Post-Traumatic Stress

People are programmed to respond to threats to their safety. Unfortunately, this set of adaptive responses in the face of terror, which are lifesaving in the moment, can leave people with ongoing, long-term psychological symptoms. The biological mechanisms that encourage the powerful and protective “fight or flight” response and maximize physical safety at the time, such as enabling a woman to fight off an attacker during a sexual assault, can create complex problems later.

When faced with terror, less critical body functions (e.g., the parts of the brain where memory, emotion and thinking are processed) get “turned off” in the service of immediate physical safety. Specifically, this “fight or flight” response increases the heart rate, moves more blood to muscles in order to run and adds stress hormones to help fight off infection and bleeding in case of a wound. As a result, the traumatic experiences are not integrated at the time they happen because the body is focusing entirely on immediate physical safety. A poorly integrated traumatic experience can be unpredictable and unexpected. The unprocessed memories of a traumatic event can occur without warning. As long as thoughts, memories and feelings associated with the trauma remain disconnected from the actual event, it is difficult for people living with PTSD to access their inner experiences because the normal flow of emotion remains deeply affected by the traumatic event.

PTSD symptoms usually start to occur directly after a traumatic event, but sometimes it may take months or years for them to show up. They may also come and go over the course of many years.

The DSM-IV criteria for identifying PTSD require that symptoms must be active for more than one month after the trauma and associated with a decline in social, occupational or other important areas of functioning. The three broad symptom clusters can be summarized as follows:

1. Persistent Re-experiencing

A person experiences one or more of the following:

• recurrent nightmares or flashbacks;

• recurrent images or memories of the event—these images or memories often occur without actively thinking about the event;

• intense distress of reminders of the trauma; and/or

• physical reactions to triggers that symbolize or resemble the event.

2. Avoident/Numbness Responses

A person experiences three or more of the following:

• efforts to avoid feelings or triggers associated with the trauma;

• avoidance of activities, places or people that remind the person of the trauma;

• inability to recall an important aspect of the trauma;

• markedly diminished interest in activities;

• feelings of detachment or estrangement from others;

* restricted range of feelings; and/or

• difficulty thinking about the long-term future—sometimes this expresses itself by a failure to plan for the future or taking risks because the person does not fully believe or consider the possibility that they will be alive for a normal lifespan.

3. Increased Arousal

A person experiences two or more of the following:

* difficulty falling asleep or staying asleep;

• outbursts of anger/irritability;

• difficulty concentrating;

• increased vigilance that may be maladaptive; and/ or

• exaggerated startle response

Patterns of Trauma Response

There are various ways in which PTSD can be exhibited:

* Acute Stress Disorder is diagnosed when responses to a traumatic event occur and last for less than a month. For many people, these acute symptoms resolve over time, often with the help of a support system or treatment.

* PTSD is identified when disabling symptoms persist for months or years after the traumatic event(s). These symptoms interfere with daily functioning and meet specific diagnostic criteria.
Acute PTSD is diagnosed when an individual has symptoms for less than three months.

• Chronic PTSD is diagnosed when someone has symptoms for more than three months.

• Delayed-onset PTSD appears months—sometimes more than year—after the initial trauma. In many cases, the individual may have had some symptoms before, just not enough to meet the diagnostic criteria. Many people with delayed-onset PTSD demonstrate dissociation to suppress their reactions and avoid thoughts of the event. Numbing and/or avoiding symptoms are associated with a worse prognosis in the long run for many people.

Combat, sexual assault, surviving a natural disaster or a terrorist attack are just some examples of traumatic psychological events that can cause PTSD. Events can happen once or be reoccurring and such examples would be ongoing physical abuse or an extended or repeated tour of duty in a war zone.

These events can be a single occurrence in a person’s lifetime or occur repeatedly, such as in the case of ongoing physical abuse or an extended or repeated tour of duty in a war zone. The severity of traumatic events and duration of exposure are critical risk factors for developing PTSD.

Proximity to a traumatic event can determine whether a person develops PTSD. For example, a person who was working in the Twin Towers of the World Trade Center on Sept. 11, 2001 has a much greater chance of developing PTSD than a person hearing about the attack on television.

The signs of the poorly integrated traumatic experience can appear unexpectedly and unpredictably. A flashback or intrusive nightmare can occur without warning, representing unprocessed memories of the traumatic event. As long as thoughts, memories and feelings associated with the trauma remain shut off from the actual event, it is difficult for people living with PTSD to access their inner experiences because the normal flow of emotion remains deeply affected by the traumatic event. For decades, trauma survivors have described being under-responsive (hypoarousal) or over-responsive (hyperarousal) to all types of events—even if they are unrelated.

However, because PTSD is the result of a traumatic event that occurs during the life of an individual, genetic predisposition does not play as a predominant role as it does in mental illnesses such as schizophrenia and ADHD. This is not to say that certain individuals are not inclined to react to traumatic events that may produce negative outcomes, but there is not a gene that “gives you” PTSD.

