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Posttraumatic Stress Disorder

Neuroses Post Traumatic

Posttraumatic stress disorder is a pathological anxiety that can develop after an individual has experienced or witnessed a major trauma. The events experienced may be natural disasters, war, physical and sexual assault or abuse.


Presentation

  • Re-experiencing symptoms (Flashbacks) [2]: Reliving the trauma again and again, including physical symptoms like chest pain, palpitations or sweating. Negative dreams. Scary thoughts.
  • Symptoms of neglecting that painful memory [3]: Patient remains away from places, objects and events that remind the patient of the experience. Patient feels emotionally numb. Develops strong guilt, depression, or anxiety. Loses interest in activities that were once enjoyable. Has trouble in remembering the dangerous event.
  • Hyperarousal symptoms: Gets easily startled. Feels tense or "on the edge" [4]. The patient has sleeping difficulties or develops frequent anger out-bursts. Hyperarousal symptoms are usually constant unlike other symptoms which are triggered by the things which remind the individual of the traumatic event. They tend to make the person feel pressurized and tensed. These symptoms affect the daily routine like sleeping, eating, or focusing on one’s work and chores. It is natural to have some of these things upset one after a traumatic event. It is called acute stress disorder. But when it persists even after 6 months of the event and lasts for over a month, it is termed as posttraumatic stress disorder.
  • Children tend to have different response to traumatic event. Bedwetting, when they use to be dry before the event. The child may forget how to or is unable to talk. The child acts out the scary event during playtime. The child unusually clings [5] to a parent or other adults and avoids being left alone.
Nightmare
  • The majority of patients (72%) receiving nabilone experienced either cessation of nightmares or a significant reduction in nightmare intensity.[ncbi.nlm.nih.gov]
  • […] of prazosin in veterans with nightmares related to PTSD, there was a decrease in nightmares and an improved quality of sleep. 30 Prazosin is generally well tolerated but can cause hypotension and dizziness.[healio.com]
Fatigue
  • Sub-category Cronbach α was 0.92 for snoring and 0.63 for fatigue. However, when “sleepiness behind the wheel” was excluded, Cronbach α for fatigue increased to 0.86.[aasmnet.org]
  • A literature review for 1994-2011 was conducted for the following keywords: secondary traumatic stress, compassion fatigue, vicarious traumatization, posttraumatic stress disorder, and nurse.[ncbi.nlm.nih.gov]
  • Also: acute stress disorder, battle fatigue * American Psychiatric Association : Diagnostic and Statistical Manual of Mental Disorders, fourth Edition.[web.archive.org]
  • The Art and Science of Caring for Others without Forgetting Self-Care Compassion Fatigue: An Introduction The MASTERS Process: Transforming Your Career and Life J. Eric Gentry, PhD, LMHC Compassion Fatigue: A Crucible Of Transformation Frank M.[giftfromwithin.org]
Crying
  • She lets out a victorious war-cry as well. In the actual game Metroid: Zero Mission , Samus' eyes are briefly seen through her visor as Ridley flies down to battle.[metroid.wikia.com]
  • 905 In thy faint slumbers I by thee have watch'd, And heard thee murmur tales of iron wars; Speak terms of manage to thy bounding steed; Cry 'Courage! to the field!'[opensourceshakespeare.org]
  • Adolescents aged 12–17 years generally have responses similar to those of adults. [2] For children aged 6 years or younger, typical reactions to trauma can include regressive behavior, a fear of being separated from a parent, crying, whimpering, screaming[emedicine.com]
Wound Infection
  • The surgery was complicated by a wound infection responsible for severe postoperative pain. Such genital pain made our patient recall the traumatic experience of genital mutilation and experience a relapse of posttraumatic stress disorder symptoms.[ncbi.nlm.nih.gov]
Nausea
  • […] section, people with PTSD may also experience physical symptoms, such as increased blood pressure and heart rate, fatigue, muscle tension, nausea, joint pain, headaches, back pain or other types of pain.[psychiatry.org]
  • The main side effects include headache which decreases with continued use, nausea, sleeplessness or feeling drowsy, jitteriness and sexual problems.[symptoma.com]
  • The person may also suffer physical symptoms, such as increased blood pressure and heart rate, rapid breathing, muscle tension, nausea, and diarrhea.[webmd.com]
Fear
  • The objective herein is to determine whether extinction of fear responses is impaired in PTSD and whether such impairment is related to dysfunctional activation of brain regions known to be involved in fear extinction, viz., amygdala, hippocampus, ventromedial[ncbi.nlm.nih.gov]
  • […] related to mood and is associated with fear response.[symptoma.com]
Anxiety Disorder
  • In addition, studies are being conducted on the “natural history” (what course the illness takes without treatment) of many anxiety disorders, combinations of anxiety disorders, and anxiety disorders accompanied by other mental illnesses such as depression[web.archive.org]
  • This article provides an overview of several anxiety disorders that are diagnosed often during childhood and adolescence, including separation anxiety disorder, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, and posttraumatic[ncbi.nlm.nih.gov]
