Living in today’s world is stressful, chaotic and confusing, yet beautiful and joyful. It is important to find moments of happiness in one’s life, and to find a balance of stress and relaxation. Stress is a necessary biologic function of the autonomic nervous system, specifically of the sympathetic branch, that allows the human body react to stressful situations such as danger, intense emotion, or severe illness. The body releases epinephrine, the natural neurohormone or neurotransmitter when faced with a stressful situation. This is known as the fight, flight, or freeze phenomenon (p. 262 pharm book). Stress can be either negative or positive; it can be a driving force if working hard for a promotion, or winning first place in a swim meet.
Too much stress can wreak havoc on your physical health, leading from any symptoms such as high blood pressure, anxiety, depression, GI problems, trouble sleeping, to skin rashes. Scientific support shows that psychobiologic disorders affirms a connection between abnormalities in the brain and altered cognition, perception, emotion, behavior, and socialization (p. 1244). Mental illnesses are now known as psychobiological disorders, and include stress-related, anxiety disorders, mood disorders, eating disorders, chemical dependence, and thought disorders. This paper will explain post-traumatic stress disorder, a type of anxiety disorder, and it’s disease process, anatomy and physiology, objective and subjective data, signs and symptoms, diagnosis, medical management, prognosis, and socio-economic factors.
History of Disease Process
Post traumatic stress disorder is a relatively new term defined by DSM III in 1980, to give a name to an age old ailment. It is historically considered a wartime disorder; a description to give soldiers returning home who had been changed mentally by warfare in other countries. Known as ‘shell shock’, ‘soldier’s heart’, ‘battle fatigue’, or ‘Vietnam combat reaction’, each war and generation of soldiers brought on new labels coined by professionals at that time. These soldiers were suffering from insomnia, stress, fear, anorexia, nightmares, depression, guilt, hypervigilance, or melancholy. This group was suffering the same afflictions that we describe today of symptoms of PTSD. This population did not seek help for their mental health issues, as it was seen as weak by their superiors, and more or less had to get over it, or cope by self-medicating with drugs or alcohol. Medical doctors soon realized that this group was not suffering only physically, but mentally as well, thus paving the way for treatment of PTSD (https://operationcompassionatecare.org/historical-names-for-ptsd/)
Post traumatic stress disorder manifests when an individual experiences severe trauma. Many people will experience a traumatic event in their lifetime.
At least half of Americans have had a traumatic event in their lives. Not all people who experiences a traumatic event will experience PTSD. Of people who have had trauma, about 1 in 10 men and 2 in 10 women will develop PTSD (pamphlet p. 4) Some individuals are more likely to experience it than others. People who are more likely to experience PTSD are those who have had long-lasting trauma or have had a strong reaction to the event. There is no way to know with certainty who will develop PTSD.
The individual with PTSD will have a delayed anxiety response 3 or more months after the emotionally or physically traumatic experience. The traumatic event may be an actual or perceived threat of severe violence, threatened death, injury to self or others and will produce feeling of fear, helplessness or horror. (p. 1257). Feelings of survivor’s guilt are common. Examples of events that can trigger PTSD include surviving a terrorist attack or school shooting, being a victim of rape or abuse, being kidnapped, surviving a natural disaster, child sexual or physical abuse, or being in combat or other military experiences. At first, the affected person may distance themselves from family and friends using a technique called psychic numbing. As time passes, the person cannot stifle the traumatic memories and they may resurface in recurrent nightmares or flashbacks, in which the person re-experiences the precipitating event. In their mind, the person is literally reliving the event and it is real to that individual. Self-medication and unhealthy coping techniques are commonly used by individuals with PTSD to deal with feelings of guilt, grief, or anger. The individual may abuse alcohol, marijuana, heroin, methamphetamines, or other mood altering drugs. These unproductive coping strategies will prove to be ineffective and the individual may become hostile and angry. Seeking help from a mental healthcare provider will help to diagnose the individual with PTSD and the individual will be treated and taught healthy and productive coping techniques (p. 1257)
Anatomy and Physiology
Brain imaging studies of posttraumatic stress disorder have identified a few key brain regions whose function appears to be altered in PTSD, most notably the amygdala, the ventromedial prefrontal cortex, and the hippocampus (https://www.psychologytoday.com/us/blog/mouse-man/200901/the-anatomy-posttraumatic-stress-disorder).