Combat Veterans and Trauma

Extreme psychological responses to combat have been mentioned throughout history, from Homer’s writing in 800 B.C. to writings from the American Civil War and in every war that has followed. In wars prior to Vietnam, the disorder was referred to as “shell shock” or “battle fatigue.” As our understanding of PTSD has grown, recent reassessments of Vietnam veterans have found higher rates of PTSD than previously reported.

The return of combat veterans from Iraq and Afghanistan in recent years has highlighted the impact of psychological trauma not only for veterans but for members still in active duty. Research demonstrating that these veterans have high rates of suicide also illustrates the severity of their psychological distress. A 2007 survey of entry-level military personnel revealed that 26 percent had a history of substance abuse and nearly 16 percent reported current depressive symptoms that were “reasonable” to “severe.”

A survey of troops in Iraq and Afghanistan found a correlation between PTSD symptoms and exposure to combat experiences. Of those responses that met the criteria for diagnosis, only 38-45 percent expressed an interest in receiving help. Some common reasons for not seeking help include fear of being seen as weak or being treated differently by leaders and peers, as well as concerns about such an admission harming one’s career.

Efforts to increase screening for trauma in primary care settings and policies that encourage the identification of troops at risk for suicide are positive developments in military culture. Similarly, policies that formerly acted as disincentives to service men and women who sought mental health services are being overturned, which creates a culture more open to earlier identification and treatment.

Trauma During Childhood

Traumatic events have a very profound impact on a child’s developing brain, body and sense of self. Children can carry these negative effects of trauma well into adulthood. More than 1 million reports of abuse or neglect are substantiated by child protective agencies every year in the U.S. Children who experience chronic physical, sexual or emotional abuse struggle in many areas of life. They are still developing the ability to process ideas, emotionally and physically, and thus express PTSD symptoms in different ways from adults. Common problems include:

• difficulty regulating their emotional reactions;
• establishing and maintaining relationships;
• controlling aggression; and/or
• low self esteem and functioning in school

Adolescents who were abused as children are overrepresented in the juvenile justice and criminal justice system. They also have high rates of substance abuse and psychiatric illness. Childhood trauma increases the risk of most psychiatric conditions and is very common in borderline personality disorder, dissociative disorder and eating disorders. Children learn how to regulate their emotions and sense of self over time through caring relationships. When these relationships are the source of trauma for the child, they can cause confusion and lead to isolation and withdrawal.

Women and PTSD

Studies of the general population suggest that women experience PTSD at more than twice the rate of men. This may be due to the greater likelihood of a woman experiencing a traumatic event. In the military, women run a double risk of developing PTSD for reasons ranging from battle stress and sexual harassment to assault. In a recent study, women in the military were more than twice as likely to develop PTSD as their male counterparts.

Women, however, had been denied insurance coverage for PTSD because of a former stipulation that required combat experience to qualify for the benefit. In addition, women may take longer to recover from PTSD and are four times more likely than men to experience long-lasting PTSD. Military Sexual Trauma (MST), defined by the Department of Veterans Affairs as sexual assault or repeated threatening acts of sexual harassment, is another factor women are faced with.

The American Psychiatric Association classifies PTSD as an anxiety disorder in the Diagnostic and Statistical Manual-IV (DSM-IV). If symptoms from a traumatic event continue through four weeks, PTSD is a possibility.

The Symptoms of PTSD

The DSM-IV criteria for identifying PTSD require that symptoms must be active for more than one month after the trauma and associated with a decline in social, occupational or other important areas of functioning. The three broad symptom clusters can be summarized as follows:

1. Persistent Re-experiencing

A person experiences one or more of the following:

• recurrent nightmares or flashbacks;

• recurrent images or memories of the event—these images or memories often occur without actively thinking about the event;

• intense distress of reminders of the trauma; and/or

• physical reactions to triggers that symbolize or resemble the event.

2. Avoidant/Numbness Responses

A person experiences three or more of the following:

• efforts to avoid feelings or triggers associated with the trauma;

• avoidance of activities, places or people that remind the person of the trauma;

• inability to recall an important aspect of the trauma;

• markedly diminished interest in activities;

• feelings of detachment or estrangement from others;

• restricted range of feelings; and/or

• difficulty thinking about the long-term future—sometimes this expresses itself by a failure to plan for the future or taking risks because the person does not fully believe or consider the possibility that they will be alive for a normal lifespan.

3. Increased Arousal

A person experiences two or more of the following:

• difficulty falling asleep or staying asleep;

• outbursts of anger/irritability;

• difficulty concentrating;

• increased vigilance that may be maladaptive; and/ or

• exaggerated startle response

No one really knows what causes panic disorder, but several ideas are being researched. Panic disorder seems to run in families, which suggests that it has at least some genetic basis. Some theories suggest that panic disorder is part of a more generalized anxiety in the people who have panic attacks or that severe separation anxiety can develop into panic disorder or phobias, most often agoraphobia.

Biological theories point to possible physical defects in a person’s autonomic (or automatic) nervous system. General hypersensitivity in the nervous system, increased arousal, or a sudden chemical imbalance can trigger panic attacks. Caffeine, alcohol, and several other agents can also trigger these symptoms.