Posttraumatic stress disorder

Infobox_Disease
Name = Post Traumatic Stress Disorder


Caption =
DiseasesDB = 33846
ICD10 = ICD10|F|43|1|f|40
ICD9 = ICD9|309.81
ICDO =
OMIM =
MedlinePlus = 000925
eMedicineSubj = med
eMedicineTopic = 1900
MeshID = D013313
Post traumatic stress disordercite book |author= |title=Diagnostic and statistical manual of mental disorders: DSM-IV |publisher=American Psychiatric Association |location=Washington, DC |year=1994 |pages= |isbn=0890420610 |oclc= |doi=; [http://www.behavenet.com/capsules/disorders/ptsd.htm on-line] ] (PTSD) is an anxiety disorder that can develop after exposure to one or more terrifying events that threatened or caused grave physical harm. [http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml National Institute of Mental Health, US National Institutes of Health] ] It is a severe and ongoing emotional reaction to an extreme psychological trauma.cite book | year=1999| chapter=Chapter 4.2 | author=David Satcher et al.| title=Mental Health: A Report of the Surgeon General| url=http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html] This stressor may involve someone's actual death, a threat to the patient's or someone else's life, serious physical injury, or threat to physical or psychological integrity, overwhelming usual psychological defenses coping. In some cases it can also be from profound psychological and emotional trauma, apart from any actual physical harm. Often, however, the two are combined. PTSD is a condition distinct from traumatic stress, which has less intensity and duration, and combat stress reaction, which is transitory. PTSD has also been recognized in the past as railway spine, shell shock, traumatic war neurosis, or post-traumatic stress syndrome (PTSS).

Causes

PTSD is believed to be caused by psychological trauma. Possible sources of trauma includes experiencing or witnessing childhood or adult physical, emotional or sexual abuse. In addition, experiencing or witnessing an event perceived as life-threatening such as physical assault, adult experiences of sexual assault, accidents, drug addiction, illnesses, medical complications, or the experience of, or employment in occupations exposed to war (such as soldiers) or disaster (such as emergency service workers). Traumatic events that may cause PTSD symptoms to develop include violent assault, kidnapping, torture, being a hostage, prisoner of war or concentration camp victim, experiencing a disaster, bad car accidents or getting a diagnosis of a life-threatening illness. Children may develop PTSD symptoms by experiencing sexually traumatic events like age-inappropriate sexual experiences. Witnessing traumatic experiences or learning about these experiences may also cause the development of PTSD symptoms. The amount of dissociation that follows directly after a trauma predicts PTSD. Individuals who are more likely to dissociate during a traumatic event are considerably more likely to develop chronic PTSD.cite book |last= Brown, Scheflin and Hammond |title=Memory, Trauma Treatment, And the Law |year= 1998 |publisher= W. W. Norton |location= New York, NY |isbn= 0-393-70254-5] Many servicemen and women returning from Iraq and Afghanistan have PTSD. [cite news | last =Barnes | first =Julian E. | title =U.S. veterans struggle with war stress | publisher =LATimes.com | date =2008-04-18 | url =http://www.latimes.com/news/nationworld/nation/la-na-stress18apr18,0,6748314.story |quote=An estimated 300,000 veterans among the nearly 1.7 million who have served in Iraq and Afghanistan are battling depression or post-traumatic stress disorder. | accessdate =2008-04-18 [http://www.rand.org/pubs/monographs/MG720/] ] The diagnosed cases of PTSD in United States troops sent to either Afghanistan or Iraq rose 46.4 percent in 2007, bringing the five year total to almost 40,000 (from U.S. military data). cite news | last=Morgan | first=David | title=Post-Traumatic Stress Soars in US Troops | language =English | publisher=Reuters | date=2008-05-27 |url =http://www.truthout.org/article/post-traumatic-stress-soars-us-troops | accessdate =2008-05-28] Members of the Marines and Army are much more likely to develop PTSD than Air Force and Navy personnel, because of greater exposure to combat. A preliminary study found that mutations in a stress-related gene interact with child abuse to increase the risk of PTSD in adults. [cite journal |last=Binder, MD. PhD |first=E. B. |coauthors=Bradley, PhD, R. G.; Liu, PhD, W.; Epstein, PhD, M.; Deveau, BS, T.; Mercer, MPH, K.; Tang, MD, PhD, Y; Gillespie, MD, PhD, C.; Heim, PhD, C; Nemeroff, MD, C. ; Schwartz, MD, A.; Cubells, MD, PhD, J.; Ressler, MD, PhD, K. |year=2008 |month=March 19 |title=Association of FKBP5 Polymorphisms and Childhood Abuse With Risk of Posttraumatic Stress Disorder Symptoms in Adults |journal=JAMA |volume=299 |issue=11 |pages=1291–1305 |url=http://jama.ama-assn.org/cgi/content/short/299/11/1291 |accessdate= 2008-03-31 |doi=10.1001/jama.299.11.1291 |pmid=18349090] [cite article |url=http://www.medpagetoday.com/Genetics/GeneticTesting/dh/8824 |title=Genes May Affect Lifelong Impact of Child Abuse |author=Peggy Peck, Executive Editor |publisher=MedPage Today |date=2008-03-09] [cite article |url=http://sciencenow.sciencemag.org/cgi/content/full/2008/318/2?etoc |title=Seeds of PTSD Planted in Childhood |author=Constance Holden|publisher=ScienceNOW Daily News |date=2008-03-18]