Panic Attacks
  • The high level of anxiety of PTSD can lead to associated problems like panic attacks, depression, alcoholism and substance abuse. PTSD affects 7.7 million adults, but it can affect children and the elderly.[tm.org]
  • This review presents a case report of a 19-year-old male patient with a spectrum of severe PTSD symptoms, such as intense flashbacks, panic attacks, and self-mutilation, who discovered that some of his major symptoms were dramatically reduced by smoking[ncbi.nlm.nih.gov]
  • These emotions may play out physically in the form of chills, shaking, headaches , heart palpitations , and panic attacks . Avoidance You don't want to think about it. You don't want to talk about it.[webmd.com]
Depersonalization
  • RESULTS: Model A, the depersonalization/derealization model, had 5 classes: dissociative subtype/high PTSD; high PTSD; anxious arousal; dysphoric arousal; and a low symptom/reference class.[ncbi.nlm.nih.gov]
  • The dissociative sub-type involves depersonalization or derealization rather than just additional dissociation, and is clinically different from severe PTSD.[traumadissociation.com]
  • Two specifications: Dissociative Specification In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli: Depersonalization.[brainline.org]
  • […] whether: With dissociative symptoms: The individual’s symptoms meet the criteria for Posttraumatic Stress Disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: Depersonalization[veterans.gc.ca]
Withdrawn
  • Whereas the attentional bias away from angry faces was associated with social problems, the attentional bias towards sad faces was associated with depressive and withdrawn symptoms.[ncbi.nlm.nih.gov]
  • They may also become less responsive emotionally, depressed, withdrawn, and more detached from their feelings.[aacap.org]
  • The total volume of CSF withdrawn was less than 10% of the normal daily volume of CSF produced.[doi.org]
  • These symptoms include remembering or reliving the trauma when you do not choose to; feeling numb and withdrawn; and, having forms of anxiety that interfere with daily life.[ptsdinfo.org]
  • In addition, she hardly sleeps, is irritable and withdrawn, and appears to have lost weight.[anxietybc.com]
Irritability
  • In this case, a single Caucasian female resolved her symptoms of bipolar disorder (BD) including psychotic features and suicidality, posttraumatic stress disorder symptoms from childhood torture, disordered eating, fibromyalgia, and irritable bowel syndrome[ncbi.nlm.nih.gov]
  • ., irritability, on constant alert for danger), and re-experiencing of the trauma (e.g., flashbacks, intrusive emotions).[healthcommunities.com]
  • Finally, a person with PTSD feels “on edge” much of the time, resulting in increased irritability, difficulty with sleep and concentration.[psychcentral.com]
Insomnia
  • Cognitive Behavior Therapy for Insomnia provided insomnia symptom relief psychoeducation and self-monitoring of PTSD symptoms prepared the patient to enter exposure therapy.[ncbi.nlm.nih.gov]
  • There are highly efficacious behavioral interventions available for both insomnia and nightmares ( Table 2 ).[healio.com]
  • Nabilone was used to treat a mean of 3.5 indications per patient, most commonly nightmares, insomnia, and chronic pain.[doi.org]
Headache
  • Patients most likely to meet criteria for posttraumatic stress disorder reported significantly higher levels of stress, depression, anxiety, and suicide ideation as well as more severe headaches, chest pains, dizziness, and poorer health care.[ncbi.nlm.nih.gov]
  • Baron , Medicinal Properties of Cannabinoids, Terpenes, and Flavonoids in Cannabis, and Benefits in Migraine, Headache, and Pain: An Update on Current Evidence and Cannabis Science , Headache: The Journal of Head and Face Pain , 58 , 7 , (1139-1186) ,[doi.org]
  • PTSD often exists simultaneously with other physical symptoms of high stress such as digestive disorders, headaches, chest pain and dizziness.[tm.org]
  • […] again developing repeated physical or emotional symptoms when the child is reminded of the event Children with PTSD may also show the following symptoms: worry about dying at an early age losing interest in activities having physical symptoms such as headaches[aacap.org]
Behavior Problem
  • Abstract The purpose of this study was to examine differences in: (1) mental health emotional and behavioral problems between young children experiencing PTSD with and without MDD; (2) the incidence of caregiver PTSD and MDD between children with PTSD[ncbi.nlm.nih.gov]
  • This was driven by clinical experience that engagement and retention of young children and their caregivers in interventions for emotional and behavioral problems was a critical problem.[medicine.tulane.edu]
  • problems 267 (6.7) 95 (21.6) 3.8 (3.0–5.0) 309 (8.7) 68 (17.3) 2.2 (1.7–2.9) Home behavior problems 313 (7.9) 125 (28.3) 4.6 (3.7–5.9) 380 (10.7) 115 (29.1) 3.4 (2.7–4.4) Poor grades in school 284 (7.2) 98 (22.5) 3.8 (2.9–4.8) 316 (8.9) 68 (17.4) 2.2[ehp.niehs.nih.gov]
Encephalopathy
  • Following his discovery of chronic traumatic encephalopathy (CTE) in football players in 2002, Dr. Bennet Omalu hypothesized that posttraumatic stress disorder (PTSD) in military veterans may belong to the CTE spectrum of diseases.[ncbi.nlm.nih.gov]
  • Acute and chronic traumatic encephalopathies: pathogenesis and biomarkers. Nat. Rev. Neurol. 9, 192–200. doi: 10.1038/nrneurol.2013.36 Pubmed Abstract Pubmed Full Text CrossRef Full Text Diamond, D. M., Campbell, A. M., Park, C.[doi.org]

