Post-traumatic stress disorder (PTSD)
Post-traumatic stress disorder (PTSD) is an anxiety disorder characterized hyper-arousal, re-experiencing of images of the stressful events and avoidance of reminders.
> It is a disorder that develops after a person sees, is involved in or hears
(experiences) of an extreme traumatic stressor.
> Is a condition occurring when an individual experiences extreme rare stressful event, the person reacts with severe anxiety, feeling of numbing and avoidance of thinking about the events which is often interrupted at times by sudden vivid and distressing recall of these events.
> It is a mental health disorder associated with torture.
PTSD may be immediate response to the stressor or may follow an interval of days or occasionally months. It usually improves within months, but may persist for years.
Post Traumatic Stress Disorder was first recognized in 1980 by American Psychiatric Association (APA). Before, it was known as:-
- Shell shock
- Soldiers’ heart
- Rape trauma syndrome
- Concentration camp syndrome.
Aetiology
1. An exceptionally stressful event in which the person was involved in directly or as a witness.
Examples of stressful events.
- Wars
- Floods
- Earthquakes
- Gang rape
- Terrorism
- Accidents
- Fire out break
2. However there is a variation in responses depending on personal vulnerability.
3. Genes was found to be part of the vulnerability by twin studies.
4. Other predisposing factors. For example:
- Uncontrolled temperament.
- Age: children and old people are more vulnerable.
- Gender: women are more vulnerable
- History of psychiatric disorders
- Previous traumatic experiences including separation from the parents and child abuse.
- Differences in a way threatening events are appraised and encoded in the brain.
5. Neuroendocrine factors which include: sensitization of noradrenergic system.
Sensitization of serotonergic system. Reduction in cortisol levels.
6. Psychological factors:
- Fear conditioning. Classical conditioning may be involved.
- Cognitive theory: PTSD arises when the normal processing of emotionally charged information is over whelmed, so that memories persist in an unprocessed form in which they can intrude into the conscious awareness.
- Psychodynamic theory: emphasizes the role of the previous experience in determining the individual variations in response to severely stressful events.
7. Maintaining factors:
- Negative appraisal of early symptoms
- Avoidance of reminders which prevents deconditioning and cognitive reappraisal.
- Suppression of anxious thoughts.
Diagnostic criteria signs/ symptoms
1. The child has been exposed to a very traumatic event outside the usual range of human experience and would be frightening to any one.
- Could be the subject of trauma
- Could be the perpetrator of the trauma.
- Could be a mere observer.
2. Persistent re-experiencing of traumatic event.
- Recurrent and intrusive recollections of the events. (In young children, repetitive play may occur in which themes or aspects of trauma are expressed).
- Recurrent distressing dreams of events. (A child may have frightening dreams without recognizable content).
- Acting or feeling as if the traumatic event were recurring. (Trauma specific re-enactment may occur)
- Experience intense psychological distress at exposure to events that symbolize or resemble the traumatic event).
3. Persistent avoidance of stimuli associated with trauma
- Efforts to avoid thought or feeling associated with trauma.
- Avoiding activities or situations resembling the trauma.
- In ability to recall important aspects of trauma.
- Diminished interest in activities.
- Feeling of detachment from others.
- Restricted range of affect.
- Sense of foreshortened future.
4. Persistent symptoms of increased arousal
- Difficult in falling or staying asleep.
- Irritability or out burst of anger.
- Difficulty in concentrating.
- Hyper-vigilance – not settled.
- Exaggerated startle response.
- Physiological reactivity upon exposure to events symbolizes or resembles the trauma.
5. Symptoms for at least one month.
If symptoms last for:-
- Less than 3 months – acute PTSD
- More than 3 months – chronic PTSD
- Begin 6 months after the stressor- delayed PTSD.
Summary of symptoms of PTSD
The principle symptoms of post traumatic stress disorder includes;
Hyper-arousal
- Persistent anxiety
- Irritability
- Insomnia
- Poor concentration.
Intrusions
- Difficulty in recalling stressful events at will.
- Intense intrusive imagery (flash back).
- Recurrent distressing dreams.
Avoidance
- Avoidance of reminders of the vents
- Detachment
- Inability to feel emotion (numbness).
- Diminished interest in activity.
Reactions
- Night mares
- Terrifying dreams
- Vivid recall of the events (images)
- Depression/ sadness
- Irritable
- Anxiety
- Anti-social behaviors.
Management of PTSD
Treatment usually involves psychotherapy and counseling, medication, or a combination.
Assessment
Assess the following;
- Nature and severity of the stressful event
- The nature and duration of the symptoms
- Previous psychiatric history
- Previous personality
- Neurological examination should be done to exclude a subdural haematoma or other forms of cerebral injury. If the event included injury like from assault or accident.
Treatment
1. Early treatment
- If the response is not severe, sympathetic support and help with practical problems subsequent to disaster may suffice.
- Counseling provides emotional support and discourages recall.
- Facilitates working through the associated emotions.
- Few doses of anxiolytic drugs may be needed to calm the person.
- The person is helped to talk about and reconsider the event and express feelings about them. This may need to be done repeatedly.
2. Chronic PTSD is difficult to treat.
- It requires series of interview where by the person is encouraged to recall, re-experience and work through the emotions associated with the event.
- Cognitive therapy or techniques have been used to desensitize patients to reminders and images of the stressful events.
Options for psychotherapy will be specially tailored for managing trauma.
3. Cognitive processing therapy (CPT): Also known as cognitive restructuring, the patient is taught to think about things in a new way. Mental imagery of the traumatic event may help them work through the trauma, to gain control of the fear and distress.
4. Exposure therapy: Talking repeatedly about the event or confronting the cause of the fear in a safe and controlled environment may help the person feel they have more control over their thoughts and feelings.
5. Medications
Some medications can be used to treat the symptoms of PTSD.
- Selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, are commonly used. SSRIs also help treat depression, anxiety and sleep problems, symptoms that are often linked to PTSD.
- benzodiazepines may be used to treat irritability, insomnia, and anxiety. However, the National Center for PTSD do not recommend these, because they do not treat the core symptoms and they can lead to dependency.
- anxiolytics should be avoided unless other wise because of dependence after prolonged use. Antidepressants may be used in low doses for example fluoxetine could be given.
The patient has to be taught about the following self help techniques
Active coping is a key part of recovery. It enables a person to accept the impact of the event they have experienced, and take action to improve their situation.
- learning about PTSD and understanding that an ongoing response is normal and that recovery takes time
- accepting that healing does not necessarily mean forgetting, but gradually feeling less bothered by the symptoms and having confidence in the ability to cope with the bad memories
Other things that can help include:
- finding someone to confide in
- spending time with other people who know what happened
- letting people know what might trigger symptoms
- breaking down tasks into smaller parts, to make them easier to prioritize and complete
- doing some physical exercise, such as swimming, walking ETC.
- practicing relaxation, breathing, or meditation techniques
- listening to quiet music or spending time in nature
- understanding that it will take time for symptoms to go away
- accepting that PTSD is not a sign of weakness but can happen to anyone
- participating in enjoyable activities that can provide distraction