Neuroendocrinology

PTSD displays biochemical changes in the brain and body that differ from other psychiatric disorders such as major depression. Individuals diagnosed with PTSD respond more strongly to a dexamethasone suppression test than individuals diagnosed with clinical depression.Fact|date=June 2008 In addition, most PTSD also show a low secretion of cortisol and high secretion of catecholamine in urine, with a norepinephrine/cortisol ratio consequently higher than comparable non-diagnosed individuals. [cite journal |author=Mason JW, Giller EL, Kosten TR, Harkness L |title=Elevation of urinary norepinephrine/cortisol ratio in posttraumatic stress disorder |journal=J Nerv Ment Dis |volume=176 |issue=8 |pages=498-502 |year=1988 |pmid=3404142] This is in contrast to the normative fight-or-flight response, in which both catecholamine and cortisol levels are elevated after exposure to a stressor.Fact|date=March 2008 Brain catecholamine levels are low,Fact|date=September 2008 and corticotropin-releasing factor (CRF) concentrations are high. [cite journal |author=Sautter FJ, Bisette G, Wiley J, Manguno-Mire G, Schoenbachler B, Myers L, Johnson JE, Cerbone A, Malaspina D |title=Corticotropin-releasing factor in posttraumatic stress disorder with secondary psychotic symptoms, nonpsychotic PTSD, and healthy control subjects |journal=Biol Psychiatry |volume=54 |issue=12 |pages=1382-8 |year=2003 |pmid=14675802 |doi=] [cite journal |author=de Kloet CS, Vermetten E, Geuze E, Lentjes EG, Heijnen CJ, Stalla GK, Westenberg HG |title=Elevated plasma corticotrophin-releasing hormone levels in veterans with posttraumatic stress disorder |journal=Prog Brain Res |volume=167 |issue= |pages=287-91 |year=2008 |pmid=18037027 |doi=] Together, these findings suggest abnormality in the hypothalamic-pituitary-adrenal axis (HPA). Given the strong cortisol suppression to dexamethasone in PTSD, HPA axis abnormalities are likely predicated on strong negative feedback inhibition of cortisol, itself likely due to an increased sensitivity of glucocorticoid receptors. [cite journal |author=Yehuda R |title=Biology of posttraumatic stress disorder |journal=J Clin Psychiatry |volume=62 Suppl 17 |issue= |pages=41–6 |year=2001 |pmid=11495096 |doi=] Some researchers have associated the response to stress in PTSD with long-term exposure to high levels of norepinephrine and low levels of cortisol, a pattern associated with improved learning in animals.Fact|date=June 2008 Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response through a hypersensitive, hyperreactive and hyperresponsive HPA axis. [cite journal |author=Yehuda R |title=Clinical relevance of biologic findings in PTSD |journal=Psychiatr Q |volume=73 |issue=2 |pages=123–33 |year=2002 |pmid=12025720| doi = 10.1023/A:1015055711424]

Low cortisol levels may predispose individuals to PTSD; following war trauma, Swedish soldiers serving in Bosnia and Herzegovina 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. [cite journal |author=Aardal-Eriksson E, Eriksson TE, Thorell LH |title=Salivary cortisol, posttraumatic stress symptoms, and general health in the acute phase and during 9-month follow-up |journal=Biol. Psychiatry |volume=50 |issue=12 |pages=986–93 |year=2001 |pmid=11750895| doi = 10.1016/S0006-3223(01)01253-7] Because cortisol is normally important in restoring homeostasis after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD. However, there is considerable controversy within the medical community regarding the neurobiology of PTSD. A review of existing studies on this subject showed no clear relationship between cortisol levels and PTSD. Only a slight majority have found a decrease in cortisol levels while others have found no effect or even an increase. [cite journal | author =Lindley SE, Carlson EB, Benoit M |title=Basal and dexamethasone suppressed salivary cortisol concentrations in a community sample of patients with posttraumatic stress disorder |journal=Biol. Psychiatry |volume=55 |issue=9 |pages=940–5 |year=2004 |pmid=15110738 |doi=10.1016/j.biopsych.2003.12.021]

Neuroanatomy

In addition to biochemical changes, PTSD also involves changes in brain morphology. In a study by Gurvits et al., Combat veterans of the Vietnam war with PTSD showed an 20% reduction in the volume of their hippocampus compared with veterans who suffered no such symptoms. [Carlson, Neil R. (2007). Physiology of Behavior (9 ed.). Pearson Education, Inc.]

In 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.