Workup

Not everyone who faces stressful event develops the disorder. Usually symptoms develop within first three months, sometimes they may develop after many years. Symptoms should last for more than one month to be diagnosed as posttraumatic stress disorder and a person must have all of the following for at least 1 month:

  1. At least one re-experiencing symptom [6].
  2. At least three symptoms of negligence or avoidance.
  3. Minimum of two positive symptoms of increased arousal.

Posttraumatic stress disorder is seen in conjunction with depression and anxiety disorders that must be treated accordingly.

ST Elevation
  • Have signs of ischemia (defined as ST elevation or depression) or significant arrhythmia (defined as atrial fibrillation or flutter, ventricular fibrillation or flutter) on the screening electrocardiogram.[clinicaltrials.gov]
  • Relation of low T3 to one-year mortality in non-ST-elevation acute coronary syndrome patients. J Clin Lab Anal (2017) 31(2):e22036. doi:10.1002/jcla.22036 PubMed Abstract CrossRef Full Text Google Scholar 293.[doi.org]
Neurofibrillary Tangle
  • Histochemical and immunohistochemical brain tissue analysis revealed CTE changes comprising multifocal, neocortical, and subcortical neurofibrillary tangles and neuritic threads (ranging from none, to sparse, to frequent) with the skip phenomenon, accentuated[ncbi.nlm.nih.gov]

Treatment

The mainstay for the treatment includes psychotherapy and medications. As every individual is different, treatment needs to be individualized. If someone with is going through continuous trauma, such as being in a stressed and bothersome relationship, then both the problems need to be treated simultaneously. Other ongoing problems can be panic disorder, depression and substance abuse which need attention and the necessary treatment.