The amygdala is the part of the brain that evaluates stress and sends messages to the body to react. During a traumatic event, the amygdala will send out a danger signal, initiates the fight or flight response, stores memories associated with the event (smell, sight, sound). The amygdala will then produce calming thoughts when the individual is out of danger. When an individual develops PTSD, the amygdala has stored the sights, sounds, and smells associated with that event. If one or more of these stimuli are encountered, after the event, the amygdala will trigger a danger signal and prepare the body.
The individual may remain in hypervigilance or hyperarousal, meaning that person will be constantly scanning their surroundings, or always checking for danger. Being hypervigilant is positive when a person is in a dangerous situation, however for the person with PTSD, this is counterproductive because the amygdala remains overactive, and interferes with sleep, work, relationships, and day-to-day life (https://www.brainline.org/slideshow/anatomy-ptsd).
The hippocampus forms memories in the brain. When a person develops PTSD, the hippocampus plays a role in the person re-experiencing the traumatic event. A traumatic memory could be involuntarily retrieved when triggered by a stimulus. The hippocampus is overactive in those with PTSD because the memories are very strong and the danger is perceived as real. Then, the hippocampus is unable to calm down the amygdala.
The prefrontal cortex controls behavior, emotions, and impulses. After a traumatic event occurs, the prefrontal cortex sends signals to the amygdala to calm and return to normal once the danger has passed. In people with PTSD, the prefrontal cortex is less active, and manifests as symptoms such as social withdrawal, avoidance of places or people associated with the trauma, and emotional number. The prefrontal cortex is unable to override the hippocampus, and the person will continue to act in a way that they believe they are in danger.
The criteria for PTSD are listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV) and include symptoms of re-experiencing, intrusive recollections of a traumatic event, such as flashbacks or nightmares; avoidance and numbing, efforts to avoid anything associated with the trauma and numbing of emotions; and hyperarousal as manifested by, for example, difficulty in sleeping or irritability. PTSD symptoms can vary in severity and frequency and can leave patients with an array of disabilities from mildly distressing to severely incapacitating. Although the onset typically occurs shortly after exposure, the lag between exposure and full manifestation of PTSD is variable and in some cases long. PTSD can be chronic or recurrent (Friedman 2003). In some cases, it occurs alone, but most people who have PTSD also have other psychiatric disorders, such as major depressive disorder (https://www.nap.edu/read/11674/chapter/4).
The following are examples of how patients describe what the disease feels like when one is going through the disorder. These quotations are taken from the National Center for PTSD pamphlet, (www.ptsd.va.gov). PTSD manifests itself differently in every patient. It is insightful to help to understand how patients are able to put their emotions, thoughts, and feelings into words, and how the disorder affects patients physically as well. The following example explains how one’s emotions will affect the person’s personal relationships. “The emotional numbness…will just tear away all of the relationships in your life, you know, if you don’t learn to unlock them [and] get those emotions out.”-Sarah C. Humphries, U.S. Army (1994-2012). The next example demonstrates how PTSD can affect an individual when trying to go to sleep. “Even just falling asleep was tough. The minute I would start dozing off I would get a surge of adrenaline or anxiety, and would wake up. And even when I did fall asleep, I would wake up with night terrors or sweats.”-Stacy L. Pearsall, U.S. Air Force (1998-2008). The next example shows how treatment can be successful and help the individual cope with emotions. “My treatment has been a blessing to me and my family. It’s hard to put into words just how you feel after you know that you can control your anger, and you can control your emotions”-Bradley Seitz, U.S Marine Corps (2002-2005). With an understanding of how patients feel and react in everyday life, will help the healthcare team to treat and care for the patient.
Signs and Symptoms
There are four types of PTSD symptoms, but they vary for everyone. Each person experiences different symptoms uniquely. Symptoms include reliving the event, avoiding things that remind you of the event, having more negative thoughts and feelings than before, and feeling on edge. Reliving the event most often appears as flashbacks, while the person is awake, or the individual may have nightmares. Avoidance is a mechanism some individuals will use to not have to face where the situation happened, or face a person or people. Other individuals may feel sad or numb, and lose interest in activities one used to enjoy. Other people may feel as if it’s hard to relax, and may have trouble concentrating. (pamphlet p. 6).
The symptoms presented by the patient and the first diagnoses vary, and will need a brief or long assessment. The assessment depends on the person’s symptoms, mental and physical health, and willingness to receive help and get better, and the capacity to work with the health professional. The person may have other physical or psychiatric disorders.