Genetics

PTSD runs in families: For twin pairs exposed to combat in Vietnam, having a monozygotic (identical) twin with PTSD was associated with an increased risk of the co-twin having PTSD compared to twins that were dizygotic (non-identical twins). [cite journal |author=True WR, Rice J, Eisen SA, "et al" |title=A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms |journal=Arch. Gen. Psychiatry |volume=50 |issue=4 |pages=257–64 |year=1993 |pmid=8466386 |doi=] Because of the difficulty in performing genetic studies on a condition with a major environmental factor (ie., trauma), genetic studies of PTSD are in their infancy.A functional polymorphism in the monoamine oxidase A (MAOA) gene promoter can moderate the association between early life trauma and increased risk for violence and antisocial behavior. Low MAOA activity is a significant risk factor for aggressive and antisocial behavior in adults who have been victimized as children. Persons who were abused as children but have a genotype conferring high levels of MAOA expression are less likely to develop antisocial symptoms. These findings help explain why not all persons who have experienced early childhood trauma victimize others. [Caspi, A. u. a.: Role of genotype in the cycle of violence in maltreated children. Science, Vol. 297, No. 5582, August 2002, 851-854 [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12161658&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RV] ] [Frazzetto G, Di Lorenzo G, Carola V, Proietti L, Sokolowska E, Siracusano A, Gross C, Troisi A.: Early trauma and increased risk for physical aggression during adulthood: the moderating role of MAOA genotype. PLoS ONE. 2007 May 30;2(5):e486. [http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=17534436&cmd=showdetailview&indexed=google] ]

Risk and protective factors for PTSD development

Although most people (50-90%) encounter trauma over a lifetime [Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB: Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-1060] [Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P: Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 1998;55:626-632] , only about 8% develop full PTSD [Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB: Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-1060] . Vulnerability to PTSD presumably stems from an interaction of biological diathesis, early childhood developmental experiences, and trauma severity. Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood [Koenen KC, Moffitt TE, Poulton R, Martin J, Caspi A: Early childhood factors associated with the development of post-traumatic stress disorder: results from a longitudinal birth cohort. Psychol Med 2007 37:181-92] [Lapp KG, Bosworth HB, Strauss JL, Stechuchak KM, Horner RD, Calhoun PS, Meador KG, Lipper S, Butterfield MI: Lifetime sexual and physical victimization among male veterans with combat-related post-traumatic stress disorder. Mil Med 2005;170:787-90] [Otte C, Neylan TC, Pole N, Metzler T, Best S, Henn-Haase C, Yehuda R, Marmar CR: Association between childhood trauma and catecholamine response to psychological stress in police academy recruits. Biol Psychiatry 2005;57:27-32] [Resnick HS, Yehuda R, Pitman RK, Foy DW: Effect of previous trauma on acute plasma cortisol level following rape. Am J Psychiatry 1995;152:1675-1677] . This effect of childhood trauma, which is not well understood, may be a marker for both traumatic experiences and attachment problems [Laor N, Wolmer L, Mayes LC, Golomb A, Silverberg DS, Weitzman R, Cohen DJ: Israeli preschoolers under Scud missile attacks: A developmental perspective on risk-modifying factors. Arch Gen Psych 1996;53:416-23] [Laor N, Wolmer L, Mayes LC, Gershon A, Weitzman R, Cohen DJ: Israeli preschool children under Scuds: a 30-month follow-up. JAACAP 1997;36:349-56] . Proximity to, duration of, and severity of the trauma also make an impact; and interpersonal traumas cause more problems than impersonal ones [Janoff-Bulman R: Shattered Assumptions: Toward a New Psychology of Trauma. New York: Free Press, 1992] .

Schnurr, Lunney, and Sengupta identified risk factors for the development of PTSD in Vietnam veterans. Among those are:
*Hispanic ethnicity, coming from an unstable family, being punished severely during childhood, childhood asocial behavior and depression as pre-military factors
* war-zone exposure, peritraumatic dissociation, depression as military factors
* recent stressful life events, post-Vietnam trauma and depression as post-military factorsThey also identified certain protective factors, such as:
*Japanese-American ethnicity, high school degree or college education, older age at entry to war, higher socioeconomic status and a more positive paternal relationship as pre-military protective factors
*Social support at homecoming and current social support as post-military factorsJennifer L. Price, Ph.D.: Findings from the National Vietnam Veterans' Readjustment Study - Factsheet. National Center for PTSD. United States Department of Veterans Affairs [http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_nvvrs.html?opm=1&rr=rr45&srt=d&echorr=true] ] Other research also indicates the protective effects of social support in averting and recovery from PTSD [Brewin CR, Andrews B, Valentine JD: Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychology 2000;68:748-766] [Ozer EJ, Best SR, Lipsey TL, Weiss DS: Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull 2003;129:52-73] .

There may also be an attitudinal component e.g. a soldier who believes that they will not sustain injuries may be more likely to develop symptoms of PTSD than one who anticipates the possibility, should either be wounded. Likewise, the later incidence of suicide amongst those injured in home fires above those injured in fires in the workplace suggests this possibility.