Psychotherapy involves talking one’s mind out regarding all the experiences of the traumatic event with a mental health professional in order to treat the mental illness. Psychotherapy can occur either one-on-one or in a group. Psychotherapy usually lasts for 6 to 12 weeks, but can take more time. Few psychotherapies target the negative memories directly. Other therapies focus on accompanying problems relating to the social aspect, family and job. The doctor or therapist may apply more than one therapy depending on individual's needs.

Cognitive behavior therapy (CBT) [7] is widely used and consists of exposure therapy, cognitive reconstruction and stress inoculation therapy. CBT helps people face fear, it helps develop a healthy outlook to the traumatic event and helps people recall their memories in a healthy way.

Selective serotonin reuptake inhibitors (SSRIs) are used primarily in depression, sertraline [8] and paroxetine are used for PTSD. The main side effects include headache which decreases with continued use, nausea, sleeplessness or feeling drowsy, jitteriness and sexual problems. Other group of drugs like benzodiazepines which reduce anxiety and antipsychotics are also used in PTSD.

Treatment after mass trauma

Most people will have PTSD like symptoms in the initial days. Most people can be helped to uplift their confidence with basic support, such as providing a safe shelter, seeing a doctor if injured or diseased, getting basic needs of food and clean water, contacting one's family and friends, learning what is being done to help. As communities try to readjust after a community disaster, people also experience ongoing stress from loss of employment or education, economical stress - trouble paying finances, finding shelter, and getting medical care. This delay in community recovery will cause delay in recovery in patients from PTSD. In the first few weeks after a mass disaster, brief versions of CBT [9] are helpful for some people who face severe distress.

Prognosis

Prognosis is good as most of the memories of the events are erased by repeated cognitive behavioural therapy. Play therapy for children and talking out with mental health professionals removes all the remnant memories of the disturbing event.

Etiology

Scientists have found genes that contribute to memories of the fear. Stathmin is a protein needed to form fear memories. Gastrin-releasing peptide (GRP) is a signaling chemical in the brain that peaks during such traumatic emotional events. GRP controls the fear response and accounts for healing of the traumatic memories and lack of GRP leads to the development of lasting and grandeur memories of the frightening experience. 5-HTTLPR gene controls levels of serotonin which is a neurotransmitter related to mood and is associated with fear response.

Risk factors for the disorder are experiencing dreadful events, history of mental illness, getting hurt, seeing close relatives being hurt or killed, feeling extremely helpless, or extreme fear and anxiety. Having lack of social support after the event, facing rising levels of stress after the event, such as permanent loss of a loved one, pain due to the event and physical injury of oneself, or loss of work or shelter may also lead to the condition.

Supportive factors that may reduce the risk of developing posttraumatic stress include calling for help from friends and family, finding a support group after the act or the event took place. One should be able to react and respond instead of being afraid.

Epidemiology

Women are more commonly affected than men. More than 60% of men and women have one such experience in their life which gives a posttraumatic stress disorder-like effect. Around 80% of people both men and women have comorbid symptoms along with PTSD. Rape in women commonly leads to the condition whereas sexual abuse in men may produce lasting stress.

Sex distribution
Age distribution

Pathophysiology

The amygdala appears to be responsible for acquisition of fear or learning to fear an event (such as coming in contact with a hot object). Storing memories of such events that will again bring on the original fear response leads to posttraumatic stress. This type of fear involves the prefrontal cortex (PFC) area of the brain.

Individual differences in brain areas will still lead to the disorder without actually causing symptoms; this is called as subclinical posttraumatic stress disorder. Other factors like head injury or
history of mental illness or childhood trauma, further increase a person's risk by affecting the development and functioning of the brain.

