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Posttraumatic stress disorder

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ICD-10 ICD-9 DiseasesDB MedlinePlus eMedicine MeSH
Post Traumatic Stress Disorder
Classification and external resources
F43.1
309.81
33846
000925
med/1900
D013313
Post traumatic stress disorder[1][2] (PTSD) is an anxiety disorder that can develop after exposure to one or more terrifying events that threatened or caused grave physical harm.[3] It is a severe and ongoing emotional reaction to an extreme psychological trauma.[4] This stressor may involve someone's actual death, a threat to the patient's or someone else's life, serious physical injury, or threat to physical and/or psychological integrity, overwhelming usual psychological defenses coping. In some cases it can also be from profound psychological and emotional trauma, apart from any actual physical harm. Often, however, the two are combined.
PTSD is a condition distinct from traumatic stress, which has less intensity and duration, and combat stress reaction, which is transitory. PTSD has also been recognized in the past as railway spine, shell shock, traumatic war neurosis, or post-traumatic stress syndrome (PTSS).

Contents

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[edit] Causes

Main article: Psychological trauma
PTSD is believed to be caused by psychological trauma.[1] Possible sources of trauma includes experiencing or witnessing childhood or adult physical, emotional or sexual abuse.[1] In addition, experiencing or witnessing an event perceived as life-threatening such as physical assault, adult experiences of sexual assault, accidents, drug addiction, illnesses, medical complications, or the experience of, or employment in occupations exposed to war (such as soldiers) or disaster (such as emergency service workers). Traumatic events that may cause PTSD symptoms to develop include violent assault, kidnapping, torture, being a hostage, prisoner of war or concentration camp victim, experiencing a disaster, bad car accidents or getting a diagnosis of a life-threatening illness.[1] Children may develop PTSD symptoms by experiencing sexually traumatic events like age-inappropriate sexual experiences. [1] Witnessing traumatic experiences or learning about these experiences may also cause the development of PTSD symptoms. [1] The amount of dissociation that follows directly after a trauma predicts PTSD.[5] Individuals who are more likely to dissociate during a traumatic event are considerably more likely to develop chronic PTSD.[5] Many servicemen and women returning from Iraq and Afghanistan have PTSD. [6] The diagnosed cases of PTSD in United States troops sent to either Afghanistan or Iraq rose 46.4 percent in 2007, bringing the five year total to almost 40,000 (from U.S. military data). [7] Members of the Marines and Army are much more likely to develop PTSD than Air Force and Navy personnel, because of greater exposure to combat. [1] A preliminary study found that mutations in a stress-related gene interact with child abuse to increase the risk of PTSD in adults. [8][9][10]

[edit] Neuroendocrinology

PTSD displays biochemical changes in the brain and body that differ from other psychiatric disorders such as major depression. Individuals diagnosed with PTSD respond more strongly to a dexamethasone suppression test than individuals diagnosed with clinical depression.[citation needed] In addition, most PTSD also show a low secretion of cortisol and high secretion of catecholamine in urine, with anorepinephrine/cortisol ratio consequently higher than comparable non-diagnosed individuals.[citation needed] This is in contrast to the normative fight-or-flight response, in which both catecholamine and cortisol levels are elevated after exposure to a stressor.[citation needed] Brain catecholamine levels are low, and corticotropin-releasing factor (CRF) concentrations are high.[citation needed] Together, these findings suggest abnormality in the hypothalamic-pituitary-adrenal axis (HPA). Given the strong cortisol suppression to dexamethasone in PTSD, HPA axis abnormalities are likely predicated on strong negative feedback inhibition of cortisol, itself likely due to an increased sensitivity of glucocorticoid receptors.[11] Some researchers have associated the response to stress in PTSD with long-term exposure to high levels of norepinephrine and low levels of cortisol, a pattern associated with improved learning in animals.[citation needed] Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response through a hypersensitive, hyperreactive and hyperresponsive HPA axis.[12]
Low cortisol levels may predispose individuals to PTSD; following war trauma, Swedish soldiers serving in Bosnia and Herzegovina with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels.[13] Because cortisol is normally important in restoring homeostasis after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD. However, there is considerable controversy within the medical community regarding the neurobiology of PTSD. A review of existing studies on this subject showed no clear relationship between cortisol levels and PTSD. Only a slight majority have found a decrease in cortisol levels while others have found no effect or even an increase.[14]

