Post-Traumatic Stress Disorder
"I was raped when I was 25 years old. For a long time, I spoke
about the rape as though it was something that happened to
someone else. I was very aware that it had happened to me, but
there was just no feeling.
"Then I started having flashbacks. They kind of came over me
like a splash of water. I would be terrified. Suddenly I was
reliving the rape. Every instant was startling. I wasn't aware
of anything around me, I was in a bubble, just kind of floating.
And it was scary. Having a flashback can wring you out.
"The rape happened the week before Thanksgiving, and I can't
believe the anxiety and fear I feel every year around the
anniversary date. It's as though I've seen a werewolf. I can't
relax, can't sleep, don't want to be with anyone. I wonder
whether I'll ever be free of this terrible problem."
Post-traumatic stress disorder (PTSD) is a debilitating
condition that can develop following a terrifying event. Often,
people with PTSD have persistent frightening thoughts and
memories of their ordeal and feel emotionally numb, especially
with people they were once close to. PTSD was first brought to
public attention by war veterans, but it can result from any
number of traumatic incidents. These include violent attacks
such as mugging, rape, or torture; being kidnapped or held
captive; child abuse; serious accidents such as car or train
wrecks; and natural disasters such as floods or earthquakes. The
event that triggers PTSD may be something that threatened the
person's life or the life of someone close to him or her. Or it
could be something witnessed, such as massive death and
destruction after a building is bombed or a plane crashes.
Whatever the source of the problem, some people with PTSD
repeatedly relive the trauma in the form of nightmares and
disturbing recollections during the day. They may also
experience other sleep problems, feel detached or numb, or be
easily startled. They may lose interest in things they used to
enjoy and have trouble feeling affectionate. They may feel
irritable, more aggressive than before, or even violent. Things
that remind them of the trauma may be very distressing, which
could lead them to avoid certain places or situations that bring
back those memories. Anniversaries of the traumatic event are
often very difficult.
PTSD affects about 5.2 million adult Americans. 1 Women are
more likely than men to develop PTSD. 7 It can occur at any age,
including childhood, 8 and there is some evidence that
susceptibility to PTSD may run in families. 9 The disorder is
often accompanied by depression, substance abuse, or one or more
other anxiety disorders. 4 In severe cases, the person may have
trouble working or socializing. In general, the symptoms seem to
be worse if the event that triggered them was deliberately
initiated by a person--such as a rape or kidnapping.
Ordinary events can serve as reminders of the trauma and
trigger flashbacks or intrusive images. A person having a
flashback, which can come in the form of images, sounds, smells,
or feelings, may lose touch with reality and believe that the
traumatic event is happening all over again.
Not every traumatized person gets full-blown PTSD, or
experiences PTSD at all. PTSD is diagnosed only if the symptoms
last more than a month. In those who do develop PTSD, symptoms
usually begin within 3 months of the trauma, and the course of
the illness varies. Some people recover within 6 months, others
have symptoms that last much longer. In some cases, the
condition may be chronic. Occasionally, the illness doesn't show
up until years after the traumatic event. People with PTSD can
be helped by medications and carefully targeted psychotherapy.
Ordinary events can serve as reminders of the trauma and
trigger flashbacks or intrusive images. Anniversaries of the
traumatic event are often very difficult. Posttraumatic Stress
Disorder, or PTSD, is a psychiatric disorder that can occur
following the experience or witnessing of life-threatening
events such as military combat, natural disasters, terrorist
incidents, serious accidents, or violent personal assaults like
rape. People who suffer from PTSD often relive the experience
through nightmares and flashbacks, have difficulty sleeping, and
feel detached or estranged, and these symptoms can be severe
enough and last long enough to significantly impair the person's
daily life.
PTSD is marked by clear biological changes as well as
psychological symptoms. PTSD is complicated by the fact that it
frequently occurs in conjunction with related disorders such as
depression, substance abuse, problems of memory and cognition,
and other problems of physical and mental health. The disorder
is also associated with impairment of the person's ability to
function in social or family life, including occupational
instability, marital problems and divorces, family discord, and
difficulties in parenting. Understanding PTSD
PTSD is not a new disorder. There are written accounts of
similar symptoms that go back to ancient times, and there is
clear documentation in the historical medical literature
starting with the Civil War, when a PTSD-like disorder was known
as "Da Costa's Syndrome." There are particularly good
descriptions of posttraumatic stress symptoms in the medical
literature on combat veterans of World War II and on Holocaust
survivors.
Careful research and documentation of PTSD began in earnest
after the Vietnam War. The National Vietnam Veterans
Readjustment Study estimated in 1988 that the prevalence of PTSD
in that group was 15.2% at that time and that 30% had
experienced the disorder at some point since returning from
Vietnam.
PTSD has subsequently been observed in all veteran populations
that have been studied, including World War II, Korean conflict,
and Persian Gulf populations, and in United Nations peacekeeping
forces deployed to other war zones around the world. There are
remarkably similar findings of PTSD in military veterans in
other countries. For example, Australian Vietnam veterans
experience many of the same symptoms that American Vietnam
veterans experience. PTSD is not only a problem for veterans,
however. Although there are unique cultural- and gender-based
aspects of the disorder, it occurs in men and women, adults and
children, Western and non-Western cultural groups, and all
socioeconomic strata. A national study of American civilians
conducted in 1995 estimated that the lifetime prevalence of PTSD
was 5% in men and 10% in women. How does PTSD develop?
Most people who are exposed to a traumatic, stressful event
experience some of the symptoms of PTSD in the days and weeks
following exposure. Available data suggest that about 8% of men
and 20% of women go on to develop PTSD, and roughly 30% of these
individuals develop a chronic form that persists throughout
their lifetimes.