:: See also: Psychological resilience

Diagnosis

The diagnostic criteria for PTSD, per the "Diagnostic and Statistical Manual of Mental Disorders IV (Text Revision)" (DSM-IV-TR), may be summarized as:cite book |author= |title=Diagnostic and statistical manual of mental disorders: DSM-IV |publisher=American Psychiatric Association |location=Washington, DC |year=1994 |pages= |isbn=0890420610 |oclc= |doi=; [http://www.behavenet.com/capsules/disorders/ptsd.htm on-line] ] :A. Exposure to a traumatic event:B. Persistent reexperience (e.g. flashbacks, nightmares):C. Persistent avoidance of stimuli associated with the trauma (e.g. inability to talk about things even related to the experience. Avoidance of things and discussions that trigger flashbacks and reexperiencing symptoms. Fear of losing control.):D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep, anger and hypervigilance):E. Duration of symptoms more than 1 month:F. Significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and relationships.)

Notably, criterion A (the "stressor") consists of two parts, both of which must apply for a diagnosis of PTSD. 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-TR 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%.cite journal |author=Breslau N, Kessler RC |title=The stressor criterion in DSM-IV posttraumatic stress disorder: an empirical investigation |journal=Biol. Psychiatry |volume=50 |issue=9 |pages=699–704 |year=2001 |pmid=11704077| doi = 10.1016/S0006-3223(01)01167-2] Various scales exist to measure the severity and frequency of PTSD symptoms. [Blake DD, Weather FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS, Keane TM: The development of a clinician-administered PTSD scale. J Traumatic Stress 1995;8:75-90] [Foa E: The Post Traumatic Diagnostic Scale Manual. Minneapolis, NCS, 1995]

Treatment

Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. 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 social stigma. [Foy 2002] The psychotherapy programs with the strongest demonstrated efficacy are all cognitive behavioral programs and include variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and combinations of these procedures. [Cahill, S. P., & Foa, E. B. (2004). A glass half empty or half full? Where we are and directions for future research in the treatment of PTSD. In S. Taylor (Ed.),Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives (pp. 267-313) New York: Springer.] Exposure involves assisting trauma survivors to therapeutically confront distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders.

Indeed, the success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD. Some organizations have endorsed the need for exposure [American Psychiatric Association: Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry 2004;161:11(suppl)] , [Committee on Treatment of Posttraumatic Stress Disorder, Institute of Medicine: Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, D.C.: National Academies Press, 2008 ISBN -10: 0-309-10926-4] . Yet other approaches, particularly involving social supports [Brewin CR, Andrews B, Valentine JD: Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychology 2000;68:748-766] , [Ozer EJ, Best SR, Lipsey TL, Weiss DS: Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull 2003;129:52-73] , may also be important. A recent open trial of interpersonal psychotherapy [Weissman MM, Markowitz JC, Klerman GL: Clinician’s Quick Guide to Interpersonal Psychotherapy. New York: Oxford University Press, 2007] reported high rates of remission from PTSD symptoms without using exposure [Bleiberg KL, Markowitz JC: Interpersonal psychotherapy for posttraumatic stress disorder. Am J Psychiatry 2005;162-181-183] . A randomized controlled trial funded by the National Institute of Mental Health is currently comparing exposure-based psychotherapy to interpersonal psychotherapy at the New York State Psychiatric Institute (www.columbiatrauma.org; 212 543-6747).

Critical incident stress management

Early intervention after a traumatic incident, [Brown, Asa Don Ph.D., "The effects of childhood trauma on adult perception and worldview", Capella University, 2008, 152 pages; AAT 3297512] known as Critical Incident Stress Management (CISM) is used to attempt 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. [cite journal | title = Disaster-related post-traumatic stress in police officers: A field study of the impact of debriefing | journal = Stress Medicine | volume = 14 | issue = 3 | pages = 143–8 | last = Carlier | first = IVE | coauthors = Lamberts RD; van Uchelen AJ; Gersons BPR | year = 1998 | url = http://doi.apa.org/?uid=1998-10258-001 | doi = 10.1002/(SICI)1099-1700(199807)14:3<143::AID-SMI770>3.0.CO;2-S ] [cite journal |author=Mayou RA, Ehlers A, Hobbs M |title=Psychological debriefing for road traffic accident victims. Three-year follow-up of a randomised controlled trial |journal=Br J Psychiatry |volume=176 |issue= |pages=589–93 |year=2000 |pmid=10974967| doi = 10.1192/bjp.176.6.589] Six studies have formally looked at the effect of CISM, four finding no benefit for preventing PTSD, and the other two studies indicating that CISM actually made things worse. Hence this is not a recommended treatment. Some benefit was found from being connected early to cognitive behavioral therapy, or for some medications such as propranolol. Effects of all these prevention strategies was modest. [cite journal |author=Feldner MT, Monson CM, Friedman MJ |title=A critical analysis of approaches to targeted PTSD prevention: current status and theoretically derived future directions |journal=Behav Modif |volume=31 |issue=1 |pages=80–116 |year=2007 |pmid=17179532 |doi=10.1177/0145445506295057]