Personality traits and cognitive factors, such as tendency to look at challenges in a positive or negative way, optimistic or pessimistic attitude and social factors such having a good family support and using a support group, influence an individual's response to traumatic stimuli.

Prevention

One can prevent such an occurrence by early identification of such patients and early initiation of cognitive behavioural therapy. The condition occurs as the event repeatedly hampers the mind for over a month, but if the victim is given therapy early after the event there will not be any occurrence of the disorder at all.

Summary

In patients with posttraumatic stress disorder, the fight or flight reaction to perceived danger is changed or damaged. People with the condition feel afraid even when not in danger. Posttraumatic stress disorder (PTSD) usually develops after a person is exposed to one or more traumatic events, such as sexual abuse, physical injury, warfare or threats of death, death or threat to life of loved ones, that result in feelings of intense fear and horror, or helplessness.

Posttraumatic stress disorder consists of recurrent disturbing flashbacks, avoidance of memories of the event, and increased excitement continuing for more than one month after the occurrence of traumatic event [1]. The disorder was first noticed in war veterans, but later it was found in association with a variety of traumatic events, such as rape, child abuse, torture, being kidnapped, accidents of cars, mugging train derailment, blasts due to bombs, airplane crashes, or natural disasters such as floods or earthquakes.

Patient Information

Posttraumatic stress disorder (PTSD) may develop after a person has experienced one or more traumatic dreadful events, such as sexual assault, warfare, serious physical injury, natural disasters or threats of death that result in feelings of intense fear, horror, and powerlessness.

It is diagnosed when symptoms such as avoidance or non-recalling of memories of the event, recurrent disturbing memories of flashbacks, and hyper-arousal, continue for over a month after the occurrence of traumatic event.

The mainstay in the treatment includes psychotherapy and antidepressant drug therapy. Cognitive behavioral therapy is widely used too which helps the individual fight fear and develop healthy memories of the event.

References

Article

  1. Risser HJ, Hetzel-Riggin MD, Thomsen CJ, McCanne TR. PTSD as a mediator of sexual revictimization: the role of reexperiencing, avoidance, and arousal symptoms. J Trauma Stress. 2006 Oct. 19(5):687-98.
  2. Kaplan HI, Sadock BJ and Grebb JA. Posttraumatic Stress Disorder. Kaplan and Sadock's synopsis of psychiatry: Behavioral sciences, clinical psychiatry (7th ed.) 1994. Baltimore: Williams & Williams.
  3. Fullerton CS, Ursano RJ, Wang L. Acute Stress Disorder, Posttraumatic Stress Disorder, and Depression in Disaster or Rescue Workers. Am J Psychiatry. 2004 Aug; 161(8):1370-6.
  4. McCloskey LA, Walker M. Posttraumatic stress in children exposed to family violence and single-event trauma. J Am Acad Child Adolesc Psychiatry. 2000 Jan; 39(1): 108-15.
  5. Spoont M, Arbisi P, Fu S, Greer N et al. Screening for Post-Traumatic Stress Disorder (PTSD) in Primary Care: A Systematic Review. Washington DC: Department of Veterans Affairs. 2013 Jan.
  6. Binder EB, Bradley RG, Liu W, Epstein MP, et al. Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults. JAMA. 2008 Mar 19; 299(11): 1291-305.
  7. Hassija CM, Gray MJ, et al. Behavioral Interventions for Trauma and Posttraumatic Stress Disorder. International Journal of Consultation and Therapy. 2007; 3(2):166-75.
  8. Ehlers A, Hackmann A, Michael T. Intrusive re-experiencing in post-traumatic stress disorder: Phenomenology, theory, and therapy. Memory. 2004 Jul; 12(4): 403-415.
  9. Mulick PS, Naugle AE. Behavioral Activation in the Treatment of Comorbid Posttraumatic Stress Disorder and Major Depressive Disorder. International Journal of Behavioral Consultation and Therapy. 2009; 5 (2): 330–339.

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Last updated: 2019-07-11 20:15