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Post Traumatic Stress Disorder
October 19, 2012
By Harvey B. Simon, M.D.
Harvard Medical School
Post-traumatic stress disorder (PTSD) is a well-known, often serious result of military service in war zones. And because trauma occurs so frequently in modern life. PTSD has also become distressingly common here at home. In fact, doctors estimate that an American civilian has a 5 to 10 percent chance of developing PTSD at some time in his or her life.
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PTSD didn't get its name until 1980, but the symptoms were first reported following the American Civil War. At that time they were known by the curiously peaceful name of "nostalgia."
World War I produced a dramatic increase in PTSD cases. It's also when the disorder got the more graphic name, "shell shock."
Doctors called PTSD "combat neurosis" after World War II. And "combat fatigue" after the Korean War.
Despite 150 years of history, PTSD was considered uncommon until the Vietnam War. Up to 30% of male combat veterans developed symptoms of the disorder. That's what led to the current name. PTSD gained urgency with the explosion of cases in soldiers who've served in Iraq and Afghanistan.
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What Triggers PTSD?
You don't have to be pinned down in a foxhole to get PTSD, but you do have to experience major trauma. It can be a single crisis or a series of events, as long as they are severe enough. Typical examples include:
- Serious car crashes
- Airplane accidents
- Physical assaults, robberies or kidnappings
- Heart attacks and other major physical illnesses
- Natural disasters, such as hurricanes, floods and earthquakes
Although it's much less common, even the death of a loved one can trigger PTSD, particularly if it's unexpected and violent or gruesome. Although anyone can develop PTSD after a frightening, threatening event, people with pre-existing stress or depression may be particularly vulnerable.
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Nearly every trauma victim will experience fear and horror, shock, numb disbelief, confusion and helplessness, sorrow, stress and extreme sadness soon after a traumatic event.
Do You Have PTSD?
The symptoms of PTSD can be confused with other problems. To find out if you may have PTSD, answer these seven simple questions:
- Do you avoid being reminded of the experience by staying away from certain places, people or activities?
- Have you lost interest in activities that were once important or enjoyable?
- Have you begun to feel more isolated or distant from other people?
- Do you find it hard to feel love or affection for other people?
- Have you begun to feel that there is no point in planning for the future?
- Have you had more trouble than usual falling asleep or staying asleep?
- Do you become jumpy or get easily startled by ordinary noises or movements?
Count each "Yes" as one point, each "No" as 0 points. If your score is four or higher, you may have PTSD.
People who are grieving have similar reactions. If these normal early emotions remain severe enough to be disabling for more than two days, doctors characterize them as an acute stress disorder; if they persist for more than four weeks they may qualify as PTSD.
PTSD has three characteristics:
- Hyperarousal This often occurs first. It's an ongoing state of tension with many similarities to the primitive "fight or flight" response to danger. Characteristic symptoms include insomnia, outbursts of anger, an exaggerated startle response and extreme wariness or hypervigilance. Physical symptoms such as headaches, trembling, diarrhea and fatigue often occur.
- Avoidance These common symptoms involve feelings of detachment or numbness. Often the person is unable to talk about the traumatic event or revisit the place where it occurred. And in many cases, avoidance goes far beyond the event itself: PTSD patients withdraw from people and social events, particularly those that have even a remote association with the trauma.
- Re-experiencing This is the worst symptom of PTSD. In most cases, a person has unwelcome and disruptive thoughts about the event. These interfere with normal concentration and function. Recurrent nightmares are also quite typical. In extreme cases, PTSD produces flashbacks, where the person mentally relives the traumatic experience.
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Doctors are not sure what causes PTSD. Many suspect there is a chemical side to the disorder.
Researchers have identified abnormalities in the stress hormones adrenaline and cortisone in some PTSD patients. That has led some doctors to treat PTSD patients with beta-blockers as soon as possible after severe emotional trauma. They give it as a preventive treatment to counter some effects of adrenaline. It's an interesting approach, but it's still unproven and will need more research.
PTSD can take a major toll on relationships, jobs and personal fulfillment. It can also contribute to substance abuse, depression and personality disorders. And if that's not bad enough, patients with severe PTSD face an increased risk of heart disease and dementia.
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The treatment of PTSD has come a long way from the sanatorium days of World War I. Indeed, there is no convincing evidence that hospitalizing patients or keeping them in other protected environments is helpful. At present, people with PTSD can get help from psychological support, drug therapy or a combination of these.
- Whenever possible, a crisis team should provide psychological support soon after the trauma. Tragedies such as the terrorist attacks of 9/11 and the movie theatre massacre in Aurora, Colorado have clearly shown the value of providing both professional and personal help early.
- The type of psychological support depends on the needs of the patient, and the experience and skill of the therapist. In many cases, cognitive behavior therapy that focuses on trauma is an excellent choice. Newer, much less well-established methods include imagery reversal therapy, eye-movement desensitization and reprocessing.
- Medications can also help, particularly in severe or long-lasting cases. According to most experts, selective serotonin-reuptake inhibitors (SSRIs) are the first choice. Paroxetine (Paxil) and sertraline (Zoloft) have proved useful in PTSD.
Other psychiatric medications that may help some PTSD patients include nefazone (Serzone), venlafaxine (Effexor) and older tricyclic antidepressants such as amitriptyline (Elavil). Although all of these medications are antidepressants, their benefit for PTSD appears to be separate from their antidepressant activity.
Even without therapy, PTSD may start to fade away after a few months or years. But it can persist or recur, even decades after the trauma itself; at least two percent of Vietnam combat vets are still struggling with PTSD nearly 40 years after the war's end.
In all, PTSD will strike an estimated 22 million Americans at some time in their lives. It is fortunate indeed that we are witnessing major progress in the prevention, recognition and therapy of this once obscure "battlefield" disorder.
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Lending a Hand
Here are a few tips for helping a relative or friend who has been the victim of emotional trauma:
- Talk about the event. It will be easier to avoid the subject, but your friend may benefit from a simple review of the details not just once, but as often as necessary.
- Provide companionship. Trauma victims may become isolated unless they're forced to stay in touch with people.
- Encourage activity. Physical exercise, work and daily routines can all help restore feelings of order and control. When the victim is strong enough, help him return to the activity that triggered the trauma, such as driving after a motor vehicle accident or going back to the scene of assault or robbery.
- Promote prevention. Help develop feelings of confidence and mastery to replace helplessness. For example, people can take safe driving courses or self defense classes to help them avoid recurrent events.
- Encourage professional help. It's the emotional equivalent of calling 911, but it's a lot harder for some people to do. Still, professional help from a trained counselor or physician can be very beneficial. And people who need help the most may be unable to accept it without support.
Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.