Eye movement desensitization and reprocessing

Eye Movement Desensitization and Reprocessing (EMDR) is specifically targeted as a treatment for PTSD.cite journal |author=Devilly GJ, Spence SH |title=The relative efficacy and treatment distress of EMDR and a cognitive-behavior trauma treatment protocol in the amelioration of posttraumatic stress disorder |journal=J Anxiety Disord |volume=13 |issue=1-2 |pages=131–57 |year=1999 |pmid=10225505| doi = 10.1016/S0887-6185(98)00044-9] Research on EMDR is largely supported by those with the copyright for EMDR and third-party studies of its effectiveness are lacking, but a meta-analytic comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in terms of effectiveness in treating PTSD. [cite journal |author=Seidler GH, Wagner FE |title=Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study |journal=Psychol Med |volume=36 |issue=11 |pages=1515–22 |year=2006 |pmid=16740177 |doi=10.1017/S0033291706007963]

Medication

Medications have shown benefit in reducing PTSD symptoms, but rarely achieve complete remission. Standard medication therapy useful in treating PTSD includes SSRIs (selective serotonin reuptake inhibitors) and TCAs (tricyclic antidepressants). Tricyclics tend to be associated with greater side effects and lesser improvement of the three PTSD symptom clusters than SSRIs. SSRIs for which there are data to support use include: citalopram, escitalopram, fluvoxamine, paroxetine and sertraline. [ Yehuda, R. (2000), Biology of posttraumatic stress disorder. Journal of Clinical Psychiatry, 61 (7): 14-21] [Marshall RD, Beebe KL, Oldham M, Zaninelli R: Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed dose, placebo controlled study. Am J Psychiatry Dec 2001;158:1982 1988] [Brady K, Pearlstein T, Asnis GM, Baker D, Rothbaum B, Sikes CR, Farfel GM: Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. JAMA 2000;283:1837-1844] [Davidson JRT, Rothbaum BO, van der Kolk BA, Sikes CR, Farfel GM: Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry 2001;58:485-492]

There are data to support the use of "autonomic medicines" such Propranolol (beta blocker) and Clonidine (alpha-adrenergic agonist) if there are significant symptoms of "over-arousal". These may inhibit the formation of traumatic memories by blocking adrenaline's effects on the amygdala, has been used in an attempt to reduce the impact of traumatic events.cite journal |author=Pitman RK, Sanders KM, Zusman RM, "et al" |title=Pilot study of secondary prevention of posttraumatic stress disorder with propranolol |journal=Biol. Psychiatry |volume=51 |issue=2 |pages=189–92 |year=2002 |pmid=11822998| doi = 10.1016/S0006-3223(01)01279-3] or they may simply demonstrate to the patient that the symptoms can be controlled thereby assisting with "self efficacy" and helping the patient remain calmer. There is also data to support the use of mood-stabilizers such lithium carbonate, divalproex sodium and carbemazepine if there is significant uncontrolled mood or aggression. Risperidone is used to help with dissociation, mood and aggression, and benzodiazepines are used for short-term anxiety relief.Reist C (2005) Post-traumatic Stress Disorder. Compendia, Build ID: F000005, published by Epocrates.com]

=MDMA=

While MDMA had its first exposure to the psychiatric community in the 1960s, gaining a reputation for its communication enhancing qualities, it hasn't been until recent years that formal studies have been carried out. The US Food and Drug Administration (FDA) recently approved a clinical protocol that combines the drug MDMA with talk therapy sessions. [ [http://www.maps.org/mdma/protocol/index.html "MAPS FDA and IRB approved MDMA/PTSD protocol"] ] Funded by the non-profit Multidisciplinary Association for Psychedelic Studies (MAPS), [ [www.maps.org] ] the studies are taking place in South Carolina under the supervision and direction of Dr. Michael Mithoefer. Other PTSD/MDMA research include a pilot study in Switzerland, co-sponsored by MAPS and the Swiss Medical Association for Psycholytic Therapy (SAePT), [http://www.maps.org/mdma/swissmdmaptsd/protocol280507.pdf] and another study approved in Israel to investigate MDMA as a tool in the psychotherapeutic treatment of crime and terrorism-related PTSD. [ [http://www.maps.org/mdma/israel_protocol_04.06.pdf "MDMA-assisted Psychotherapy in Twelve People with War and Terrorism-related PTSD"] ]

There are several features of MDMA that make it an excellent candidate for treating PTSD in psychotherapy. The effects of MDMA are such that activity in the left amygdala, [http://www.maps.org/research/mdma/ptsd_study/treatment-manual/053005/intro.html] responsible for fear and anxiety, decreases in rats. This makes it a promising candidate as a tool in psychotherapy, allowing the patient to explore and examine their trauma (and accompanying emotions) without the fear and retraumatization encountered without drug. Ordinarily incapacitated by the resurgence of emotions (fear, shame, anger) attached to the trauma, subjects are rendered capable of approaching their trauma in a new and constructive way. Further helpful in treating PTSD, is the new capacity to experience empathy and compassion for both others and the self. [ [http://www.maps.org/sys/nq.pl?id=1580&fmt=page Ecstasy is the Key to Treating PTSD ] ]

