Post-traumatic Stress Disorder

Background

  • Severe psychological disturbance following a major traumatic event characterised by involuntary re-experiencing of elements of the event with symptoms of hyperarousal, avoidance and emotional numbing.

Normal physiological and psychiatric response to trauma

  • Fight or flight- caused by activation of the sympathetic nervous system with an aim to increase efficiency:
    • Increased blood flow and oxygenation to muscles; increased heart rate; decreased blood flow to skin and GI tract; narrowing of attention; Dilation of pupils; relaxation of bladder
  • Freeze response: occurs when the limbic system judges that neither flight or fight is suitable i.e. usually when death or serious injury is inevitable:
    • the body goes into ‘shutdown’; altered state of reality; semi-paralysis; pain sensation reduced

Aetiology- The neurobiological theory of PTSD

  • The hippocampus is responsible for locating memories in the correct time, place and context and the amygdala stores emotionally charged memories and is connected to the medial prefrontal cortex that regulates emotional and fear responses (usually inhibitory).
  • In PTSD, the ‘triggering’ event fails to be stored correctly because the limbic system is repeatedly triggered.
  • In PTSD, there is an increase in noradrenaline and adrenaline, decreased cortisol and increased opiates (may explain the increased risk taking).

Features

  • Trauma memory
    • These can be easily triggered in a number of ways and may be vivid, as if to re-enact the memory (sights, smells, sounds, feelings/emotions).  They aren’t usually conscious worries but can engulf the individual.  They can be difficult to translate into words (fragmented or laden with affect) and can be brought on by sleeping problems, low mood, lethargy etc.
      • Nightmares are common.  Patients can wake up screaming, sweating, hot and trembling. This can lead to insomnia and further thought intrusions.
      • Avoidance is a possible defense mechanism to avoid thought intrusions but can lead to further problems, especially isolation.
      • Hypervigilance is a common finding.  Patients can be constantly on guard for threat, (pardoxically they can appear threatening), and may be easily startled with irritability and bursts of anger/aggression (may even keep weapons close).  Usually due to a sense of vulnerability and can also lead to further problems like insomnia.
      • Emotional numbing may also be an adaptation, and is characterised by feeling detached from the world with the inability to ‘feel’ and marked pessimism.
      • Re-enactment can occur- and may include taking risks or facing danger similar to the traumatic event.
      • Dissociation is the minds way of walling off painful experiences.  The patient may feel like they are observing themselves (out of body) or that things aren’t real (unreality).  This is more likely to occur in complex trauma and may present with dissociative flashbacks, fugue states (inability to recall personal identity) or dissociative identity disorder.  The patient themselves may experience time moving faster/slower; sounds and sights are muted/enhanced, blunted (loss of affect as an observer rather than participant), emotional numbing, amnesia etc.
  • Triggers
    • These are important to identify as they can activate memories/flashbacks.
    • They are often harmless cues, which the patient may or may not be aware of them (though they will be aware of the reaction).
    • Triggers can be visual, auditory, gustatory, olfactory (i.e. any sense) so the avoidance in some patients may impair activities of daily living (e.g. work).

DSM-IV criteria for diagnosis

  • The patient has been exposed to a traumatic event in which both of the following are present:
  1. The patient 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 themselves or others
  2. The patient’s response involved intense fear, helplessness or horror
  • The traumatic event is persistently re-experienced in on (or more) of the following ways:
    • Recurrent and intrusive, distressing recollections of the event, including images, thoughts and perceptions
    • Recurrent and distressing/horrific dreams
    • Recurrent flashbacks/re-enactments
    • Presence of triggers causing a) psychological distress and b) phsyiological anxiety response
  • Persistant avoidance of stimuli associated with trauma and numbing of general responses, as indicated by:
    • Efforts to avoid thoughts, feelings or conversation associated with trauma
    • Efforts to avoid activities, places or people that arouse recollections of the trauma
    • Inability to recall an important aspect of the trauma
    • Markedly diminished interest or participation in significant activities
    • Feelings of detachment or estrangement from others
    • Restricted range of affect
    • Sense of foreshortened future

Management

  • NOT Debriefing or NOT relaxation or NOT non-directive treatment i.e.
    • MUST be trauma focused
  • In Acute PTSD (mild and <4wks)- watchful waiting and support is often all that is necessary.
  • Occasionally trauma focused CBT (trauma focused psychotherapy) or Eye movement desensitisation and reprocessing (EMDR) may be used if >4 weeks
    • Ideally, treatment should should be aimed at preventing chronic and complicated PTSD (i.e. with associated depression/psychosis/GAD etc).

Treatment of complicated PTSD:

  • Depression: Fluoxetine/olanzapine
  • Anxiety: clonazepam, buspirone
  • Carbemazapine (as a mood stabiliser) may also be of benefit.
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One thought on “Post-traumatic Stress Disorder”

  1. According to a pilot study published in the latest issue of the peer-reviewed International Journal of Healing and Caring, veterans with high levels of PTSD saw their PTSD levels drop to within normal limits after treatment. They reported that combat memories that had previously haunted them, including graphic details of deaths, mutilations, and firefights, dropped in intensity to the point where they no longer resulted in flashbacks, nightmares, and other symptoms of PTSD. The study involved veterans from Vietnam, as well as more recent conflicts. ^

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