The course of chronic PTSD usually involves periods of symptom
increase followed by remission or decrease, although some
individuals may experience symptoms that are unremitting and
severe. Some older veterans, who report a lifetime of only mild
symptoms, experience significant increases in symptoms following
retirement, severe medical illness in themselves or their
spouses, or reminders of their military service (such as
reunions or media broadcasts of the anniversaries of war
events). How is PTSD assessed?
In recent years, a great deal of research has been aimed at
developing and testing reliable assessment tools. It is
generally thought that the best way to diagnose PTSD-or any
psychiatric disorder, for that matter-is to combine findings
from structured interviews and questionnaires with physiological
assessments. A multi-method approach especially helps address
concerns that some patients might be either denying or
exaggerating their symptoms. How common is PTSD?
An estimated 7.8 percent of Americans will experience PTSD at
some point in their lives, with women (10.4%) twice as likely as
men (5%) to develop PTSD. About 3.6 percent of U.S. adults aged
18 to 54 (5.2 million people) have PTSD during the course of a
given year. This represents a small portion of those who have
experienced at least one traumatic event; 60.7% of men and 51.2%
of women reported at least one traumatic event. The traumatic
events most often associated with PTSD for men are rape, combat
exposure, childhood neglect, and childhood physical abuse.
The most traumatic events for women are rape, sexual
molestation, physical attack, being threatened with a weapon,
and childhood physical abuse.
About 30 percent of the men and women who have spent time in
war zones experience PTSD. An additional 20 to 25 percent have
had partial PTSD at some point in their lives. More than half of
all male Vietnam veterans and almost half of all female Vietnam
veterans have experienced "clinically serious stress reaction
symptoms." PTSD has also been detected among veterans of the
Gulf War, with some estimates running as high as 8 percent. Who
is most likely to develop PTSD? 1. Those who experience greater
stressor magnitude and intensity, unpredictability,
uncontrollability, sexual (as opposed to nonsexual)
victimization, real or perceived responsibility, and betrayal
2. Those with prior vulnerability factors such as genetics,
early age of onset and longer-lasting childhood trauma, lack of
functional social support, and concurrent stressful life events
3. Those who report greater perceived threat or danger,
suffering, upset, terror, and horror or fear 4. Those with a
social environment that produces shame, guilt, stigmatization,
or self-hatred
What are the consequences associated with PTSD?
PTSD is associated with a number of distinctive neurobiological
and physiological changes. PTSD may be associated with stable
neurobiological alterations in both the central and autonomic
nervous systems, such as altered brainwave activity, decreased
volume of the hippocampus, and abnormal activation of the
amygdala. Both the hippocampus and the amygdala are involved in
the processing and integration of memory. The amygdala has also
been found to be involved in coordinating the body's fear
response.
Psychophysiological alterations associated with PTSD include
hyper-arousal of the sympathetic nervous system, increased
sensitivity of the startle reflex, and sleep abnormalities.
People with PTSD tend to have abnormal levels of key hormones
involved in the body's response to stress. Thyroid function also
seems to be enhanced in people with PTSD. Some studies have
shown that cortisol levels in those with PTSD are lower than
normal and epinephrine and norepinephrine levels are higher than
normal. People with PTSD also continue to produce higher than
normal levels of natural opiates after the trauma has passed. An
important finding is that the neurohormonal changes seen in PTSD
are distinct from, and actually opposite to, those seen in major
depression. The distinctive profile associated with PTSD is also
seen in individuals who have both PTSD and depression.
PTSD is associated with the increased likelihood of
co-occurring psychiatric disorders. In a large-scale study, 88
percent of men and 79 percent of women with PTSD met criteria
for another psychiatric disorder. The co-occurring disorders
most prevalent for men with PTSD were alcohol abuse or
dependence (51.9 percent), major depressive episodes (47.9
percent), conduct disorders (43.3 percent), and drug abuse and
dependence (34.5 percent). The disorders most frequently
comorbid with PTSD among women were major depressive disorders
(48.5 percent), simple phobias (29 percent), social phobias
(28.4 percent), and alcohol abuse/dependence (27.9 percent).
PTSD also significantly impacts psychosocial functioning,
independent of comorbid conditions. For instance, Vietnam
veterans with PTSD were found to have profound and pervasive
problems in their daily lives. These included problems in family
and other interpersonal relationships, problems with employment,
and involvement with the criminal justice system.
Headaches, gastrointestinal complaints, immune system problems,
dizziness, chest pain, and discomfort in other parts of the body
are common in people with PTSD. Often, medical doctors treat the
symptoms without being aware that they stem from PTSD. How is
PTSD treated?
PTSD is treated by a variety of forms of psychotherapy and drug
therapy. There is no definitive treatment, and no cure, but some
treatments appear to be quite promising, especially
cognitive-behavioral therapy, group therapy, and exposure
therapy. Exposure therapy involves having the patient repeatedly
relive the frightening experience under controlled conditions to
help him or her work through the trauma. Studies have also shown
that medications help ease associated symptoms of depression and
anxiety and help with sleep. The most widely used drug
treatments for PTSD are the selective serotonin reuptake
inhibitors, such as Prozac and Zoloft. At present,
cognitive-behavioral therapy appears to be somewhat more
effective than drug therapy.
However, it would be premature to conclude that drug therapy is
less effective overall since drug trials for PTSD are at a very
early stage. Drug therapy appears to be highly effective for
some individuals and is helpful for many more. In addition, the
recent findings on the biological changes associated with PTSD
have spurred new research into drugs that target these
biological changes, which may lead to much increased efficacy .