Combination therapies

PTSD is commonly treated using a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and medications such as antidepressants (e.g. SSRI's such as fluoxetine and sertraline, SNRI's such as venlafaxine, NaSSA's such as mirtazapine and tricyclic antidepressant such as amitriptyline [National Institute for Clinical Excellence: [http://www.nice.org.uk/nicemedia/pdf/CG026publicinfo.pdf The Treatment of PTSD in Adults and Children] ] ) or atypical antipsychotic drugs (such as quetiapine and olanzapine). [cite book |title=Manual of Clinical Psychopharmacology |last=Schatzberg |first=Alan F. |coauthors=Jonathan O. Cole, Charles DeBattista |year=2007 |publisher=American Psychiatric Pub, Inc. |isbn=1585623172 ] Recently the anticonvulsant lamotrigine has been reported to be useful in treating some people with PTSD. [cite web|url=http://www.psycom.net/depression.central.lamotrigine.html|title=Lamotrigine FAQ|accessdate=2007-05-01] [ [http://www.biopsychiatry.com/ptsd-drugs.html SSRIs versus Non-SSRIs in Post-traumatic Stress Disorder] , Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Albert Einstein College of Medicine] [ [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10331117&dopt=Abstract A preliminary study of lamotrigine for the treatment of posttraumatic stress disorder] , "Biol Psychiatry" 1999 May 1;45(9):1226-9] Geodon (ziprasidone) is one of the most effective treatments shown to work 89% of the time in PTSD patients. [ [http://www.psychiatrymmc.com/displayArticle.cfm?articleID=article43 ZIPRASIDONE TREATMENT FOR POSTTRAUMATIC STRESS DISORDER: 128 CASES ] ] Geodon works by blocking two of the fight-or-flight chemicals (catecholamines): norepinephrine (noradrenaline) and dopamine. [cite web|url=https://www.pfizerpro.com/product_info/geodon_pi_clinical_pharmacology.jsp|title=Geodon pharmacology FAQ|accessdate=2008-07-24] Carrot of Hope has been promoting the benefits of combining Geodon with the beta-adrenergic blocker propranolol to create a [http://www.carrotofhope.com/ptsd_cure.html PTSD cocktail] . Since propranolol works by blocking the third catecholamine, epinephrine (adrenaline), [cite web|url=http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=6397|title=Propranolol pharmacology FAQ|accessdate=2008-07-24] the combination of the two medicines work to block all three fight-or-flight chemicals. Propranolol (40 mg) has been commonly prescribed off-label for stage fright in the late 1970s. [cite book |title=Effect of Beta Blockade and Beta Stimulation on Stage Fright |last=Brantigan |first=CO |coauthors=et. al. |year=Jan. 1982 |publisher=American Journal of Medicine |pages=88-94] [cite book |title=Effect of Beta Blockade on Singing Performance |last=Gates |first=GA |coauthors=et. al. |year=Nov-Dec 1985 |publisher=Ann Otol Rhinol Laryngol |pages=570-4] The television show [http://www.cbsnews.com/sections/i_video/main500251.shtml?id=2940749n 60 Minutes] featured propranolol where low doses (10-20 mg) used in research have been shown to stop panic attacks and reduce the impact of traumatic memories. As propranolol lasts in the system for 4 hours, the study dosages are typically given 4 times a day to cover a 16 hour span. [cite web|url=http://www.hno.harvard.edu/gazette/2004/03.18/01-ptsd.html|title=A Pill to Calm Traumatic Memories FAQ|accessdate=2008-07-24] Alpha-adrenergic blocker prazosin has also shown impressive effects in PTSD patients, curbing brain damage and reducing nightmares. [cite web|url=http://www.news-medical.net/?id=32288|title=Prazosin curbs brain damage from PTSD FAQ|accessdate=2008-07-24] [cite web|url=http://www.news-medical.net/?id=23491|title=Prazosin drug helps post-traumatic stress nightmares FAQ|accessdate=2008-07-24] Unlike propranolol, prazosin acts on norepinephrine [cite web|url=http://www.med.howard.edu/pharmacology/handouts/alpha%20adrenergic%20receptor%20antagonists_2002.htm|title=Prazosin pharmacology FAQ|accessdate=2008-07-24] and, therefore, is contraindicated for use with Geodon.

Other techniques

Attachment- and relationship-based treatments are also often used. [cite book |author=Johnson, Susan |title=Emotionally Focused Couple Therapy with Trauma Survivors : Strengthening Attachment Bonds (Guilford Family Therapy Series) |publisher=The Guilford Press |location=New York |year= |pages= |isbn=1-59385-165-0 |oclc= |doi=] cite web | url = http://www.foxnews.com/story/0,2933,344991,00.html | title = "Marine Corps Offers Yoga, Massages to Marriages Strained by War" | publisher = Associated Press | date = 2008-04-02 | accessdate = 2008-04-03] In these cases, the treatment of complex trauma often requires a multi-modal approach. Medical Marijuana is also used for treatment of PTSD Fact|date=August 2008.
Yoga Nidra has been used to help soldiers cope with the symptoms of PTSD. [Eileen Rivers, Washington Post, Tuesday, May 6, 2008; Page HE01 ]

Epidemiology

PTSD may be experienced following any traumatic experience, or series of experiences that satisfy the criteria and that do not allow the victim to readily recuperate from the detrimental effects of stress. 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.Fact|date=March 2008

The "National Vietnam Veterans' Readjustment Study" (NVVRS) found 15.2% of male and 8.5 of female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was 30.9 for males and 26.9 for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans suffered from PTSD-symptoms. Four out of five reported recent symptoms when interviewed 20-25 years after Vietnam.

