Post-Traumatic Stress Disorder — The Dana Guide

by Rachel Yehuda

March, 2007

sections include: the mechanisms of feardiagnosis and treatment 

Post-traumatic stress disorder (PTSD) develops in response to a terrifying event or ordeal that a person has experienced, witnessed, or learned about from others. The event is usually life-threatening or capable of producing serious bodily harm, and typically involves interpersonal violence or disaster. Examples include but are not limited to being a victim of or witness to natural or man-made disasters, such as fire, earthquakes, and acts of terrorism or war; suffering or witnessing a rape or physical assault; being kidnapped or tortured; and seeing someone else suffer serious injury or death.

Such a traumatic experience causes the person to feel intense fear, horror, or helplessness. The survivor is unable to get the event out of his or her mind. This disorder can affect many aspects of a person’s life, particularly day-to-day functioning, quality of life, and relationships.

Three main symptom clusters characterize PTSD:

  • The person will reexperience the event through distressing images, unwanted memories, nightmares, or flashbacks. These reexperiences will cause distress and such physical symptoms as heart palpitations, shortness of breath, and other signs of panic.
  • The person will avoid reminders of the event, including people, places, or things associated with the trauma, and become emotionally numb, constricted, or generally detached from or unresponsive to surrounding activities and people.
  • The person will experience physical symptoms reflecting a state of anxiety or hyperarousal. These symptoms may include insomnia, irritability, impaired concentration, hypervigilance and increased startle responses.

 If family members know that an individual has experienced trauma, they will probably notice that their relative is anxious and emotionally withdrawn. However, they may not initially be alarmed by these symptoms because they will likely believe the survivor to be displaying a normal response that will pass with time. Indeed, most trauma survivors themselves wait for several weeks or months before contacting a physician about their symptoms in order to give themselves time to “get over” their reactions on their own. Ultimately, for some people, the post-traumatic symptoms do not spontaneously improve, and sleep disturbance, panic, and depression can cause increasing disability in their everyday lives. That is when these individuals or their families seek professional help.

People also seek medical help for problems that may develop after the trauma that can mask or intensify PTSD symptoms. These include chronic pain, fatigue, headaches, muscle cramps, and self-destructive behavior, including alcohol or drug abuse and suicidal gestures. Often, survivors are not aware that their physical symptoms are related to their traumatic experiences. They may even fail to mention those disturbing events to their physicians, which can make PTSD difficult to diagnose accurately.

The Mechanisms of Fear

In 1980 the mental health community established the diagnosis of PTSD and revolutionized the way the field views the effects of stress. This change acknowledged that many of the symptoms people experience after exposure to trauma can be long-lasting, if not permanent. Before that shift, the field tended to view stress-related symptoms as a transient, normal response to an adverse life event, not requiring intensive treatment. Furthermore, before 1980, people who did develop long-term symptoms following trauma were viewed as constitutionally vulnerable; the role of the actual event in precipitating their symptoms was minimized. For a while, in a reversal of previous thinking, experts expected most trauma survivors to develop PTSD. More recent research has confirmed that only about 25 percent of individuals who are exposed to trauma develop PTSD.

So who is likely to develop PTSD following a traumatic experience, and why? The answer is not yet clear, but it now appears that PTSD represents a failure of the body to extinguish or contain the normal sympathetic nervous system response to stress. This failure is associated with many factors:

  • the nature and severity of the traumatic event
  • preexisting risk factors related to previous exposure to stress or trauma, particularly in childhood
  • the individual’s history of psychological and behavioral problems, if any
  • the person’s level of education, and other cognitive factors
  • family history—whether parents or other relatives had anxiety, depression, or PTSD

People who develop PTSD are also more likely to develop other psychiatric disorders involving mood (depression,  anxiety and panic, bipolar disorder), personality, eating, and substance dependence.

For all of us, being exposed to traumatic stress results in an immediate fear response: the body initiates the natural biological reactions that help us assess the level of danger and organize an appropriate response, the familiar “fight or flight.” The limbic system in the brain, which is associated with emotion, motivation, behavior, and various involuntary actions, is part of this response. One part of the limbic system, the amygdala, switches on the neurochemical and neuroanatomical circuitry of fear by activating the startle response, the parasympathetic and sympathetic nervous system response, and the hypothalamic-pituitary-adrenal responses to stress. The hippocampus, another part of the limbic system, is involved in helping to terminate these responses. Eventually the adrenal gland releases cortisol to contain the body’s response to stress.

In individuals who develop PTSD, there is only a slight rise in cortisol in the immediate aftermath of the trauma and evidence of greater sympathetic nervous system arousal (that is, increased heart rate). That combination suggests that for these people the fear response is not efficiently contained. In fact, people with relatively low cortisol levels following trauma may be at higher biological risk for developing PTSD.

Some researchers now believe that when an individual’s sympathetic nervous system remains aroused after trauma, that leads to higher levels of the neurochemicals dopamine, norepinephrine, and epinephrine in his or her brain. Normally those three neurochemicals (together called catecholamines) help memories form by maintaining the body at a high level of arousal. If cortisol fails to adequately shut them down, a person’s traumatic memories become “overconsolidated,” or inappropriately remembered. As a result, “every little thing” has a chance of reminding the person of the traumatic event. The person’s increased distress every time he or she recalls the trauma further activates the stress-responsive systems, resulting in anxiety, hyperarousal, and ultimately, PTSD.

Diagnosis and Treatment

Studies of PTSD have demonstrated that this condition is the fourth most common psychiatric disorder, affecting about 8 percent of the population at some time in their lives. Women are twice as likely to develop PTSD as men.

Doctors diagnose PTSD if a person has had symptoms from each of the three clusters described above for one month or more, and if those symptoms cause severe problems or distress at home or work, or in general affect the person’s daily life. The reason for the time criterion is to differentiate between the acute response to a troubling event, which for most people is to be expected, and the more chronic response. A psychiatrist, psychologist, social worker, or other qualified health care professional who provides counseling related to trauma can help determine if someone has PTSD. Early diagnosis and treatment are critical and can substantially improve long-term outcome.

The symptoms of PTSD do not generally become more severe as time passes, but the failure of those symptoms to diminish often results in a cascade of secondary behavioral, emotional, or personality problems. These problems can increase the individual’s disability. Exposure to further stress or trauma increases a person’s likelihood of developing a recurrence of the symptoms. PTSD can, however, remit spontaneously or following treatment.

People who receive specialized PTSD treatment have a good chance of recovering. Psychotherapeutic or counseling methods, such as cognitive behavioral therapy, including exposure and anxiety-management treatments have been shown to be effective in treating PTSD. Many trauma survivors are reluctant to talk about their experiences, but most experts believe that confronting the event and all of the upsetting and frightening emotions and memories connected to it is essential for the symptoms to dissipate. Medications such as antidepressants and anticonvulsants have also been shown to be effective. Usually some combination of psychotherapy and medication, along with the support of family and friends, results in the best possible recovery. 

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