[edit] Neuroanatomy

In addition to biochemical changes, PTSD also involves changes in brain morphology. Combat veterans of the Vietnam war with PTSD showed an 8% reduction in the volume of their hippocampus compared with veterans who suffered no such symptoms.[citation needed]
In animal research as well as human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. Neuroimaging studies in humans have revealed both morphological and functional aspects of PTSD. The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex and the hippocampus. Further animal and clinical research into the amygdala and fear conditioning may suggest additional treatments for the condition.

[edit] Genetics

PTSD runs in families: For twin pairs exposed to combat in Vietnam, having a monozygotic (identical) twin with PTSD was associated with an increased risk of the co-twin having PTSD compared to twins that were dizygotic (non-identical twins).[15] Because of the difficulty in performing genetic studies on a condition with a major environmental factor (ie., trauma), genetic studies of PTSD are in their infancy. A functional polymorphism in the monoamine oxidase A (MAOA) gene promoter can moderate the association between early life trauma and increased risk for violence and antisocial behavior. Low MAOA activity is a significant risk factor for aggressive and antisocial behavior in adults who have been victimized as children. Persons who were abused as children but have a genotype conferring high levels of MAOA expression are less likely to develop antisocial symptoms. These findings help explain why not all persons who have experienced early childhood trauma victimize others.[16][17]

[edit] Risk and protective factors for PTSD development

Although most people (50-90%) encounter trauma over a lifetime [18][19], only about 8% develop full PTSD [20]. Vulnerability to PTSD presumably stems from an interaction of biological diathesis, early childhood developmental experiences, and trauma severity. Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood [21][22][23][24]. This effect of childhood trauma, which is not well understood, may be a marker for both traumatic experiences and attachment problems [25][26]. Proximity to, duration of, and severity of the trauma also make an impact; and interpersonal traumas cause more problems than impersonal ones [27].
Schnurr, Lunney, and Sengupta identified risk factors for the development of PTSD in Vietnam veterans. Among those are:
  • Hispanic ethnicity, coming from an unstable family, being punished severely during childhood, childhood asocial behavior and depression as pre-military factors
  • war-zone exposure, peritraumatic dissociation, depression as military factors
  • recent stressful life events, post-Vietnam trauma and depression as post-military factors
They also identified certain protective factors, such as:
  • Japanese-American ethnicity, high school degree or college education, older age at entry to war, higher socioeconomic status and a more positive paternal relationship as pre-military protective factors
  • Social support at homecoming and current social support as post-military factors[28] Other research also indicates the protective effects of social support in averting and recovery from PTSD [29][30].
There may also be an attitudinal component e.g. a soldier who believes that they will not sustain injuries may be more likely to develop symptoms of PTSD than one who anticipates the possibility, should either be wounded. Likewise, the later incidence of suicide amongst those injured in home fires above those injured in fires in the workplace suggests this possibility.See also: Psychological resilience

[edit] Diagnosis

The diagnostic criteria for PTSD, per the Diagnostic and Statistical Manual of Mental Disorders IV (Text Revision) (DSM-IV-TR), may be summarized as:[1]A. Exposure to a traumatic event B. Persistent reexperience (e.g. flashbacks, nightmares) C. Persistent avoidance of stimuli associated with the trauma (e.g. inability to talk about things even related to the experience. Avoidance of things and discussions that trigger flashbacks and reexperiencing symptoms. Fear of losing control.) D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep, anger and hypervigilance ) E. Duration of symptoms more than 1 month F. Significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and relationships.) Notably, criterion A (the "stressor") consists of two parts, both of which must apply for a diagnosis of PTSD. The first (A1) requires that "the person 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 self or others." The second (A2) requires that "the person’s response involved intense fear, helplessness, or horror." The DSM-IV-TR criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience." Since the introduction of DSM-IV, the number of possible PTSD traumas has increased and one study suggests that the increase is around 50%.[31] Various scales exist to measure the severity and frequency of PTSD symptoms ([32],[33]).