In recent history, catastrophes (by human means or not) such as the Indian Ocean Tsunami Disaster 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.

There is debate over the rates of PTSD found in populations, but despite changes in diagnosis and the criteria used to define PTSD between 1997 and 2007, epidemiological rates have not changed significantly.cite journal |author=Brunet A, Akerib V, Birmes P |title=Don't throw out the baby with the bathwater (PTSD is not overdiagnosed) |journal=Can J Psychiatry |volume=52 |issue=8 |pages=501–2; discussion 503 |year=2007 |pmid=17955912 |url = http://publications.cpa-apc.org/media.php?mid=490 | format = pdf | accessdate = 2008-03-12]

History

Earliest reports

Reports of battle-associated stress appear as early as the 6th century BC. [http://www.abc.net.au/rn/allinthemind/stories/2004/1214098.htm When trauma tips you over: PTSD Part 1] All in the Mind, Australian Broadcasting Commission, 9 October 2004] Although PTSD-like symptoms have also been recognized in combat veterans of many military conflicts since, the modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by Vietnam veterans. One of the first descriptions of PTSD was made by the Greek historian Herodotus. In 490 BCE he described, during the Battle of Marathon, an Athenian soldier who suffered no injury from war but became permanently blind after witnessing the death of a fellow soldier. [Swartz' Textbook of Physical Diagnosis: History and Examination]

The term "post-traumatic stress disorder" or "PTSD" was coined in the mid 1970s. Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders. The term was formally recognised in 1980. (In the DSM-IV, which is considered authoritative, the spelling "posttraumatic stress disorder" is used. Elsewhere, "posttraumatic" is often rendered as two words &mdash; "post-traumatic stress disorder" or "post traumatic stress disorder" &mdash; especially in less formal writing on the subject.)

Veterans and politics

The diagnosis was removed from the DSM-II, which resulted in the inability of Vietnam veterans to receive benefits for this condition. In part through the efforts of anti Vietnam war activists and the anti war group Vietnam Veterans Against the War and Chaim F. Shatan, who worked with them and coined the term post-Vietnam Syndrome, the condition was added to the DSM-III as posttraumatic stress disorder.cite book |author=Shalev, Arieh Y.; Yehuda, Rachel; Alexander C. McFarlane |title=International handbook of human response to trauma |publisher=Kluwer Academic/Plenum Press |location=New York |year=2000 |pages= |isbn=0-306-46095-5 |oclc= |doi=; [http://www.istss.org/what/history2.cfm on-line] ]

In the United States, the provision of compensation to veterans for PTSD is under review by the Department of Veterans Affairs (VA). The review was begun in 2005 after the VA had noted a 30% increase in PTSD claims in recent years. The VA undertook the review because of budget concerns and apparent inconsistencies in the awarding of compensation by different rating offices.

This led to a backlash from veterans'-rights groups, and to some highly-publicized suicides by veterans who feared losing their benefits, which in some cases constituted their only income. In response, on November 10 2005, the Secretary 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..." [ [http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1042 United States Department of Veteran Affairs] ]

The diagnosis of PTSD has been a subject of some controversy due to uncertainties in objectively diagnosing PTSD in those who may have been exposed to trauma, and due to this diagnosis' association with some incidence of compensation-seeking behavior. [cite news | url = http://www.washingtonpost.com/wp-dyn/content/article/2005/12/26/AR2005122600792.html | publisher = The Washington Post | last = Vedantam | first = Shankar | title = A Political Debate On Stress Disorder: As Claims Rise, VA Takes Stock | date = 2005-12-27 | accessdate = 2008-03-12]

The social stigma of PTSD may result in under-representation of the disorder in military personnel, emergency service workers and in societies where the specific trauma-causing event is stigmatized (e.g. sexual assault).

Many US veterans of the wars in Iraq and Afghanistan returning home have faced significant physical, emotional and relational disruptions. In response the United States Marine Corps has instituted programs to assist them in re-adjusting to civilian life - especially in their relationships with spouses and loved ones - to help them communicate better and understand what the other has gone through. Similarly, Walter Reed Army Institute of Research (WRAIR) developed the Battlemind program to assist servicemembers avoid or ameliorate PTSD and related problems.

Canadian veterans

Veterans Affairs Canada is a new program including rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support. [ [http://www.vac-acc.gc.ca/clients/sub.cfm?source=Forces/nvc&CFID=9295860&CFTOKEN=39698927 VAC-ACC.GC.CA] ]

Cultural references

Jonathan Shay, a psychiatrist for the Boston Department of Veterans' Affairs Outpatient Clinic was treating soldiers who suffered from PTSD. He was struck by the similarity of their war experiences to Homer's account of Achilles in the Iliad. He also believes Hotspur in William Shakespeares Henry IV, Part 1 is portrayed as a person suffering from PTSD. [Jonathan Shay: Achilles in Vietnam: Combat Trauma and the Undoing of Character. Simon & Schuster; First Touchstone edition]

J. R. R. Tolkien served in World War I. It is believed that he portrayed Frodo Baggins in The Lord of the Rings as a person suffering from PTSD. [Karyn Milos: Too Deeply Hurt. Mallorn Issue 36]

In 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 engage the issue in their work. Many movies, such as First Blood, Birdy, Coming Home, The Deer Hunter, Born on the Fourth of July, and Heaven & Earth deal with PTSD. It is an especially popular subject amongst "war veteran" films, often portraying Vietnam war veterans suffering from extreme PTSD and having difficulties adjusting to civilian life.

