Post-Traumatic Stress Disorder (PTSD)

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“Trauma constantly confronts us with our fragility and with man’s inhumanity to man but also with our extraordinary resilience.” 

– Bessel Van Der Kolk

PTSD is now such a familiar term, it may be surprising to know that it was first formally established as recently as 1980 in DSM-III (the American Psychiatric Association’s Diagnostic and Statistical Manual, third edition). However, the concept that experiencing or witnessing trauma (even without obvious physical injury) can have long-lasting impacts has been recognized and described since ancient times (for as long as there have been battles).

In the 1800s, soldiers were described as having “battle exhaustion,” “soldier’s fatigue,” dissociative states, the “thousand yard stare,” and (in the Civil War) “irritable heart.” In the early 1900s, a German physician serving with the Red Cross Society of Russia during the Russo-Japanese War, coined the term “war neurosis.” World War I resulted in large numbers of psychological causalities, with symptoms such as anxiety, muteness, difficulty walking, shaking, loss of memory, loss of vision, paralysis, confusion, and being dazed. Specialized hospitals were established for treatment of “shell shock.”

With World War II came better recognition of long-term consequences of war trauma, such as depression, survivor guilt and aggression. Even decades later, people can experience trauma-related nightmares, intrusive memories, attempts to avoid certain thoughts or feelings, and changes in personality. 

We now tend to associate combat PTSD with the Vietnam War. Nearly 25% of U.S. soldiers who went to Vietnam between 1964 and 1973 needed mental health care. Drug and alcohol abuse were prominent. And the fact that the psychological impacts of war can have delayed onset and a chronic course became more obvious. The recognition of the “post-Vietnam syndrome” set the stage for the establishment of the PTSD diagnosis in 1980. In more recent years, it has become clear that the act of killing others can be as traumatic, if not more so, than when one’s own life is in danger.

During the Industrial Revolution, non-combat trauma from heavy machinery and railway accidents was noted to cause physical and emotional changes, even without clear physical injury. There was controversy about whether a PSTD-like syndrome described as “railway brain” was purely psychological in nature or caused by microscopic brain lesions invisible to the examining physician.

In the 1970s, more attention was given to studying the mental health of survivors of the Holocaust, sexual assault, domestic violence, and accidents, further broadening the understanding of non-combat PTSD.  More recently, especially in the context of climate change and more frequent extreme weather events, awareness is growing regarding the psychological impacts of natural disasters. 

One of the most recent and transformational developments in our understanding of trauma is the concept of chronic developmental trauma, or “complex trauma.” Instead of one time-limited event, it entails repeated events or conditions over a prolonged period of time, often perpetrated by one’s caregivers or family members. This can include emotional abuse, neglect, general lack of safety, and community violence, in addition to physical and sexual abuse. This can profoundly impact a person’s belief that they can trust others and impair the ability to feel safe in connecting with others longer-term.

The DSM-5 (the most recent 2013 revision) describes PTSD as a syndrome occurring after “exposure to actual or threatened death, serious injury, or sexual violence,” which includes a certain constellation of symptoms, lasts for more than a month, and causes significant distress or impairment in functioning. PTSD symptoms are divided into 4 categories:

• Intrusive symptoms, such as memories, nightmares and flashbacks

• Avoidance of reminders of the traumatic event, such as places, people, feelings and memories

• Changes in thoughts and feelings, such as gaps in memory, negative beliefs about oneself or the world (“I am bad,” “the world is dangerous”), distrust, guilt, shame, loss of interest in things, detachment and difficulty experiencing joy/love

• Arousal and reactivity, such as anger outbursts, insomnia, being easily startled, hypervigilance, difficulty concentrating and self-destructive behavior (PTSD is different from Acute Stress Disorder, which generally begins right after the stressful event and resolves within a month.)

Women more often develop PTSD from sexual assault and/or childhood sexual abuse, whereas for men it’s more often from accidents, combat, or physical assault.

Good news: while most people who experience or witness an extremely traumatic event develop some short-term symptoms, the majority do not develop longer-term PTSD. While we do not fully understand why some do and some don’t, risk factors include childhood trauma, pre-existing mental illness or substance abuse, being injured, feelings of horror and/or helplessness, and lack of social support. Protective factors include having a good support network (and using it) and good coping skills. 

PTSD can have wide-ranging adverse effects on one’s physical health, relationships, career and educational functioning, mental health and sense of self.

Treatment for PTSD can make a significant difference in the duration and intensity of symptoms. Developing PTSD does not signify weakness or a failing, although shame is common and is often a barrier to seeking help. Treatment can literally be life-saving, as the suicide risk is elevated in PTSD. 

Psychotherapy (talk therapy) is the mainstay of treatment. There are several evidence-based therapies specifically for people who have experienced trauma. Examples include: CPT (Cognitive Processing Therapy), EMDR (Eye Movement Desensitization and Reprocessing), PE (Prolonged Exposure), narrative therapy, as well as several others. Effective psychotherapy may also focus on areas other than the specific trauma, such as relationships, job stress, managing anger, dealing with feelings such as shame or anxiety, and healthy routines (sleep, exercise etc.). Treatment should be individualized, as a specific person might respond better to, and be more comfortable with, one approach vs. another. Common co-occurring problems such as substance abuse and depression should be addressed in treatment as well.

Medications, some FDA-approved for PTSD and some used “off-label,” can also be helpful in some cases and for certain symptoms. These include antidepressants, Prazosin for trauma-related nightmares, and medications to target general anxiety. Of interest, studies of MDMA (Ecstasy/Molly) for severe PTSD, used in a controlled environment with trained clinicians, to complement psychotherapy, are showing promise. Warning: people should not try MDMA on their own outside of an authorized setting with clinicians trained in its use. MDMA is still an illegal recreational drug with substantial risks, include addiction, organ failure, and death. 

The effects of trauma often manifest throughout one’s body, for example with dissociation (feeling detached from one’s body, the world, or other people), insomnia, upset stomach, fatigue, pain, racing heart, and muscle aches, another example of the mind-body connection.  Holistic treatment approaches can include body-oriented therapies such breath work, yoga, dance and re-connecting with one’s body in other ways. 

For more information about PTSD and recovery, I strongly recommend the highly readable book The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, a seminal work by trauma expert Bessel van der Kolk, M.D. 

If you or someone you know is considering suicide, call 9-1-1 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

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