[edit] Treatment

Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling for PTSD includes education about the condition and provision of safety and support.[34] Cognitive therapy shows good results,[35] and group therapy may be helpful in reducing isolation and social stigma.[36] The psychotherapy programs with the strongest demonstrated efficacy are all cognitive behavioral programs and include variants of exposure therapy. Where we are and directions for future research in the treatment of PTSD. In S. Taylor (Ed.),Advances in the Treatment of Posttraumatic Stress Disorder: Cognitive-behavioral perspectives [37] Exposure involves assisting trauma survivors to therapeutically confront distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders.
Indeed, the success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD. Some organizations have endorsed the need for exposure [38],[39]. Yet other approaches, particularly involving social supports[40],[41], may also be important. A recent open trial of interpersonal psychotherapy[42] reported high rates of remission from PTSD symptoms without using exposure[43]. A randomized controlled trial funded by the National Institute of Mental Health is currently comparing exposure-based psychotherapy to interpersonal psychotherapy at the New York State Psychiatric Institute (www.columbiatrauma.org; 212 543-6747).

[edit] Critical incident stress management

Early intervention after a traumatic incident,[44] known as Critical Incident Stress Management (CISM) is used to attempt to reduce traumatic effects of an incident, and potentially prevent a full-blown occurrence of PTSD. However recent studies regarding CISM seem to indicate iatrogenic effects.[45][46] Six studies have formally looked at the effect of CISM, four finding no benefit for preventing PTSD, and the other two studies indicating that CISM actually made things worse. Hence this is not a recommended treatment. Some benefit was found from being connected early to cognitive behavioral therapy, or for some medications such as propranolol. Effects of all these prevention strategies was modest.[47]

[edit] Eye movement desensitization and reprocessing

Eye Movement Desensitization and Reprocessing (EMDR) is specifically targeted as a treatment for PTSD.[48] Research on EMDR is largely supported by those with the copyright for EMDR and third-party studies of its effectiveness are lacking, but a meta-analytic comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in terms of effectiveness in treating PTSD.[49]

[edit] Medication

Medications have shown benefit in reducing PTSD symptoms, but rarely achieve complete remission. Standard medication therapy useful in treating PTSD includes SSRIs (selective serotonin reuptake inhibitors) and TCAs (tricyclic antidepressants). Tricyclics tend to be associated with greater side effects and lesser improvement of the three PTSD symptom clusters than SSRIs. SSRIs for which there are data to support use include: citalopram, escitalopram, fluvoxamine, paroxetine and sertraline [50][51] [52] [53] [54]
There are data to support the use of "autonomic medicines" such Propranolol (beta blocker) and Clonidine (alpha-adrenergic agonist) if there are significant symptoms of "over-arousal". These may inhibit the formation of traumatic memories by blocking adrenaline's effects on the amygdala, has been used in an attempt to reduce the impact of traumatic events.[55] or they may simply demonstrate to the patient that the symptoms can be controlled thereby assisting with "self efficacy" and helping the patient remain calmer. There is also data to support the use of mood-stabilizers such lithium carbonate, divalproex sodium and carbemazepine if there is significant uncontrolled mood or aggression. Risperidone is used to help with dissociation, mood and aggression, and benzodiazepines are used for short-term anxiety relief.[51]