A very realistic depiction showed on screen was by Christian Bale in "Harsh Times". He suffers from PTSD from the horrors of war.

The song "Just Another Day" by 80s new wave group Oingo Boingo ambiguously references posttramaumatic stress disorder.

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. [Mark Jarzombek, "The Post-traumatic Turn and the Art of Walid Ra'ad and Krzysztof Wodiczko: from Theory to Trope and Beyond," in "Trauma and Visuality", Saltzman, Lisa and Eric Rosenberg, editors (University Press of New England, 2006)] Wodiczko aims 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. [Elizabeth Cowie, "Perceiving Memory and Tales of the Other: the work of Milica Tomic," "Camera Austria", no. [?] , pp. 14-16.]

George Carlin comments on the various incarnations of PTSD terminology on his 1990 album . He traces the progression of what he views as euphemisms, which followed "shell shock" in World War I: "battle fatigue" in World War II, "operational exhaustion" in the Korean War, and finally PTSD, a clinical, hyphenated term, in the Vietnam War. "The pain is completely buried under jargon. Post-traumatic stress disorder. I'll bet you if we'd have still been calling it shell shock, some of those Viet Nam veterans might have gotten the attention they needed at the time." [ [http://www.iceboxman.com/carlin/pael.php#track15 George Carlin - Parental Advisory Explicit Lyrics ] ]

Some people believe that sufferers of Post Traumatic Stress Disorder have been stereotyped in popular culture. Many dramatic television shows have featured "psycho veteran" characters. Most recently, ABC's three daytime soap operas All My Children, One Life To Live, and General Hospital have each featured an Iraq War veteran who suffers from PTSD, and two of those three characters were written as being antisocial and prone to violence, while the other killed a man in defense (after having subdued him and he was no longer a threat) during a moment of stress.

Also, the Happy Tree Friends character Flippy exhibits some PTSD because of hearing sounds that reminds him of the Vietnam War. This results in the gruesome deaths of the other characters and sometimes even himself.

See also

* Acute stress reaction
* Complex post-traumatic stress disorder
* Dissociative disorders
* Emotional dysregulation
* James Blake Miller
* Post-abduction syndrome
* Post-abortion syndrome
* Post-cult trauma
* Psychogenic amnesia
* Psychoneuroimmunology
* Survivor syndrome
* Trauma model of mental disorders
* Thousand-yard stare
* Ira Hayes

References

External links

*
* [http://www.ptsduk.co.uk UK based support site.] An online 'real-world' support site for everyone who has PTSD, people close to them and professionals.
* [http://www.patrickriley.net Riley Down Under: Surviving PTSD And Getting On WIth Life]
* [http://www.patrickriley.ca/you-dont-have-to-wear-a-uniform-to-suffer/ You Don't Have To Wear A Uniform To Suffer]
* [http://www.pbs.org/now/shows/424/index.html PBS NOW | Fighting the Army]
* National Institute for Health and Clinical Excellence (Nice): [http://www.nice.org.uk/nicemedia/pdf/CG026publicinfo.pdf Post-traumatic stress disorder (PTSD): the treatment of PTSD in adults and children]
* [http://ptsdcombat.blogspot.com PTSD Combat: Winning the War Within] Combat PTSD blog by author Ilona Meagher (Moving a Nation to Care: Post-Traumatic Stress Disorder and America's Returning Troops) featuring research, news, resources, and events for returning veterans coping with post-combat reintegration and/or post-traumatic stress disorder.
* [http://www.HealingCombatTrauma.com Healing Combat Trauma] Resources for and about healing combat trauma. The focus is on effective therapeutic care — medical, psychological and legal — and the slant is apolitical.
* [http://www.carrotofhope.org/ Carrot of Hope] nonprofit PTSD group started by individuals with PTSD and their family & friends.
* [http://www.sidran.org/sub.cfm?sectionID=4 Sidran Institute] traumatic stress education & advocacy. Will provide referrals to treatment in your area.
* [http://dailystrength.org/support/Anxiety_Disorders/Post-Traumatic_Stress_Disorder/ DailyStrength] online support group for PTSD.
* [http://www.pbs.org/wgbh/pages/frontline/shows/heart/ PBS: A Soldier's Heart] Several articles and resources related to PTSD and those who have served in Iraq or Afghanistan.
* [http://www.familyofavet.com Information about Combat-Related PTSD for Veterans & Families] Site has section devoted to PTSD from a Vet perspective; including information about how to deal with PTSD in the real world.
* [http://www.traumaticstressclinic.com.au Traumatic Stress Clinic] A free nonprofit treatment service for sufferers of Post Traumatic Stress Disorder in Sydney, Australia.