Ideally, the patient is evaluated in a private setting, with a face-to-face interview by a health-care professional. The health-care professional might be a psychiatrist, psychologist, or psychiatric nurse and have experience in the diagnosis of psychiatric disorders. The consultation should elicit the patient’s symptoms, assess the history of potentially traumatic events, and determine whether the patient meets the DSM-IV criteria for PTSD. The interview will also determine if the patient has a different psychiatric disorder, such as major depressive disorder or a neurologic disorder, such as a traumatic brain injury. The health professional will determine the recurrence and severity of symptoms. An individual might not meet full criteria for a diagnosis of PTSD but will still benefit from treatment for other mental health issues. PTSD symptoms could be mild to severe, and a variety of factors will influence the success of treatment. (https://www.nap.edu/read/11674/chapter/4#24).
There are several treatments for the patient with PTSD. Different treatments work for different individuals, and oftentimes the best treatment is a combination of therapies. Treatment is effective when the individual wants to receive treatment, even if the person does not feel ready emotionally (not wanting to confront feelings of trauma is a sign of PTSD). Two major types of treatment are psychotherapy and medication. Trauma-focused psychotherapies, prolonged exposure therapy (PE), cognitive processing therapy (CPT), or eye movement desensitization and reprocessing (EMDR) are different therapies used. ‘Trauma-focused” means that the treatment focuses on the memory of the traumatic event or its meaning. During treatment, the patient and therapist will form individual goals during each session, and the patient will meet with the therapist for 50-90 minutes a session. In prolonged exposure therapy, the patient exposes explores thoughts, feelings, and situations that one has been avoiding.
During prolonged exposure therapy, the therapist will ask the patient to talk about the trauma over and over in order for the patient to gain control of thoughts and feelings. Cognitive process therapy helps the patient to learn to identify and change negative thoughts; changing how one thinks about the trauma will help the patient change how they feel. Eye movement desensitization and reprocessing helps the patient process upsetting memories, thoughts, and feelings. By focusing on specific sounds or movements, the brain will be retrained to work through traumatic memories. With time, the patient will change their reactions to memories of the trauma.
Medications are another option for treatment for those individuals who have low levels of certain chemicals in their brain that would help to manage stress. Selective serotonin reuptake inhibitors (sertraline, paroxetine, and fluoxetine) and selective norepinephrine reuptake inhibitors (venlafaxine) help raise levels of those chemicals in your brain to feel better.
Therapy treats the underlying cause of one’s symptoms, and treatment with medication can be used alone or with therapy. If treated only with medication, the patient will need to continue taking it for continued success.
Treatment for PTSD can be successful for many patients. It is hard work to ‘retrain’ your brain to longer have fear or anxiety about certain situations. It works when the patient is willing to put in the work and feel as though they want to get better. “Long-term studies, specifically with antidepressants or antidepressants combined with psychotherapy, show promise in the continuation and maintenance phases of treatment for chronic PTSD. It is evident from both acute and long-term studies that although PTSD may respond to a variety of treatment interventions, at the end of the trials many patients still have significant symptom burden. More studies are needed to investigate combination medication and psychosocial treatment interventions. There are limited data on the effectiveness of other classes of psychotropics, especially for continuation or maintenance treatment. At this point, it is reasonable to continue to give patients with chronic PTSD an SSRI or SNRI antidepressant if they have responded to acute-phase treatment. Ideally, the antidepressant should be combined with some form of cognitive behavioral psychotherapy” (https://www.psychiatrictimes.com/comorbidity-psychiatry/long-term-treatment-posttraumatic-stress-disorder/page/0/2).
Having a support system and community is important for treatment. Group meetings and having family support at home will help the individual to cope the best. Group treatment is an ideal therapeutic setting for many people. Trauma survivors are able to seek help and support while sharing traumatic material in a safe environment. Telling one’s story and directly facing the grief, guilt, and anxiety related to trauma enables many survivors to cope with their symptoms, memories, and other aspects of life.
Family therapy is a type of counseling that involves the whole family, as PTSD can affect the family unit. Children or spouses may not understand why the individual has angry outbursts or is stressed. In family therapy, a therapist helps the family to communicate, maintain good relationships and cope with tough emotions. The family as a whole can learn more about PTSD and how it is treated. The family will be better prepared to help the individual by having discussions of the important parts of treatment and recovery (https://www.psychologytoday.com/us/conditions/post-traumatic-stress-disorder).
Post traumatic stress disorder happens when a traumatic event occurs to an individual and the brain cannot cope with the trauma. PTSD will affect an individual’s day-to-day life, relationships, work and sleep because the individual cannot face certain emotions and will often feel irritable, stressed, angry or in hyperarousal. Treatment is available. Many individuals find psychotherapy to be helpful, and others will use SSRIs or SNRIs in combination with therapy.