprise Institute, say "an underground network advises veterans where to go for the best chance of being declared disabled." The institute organized a recent meeting to discuss PTSD among veterans. In some, the diagnosis is highly controversial because of the strong connection with compensation seeking behavior and efforts and the uncertainty about the effect of this on objective diagnosis of those who may have been subjected to trauma. See recent article at [4] While PTSD-like symptoms were recognized in combat veterans following many historical conflicts, the modern understanding of the condition dates to the 1980s. Reported OEF/OIF cases of combat-PTSD incidents are currently being compiled in ePluribus Media's PTSD Timeline Canadian VeteransVeterans Affairs Canada, VAC [5]. The new program includes rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support [6] LawIf the acts and omissions of an individual suffering from PTSD result in consequences that breach the criminal law, there may be levels of confusion that prevent the formation of the relevant mens rea (Latin for "guilty mind") so mistake or reasonable excuse may be a defense. In more extreme cases, the defense of automatism may be available, with particular conditions discussed at automatism (case law). However, there is a danger that although the initial cause of the disorder will be external, it may produce an internal defect of reason or an abnormality of mind within the meaning of the M'Naghten Rules (redefined as a mental disorder defense in some criminal jurisdictions) that define insanity as an excuse. The difference is that whereas defenses that negate the mens rea and automatism result in an acquittal, insanity or mental disorder leaves the "offender" available for sentencing by the court. In the event that a death has resulted, diminished responsibility may be available as an alternative to insanity. This defense reduces what would otherwise have been murder to manslaughter. For a detailed discussion of a sometimes related condition, see battered woman syndrome and, more generally, the abuse defense in the U.S.[citation needed] Trauma and the ArtsIn recent decades, with the concept of trauma, and PTSD in particular, becoming just as much a cultural phenomenon as a medical or legal one, artists have begun to engage the issue in their work. An important breakthrough in this was the publication of Maus: A Survivor's Tale (1972) by Art Spiegelman. There is now a genre of art that focuses on, exposes, and comments on survivors and survivor-tales. Some want to see art as part of a process of healing, and in this they work in a manner akin to art therapy or the older twentieth century notion of art psychology. There are others who resist the implicit mandate that art should be put into the service of psychological repair. These artists tend to work in a direction that links trauma to questions of memory, identity and politics. As an example of the latter, one could point to the various Holocaust memorials in Germany, most of which were made beginning in the 1980s and which coincided with the increased awareness about trauma and its representational needs. These memorials have provoked a good deal of debate about the role of public space. Jochen Gertz and Esther Shavlev-Gertz's anti-fascism memorial in Harburg, Germany is a good example. Erected in 1986, it consisted of a single pillar enrobed in lead so that visitors could scratch their names and thoughts into the surface. The pillar was designed to sink beneath the ground in stages, to mirror the progress of human memories. It did so, and now can be viewed only through a glass wall. But what started as an idea to bring the community together in a repudiation of fascism turned into something altogether different when people began to write anti-semitic slogans on the pillar, and city fathers began to see the monument as an embarrassment. The recently opened Memorial to the Murdered Jews of Europe in Berlin that was designed by Peter Eisenman was held up for years because of controversies. James Young discusses the history of what are now called "anti-memorial memorials" in Germany.[25] The term "counter-monument" is also now in common usage in the art community to describe memorials that deal with difficult topics. In more recent work, an example is that of Krzysztof Wodiczko who teaches at MIT and who is known for interviewing people and then projecting these interviews onto large public buildings.[26] Wodiczko wants to bring trauma not merely into public discourse but to have it contest the presumed stability of cherished urban monuments. His work has brought to life issues such as homelessness, rape, and violence. Other artists who engage the issue of trauma are Everlyn Nicodemus of Tanzania and Milica Tomic of Serbia.[27] Related lists
See alsoFurther readingMoving a Nation to Care: Post-Traumatic Stress Disorder and America's Returning Troops, by Ilona Meagher, Introduction by Penny Coleman, Foreword by Robert Roerich, M.D. References
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