[edit] Combination therapies

PTSD is commonly treated using a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and medications such as antidepressants (i.e. SSRI's such as fluoxetine and sertraline, SNRI's such as venlafaxine, NaSSA's such as mirtazapine and tricyclic antidepressant such as amitriptyline[56]) or atypical antipsychotic drugs (such as quetiapine and olanzapine).[57] Recently the anticonvulsant lamotrigine has been reported to be useful in treating some people with PTSD.[58][59][60] Geodon (ziprasidone) is one of the most effective treatments shown to work 89% of the time in PTSD patients.[61] Geodon works by blocking two of the fight-or-flight chemicals (catecholamines): norepinephrine (noradrenaline) and dopamine.[62] Carrot of Hope has been promoting the benefits of combining Geodon with the beta-adrenergic blocker propranolol to create a PTSD cocktail. Since propranolol works by blocking the third catecholamine, epinephrine (adrenaline),[63] the combination of the two medicines work to block all three fight-or-flight chemicals. Propranolol (40 mg) has been commonly prescribed off-label for stage fright in the late 1970s.[64][65] The television show 60 Minutes featured propranolol where low doses (10-20 mg) used in research have been shown to stop panic attacks and reduce the impact of traumatic memories. As propranolol lasts in the system for 4 hours, the study dosages are typically given 4 times a day to cover a 16 hour span.[66] Alpha-adrenergic blocker prazosin has also shown impressive effects in PTSD patients, curbing brain damage and reducing nightmares. [67][68] Unlike propranolol, prazosin acts on norepinephrine[69] and, therefore, is contraindicated for use with Geodon.

[edit] MDMA

While MDMA had its first exposure to the psychiatric community in the 1960s, gaining a reputation for its communication enhancing qualities, it hasn't been until recent years that formal studies have been carried out. The US Food and Drug Administration (FDA) recently approved a clinical protocol that combines the drug MDMA with talk therapy sessions.[70] Funded by the non-profit Multidisciplinary Association for Psychedelic Research (MAPS),[71] the studies are taking place in South Carolina under the supervision and direction of Dr. Michael Mithoefer. Other PTSD/MDMA research include a pilot study in Switzerland, co-sponsored by MAPS and the Swiss Medical Association for Psycholytic Therapy (SAePT),[72] and another study approved in Israel to investigate MDMA as a tool in the psychotherapeutic treatment of crime and terrorism-related PTSD.[73]
There are several features of MDMA that make it an excellent candidate for treating PTSD in psychotherapy. The effects of MDMA are such that activity in the left amygdala,[74] responsible for fear and anxiety, decreases in rats. This makes it a promising candidate as a tool in psychotherapy, allowing the patient to explore and examine their trauma (and accompanying emotions) without the fear and retraumatization encountered without drug. Ordinarily incapacitated by the resurgence of emotions(fear, shame, anger) attached to the trauma, subjects are rendered capable of approaching their trauma in a new and constructive way. Further helpful in treating PTSD, is the new capacity to experience empathy and compassion for both others and the self.[75]

[edit] Other techniques

Attachment- and relationship-based treatments are also often used.[76][77] In these cases, the treatment of complex trauma often requires a multi-modal approach. Medical Marijuana is also used for treatment of PTSD. Yoga Nidra has been used to help soldiers cope with the symptoms of PTSD.[78]

[edit] Epidemiology

PTSD may be experienced following any traumatic experience, or series of experiences that satisfy the criteria and that do not allow the victim to readily recuperate from the detrimental effects of stress. The National Comorbidity Survey Report provided the following information about PTSD in the general adult population: The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.[citation needed]
The National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5 of female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was 30.9 for males and 26.9 for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans suffered from PTSD-symptoms. Four out of five reported recent symptoms when interviewed 20-25 years after Vietnam.[28]
In recent history, catastrophes (by human means or not) such as the Indian Ocean Tsunami Disaster may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as the Red Cross and the Salvation Army provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder.
There is debate over the rates of PTSD found in populations, but despite changes in diagnosis and the criteria used to define PTSD between 1997 and 2007, epidemiological rates have not changed significantly.[2]

[edit] History


[edit] Earliest reports

Reports of battle-associated stress appear as early as the 6th century BC.[79] Although PTSD-like symptoms have also been recognized in combat veterans of many military conflicts since, the modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by Vietnam veterans.[79]
The term post-traumatic stress disorder or PTSD was coined in the mid 1970s.[79] Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders.[80] The term was formally recognised in 1980.[79] (In the DSM-IV, which is considered authoritative, the spelling "posttraumatic stress disorder" is used. Elsewhere, "posttraumatic" is often rendered as two words — "post-traumatic stress disorder" or "post traumatic stress disorder" — especially in less formal writing on the subject.)

[edit] Veterans and politics

The diagnosis was removed from the DSM-II, which resulted in the inability of Vietnam veterans to receive benefits for this condition. In part through the efforts of anti Vietnam war activists and the anti war group Vietnam Veterans Against the War and Chaim F. Shatan, who worked with them and coined the term post-Vietnam Syndrome, the condition was added to the DSM-III as posttraumatic stress disorder.[80]
In the United States, the provision of compensation to veterans for PTSD is under review by the Department of Veterans Affairs (VA). The review was begun in 2005 after the VA had noted a 30% increase in PTSD claims in recent years. The VA undertook the review because of budget concerns and apparent inconsistencies in the awarding of compensation by different rating offices.
This led to a backlash from veterans'-rights groups, and to some highly-publicized suicides by veterans who feared losing their benefits, which in some cases constituted their only income. In response, on November 10, 2005, the Secretary of Veterans Affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for post-traumatic stress disorder..."[81]
The diagnosis of PTSD has been a subject of some controversy due to uncertainties in objectively diagnosing PTSD in those who may have been exposed to trauma, and due to this diagnosis' association with some incidence of compensation-seeking behavior.[82]
The social stigma of PTSD may result in under-representation of the disorder in military personnel, emergency service workers and in societies where the specific trauma-causing event is stigmatized (i.e. sexual assault).[2]
Because of the United States soldiers in combat in the wars in Iraq and Afghanistan, soldiers returning home have faced significant physical, emotional and relational disruptions, the United States Marine Corps has instituted programs to assist Marines in re-adjusting to life, and in particular marriage, outside of the Marine Corps.[77] Similarly, Walter Reed Army Institute of Research (WRAIR) developed the Battlemind program to assist servicemembers avoid or ameliorate PTSD and related problems.

[edit] Canadian veterans

Veterans Affairs Canada is a new program including rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support.[83]

[edit] Cultural references

Jonathan Shay, a psychiatrist for the Boston Department of Veterans' Affairs Outpatient Clinic was treating soldiers who suffered from PTSD. He was struck by the similarity of their war experiences to Homer's account of Achilles in the Iliad. He also believes Hotspur in William Shakespeares Henry IV, Part 1 is portrayed as a person suffering from PTSD[84] J. R. R. Tolkien served in World War I. It is believed that he portrayed Frodo Baggins in The Lord of the Rings as a person suffering from PTSD.[85] In recent decades, with the concept of trauma, and PTSD in particular, becoming just as much a cultural phenomenon as a medical or legal one, artists have engage the issue in their work. Many movies, such as Birdy, Coming Home, The Deer Hunter, Born on the Fourth of July and Heaven & Earth deal with PTSD. It is an especially popular subject amongst "war veteran" films, often portraying Vietnam war veterans suffering from extreme PTSD and having difficulties adjusting to civilian life.
A very realistic depiction showed on screen was by Christian Bale in Harsh Times. He suffers from PTSD from the horrors of war.
In more recent work, an example is that of Krzysztof Wodiczko who teaches at MIT and who is known for interviewing people and then projecting these interviews onto large public buildings.[86] Wodiczko aims to bring trauma not merely into public discourse but to have it contest the presumed stability of cherished urban monuments. His work has brought to life issues such as homelessness, rape, and violence. Other artists who engage the issue of trauma are Everlyn Nicodemus of Tanzania and Milica Tomic of Serbia.[87]
George Carlin comments on the various incarnations of PTSD terminology on his 1990 album Parental Advisory: Explicit Lyrics. He traces the progression of what he views as euphemisms, which followed "shell shock" in World War I: "battle fatigue" in World War II, "operational exhaustion" in the Korean War, and finally PTSD, a clinical, hyphenated term, in the Vietnam War. "The pain is completely buried under jargon. Post-traumatic stress disorder. I'll bet you if we'd have still been calling it shell shock, some of those Viet Nam veterans might have gotten the attention they needed at the time."[88]

[edit] See also


[edit] References

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