PTSD

Taken from Matthew van den Steen's research assignment

A definition

A ‘Post-Traumatic Stress Disorder’ is considered one of the twelve different types of anxiety disorders. Hence, before giving the definition of a PTSD, it is useful to look at the characteristics of an ‘anxiety disorder’ first.

According to DSM-IV [5] a generalized anxiety disorder is characterized by:

• anxiety occurring persistently

• excessive and hard to control worry

• feelings of uneasiness.

Anxiety and feelings of uneasiness are normal human reactions when someone is in a stressful situation. Sometimes anxiety even results in better performance [6]. However, when this feeling becomes excessive and influences a person’s lifestyle, it is, like most other mental disturbances, considered a disorder. A very noticeable change in one’s lifestyle is the avoidance of certain activities, people and places [5].

This definition covers anxiety disorders in general. DSM-IV provides the following description for a PTSD:

“Posttraumatic Stress disorder is characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma.” [5]

This definition already specifies certain symptoms which make a PTSD different compared to other (anxiety) disorders. Symptoms of a PTSD can be distinguished by three different symptom clusters [1]. Each cluster is related to one of the following:

• Re-experiencing

• Avoidance

• Arousal

These symptoms occur after the person has been exposed to a specific kind of stressor. However, not everyone will experience these symptoms immediately after the event. In many cases the symptoms occur days or even months after the stressor. What are the criteria for these symptoms and what is considered a traumatic event? Also, in which ways does the person re-experience these events over and over again?

Criteria

The traumatic event or ‘stressor’ has to be of an extreme nature [1]. Of course this statement is somewhat subjective, as one person is able to handle a specific stressor while others can not. Also, not everybody who experiences a traumatic event will react the same way [1, 5]. The stressor is usually of human design (kidnapping, terrorist attack, personal assault, etc.), but also exposure to natural disasters (volcano eruption, tsunami) can result in a PTSD. In both cases it is clear that these kinds of events are outside the bounds of “normal”, everyday experiences. The stressors mentioned here all have one thing in common: they can pose a serious threat to one’s life or environment. DSM-IV [5] specifies these traumatic stressors as one of the criterion of PTSD. The stressor must suit at least one of the following:

• Experience of an event which involves a serious injury or actual or threatened death.

• Witnessing an event involving death or injury of other persons.

• Learning or hearing about unexpected or violent death, harm, threat of death or injury by a family member or close relative.

This criterion is only concerned with the possible cause of a PTSD. Not everyone will develop a PTSD when confronted with one of the above mentioned stressors. Therefore more criteria are needed to cover the response and possible symptoms following a traumatic event.

DSM-IV [5] states that a person’s response to a stressor must involve fear, helplessness or horror. Next to this response, people who have developed a PTSD also experience certain symptoms related to the trauma. One such a symptom is the persistent re-experiencing of the stressor, as mentioned in the definition of a PTSD. There are various ways this symptom can occur. DSM-IV describes these as a new criterion:

• Recurrent recollections of the event. This includes thoughts, perceptions and images. Not only when the person is awake, but also when the person is asleep.

• The person feels or thinks as if the traumatic event recurs.

• The person is distressed when exposed to various stimuli related to the traumatic event.

• Physiological reactivity on exposure to the stimuli mentioned in the previous criterion.

Strongly related to this symptom is the persistent avoidance of specific stimuli. Of course the avoidance must occur after the exposure of the stressor. DSM-IV [5] states that avoidance is one of the criteria related to PTSD and that at least three of the following indicators should be true.

• Avoidance of feelings, thoughts or conversations associated to the trauma

• Avoidance of activities, places or people which may trigger recollections of the trauma

• The inability to recall an important part of the traumatic event

• Lost interest in certain activities

• Feelings of detachment from friends or family members

• Limited experience of feeling or emotion

• Only thinking about the near future

Another important symptom and criterion is the increase of arousal of a person. This may lead to difficulties sleeping and concentrating. The increased arousal can also lead to sudden outbursts of anger and hyper vigilance [5]. The duration of these symptoms, including the re-experiencing and avoidance of the stressor, must be longer than one month.

Fear structure and emotional processing theory

Some of the treatments which will be described in the next chapter, such as imaginal exposure, are strongly related to the emotional processing theory by Foa and Kozak [7]. This theory states that patients with a PTSD have developed so-called ‘fear structures’ consisting of information about:

• Stimuli associated with a traumatic event

• (Their) behavioural responses

• Meaning representations

The stimuli were already mentioned in the previous paragraph. People exposed to a stressor will remember facts about associated stimuli. For example a vehicle that exploded after it hits another car or seeing a comrade die by a mine.

Not only information about the stimuli is remembered but also facts about the behavioural response of the person at that time. For example a racing heart beat and perspiration.

And the last aspect is information about the meaning representation of the traumatic event. The meaning representation of a certain event can, of course, differ from person to person. The representation is strongly related to the stressors and criteria mentioned in the first part of the previous paragraph. One can, for example, associate an explosion to death or death of relatives.

Some treatments are based on activation of this fear structure using repeated exposure and adding new learning elements while anxiety is reduced [7, 8]. Studies [8] have shown that there is a correlation between activation of this fear structure and improvement in treatment. The treatments related to this theory will be discussed in detail in the next chapter.

Problems and statistics

Avoiding certain places or people to circumvent stimuli associated to a traumatic event can change the way a person lives. Not only changes in situations which can occur in public, but also the lack of concentration, sleep and the lost of interest may pose problems. It is possible that a traumatic event can cause feelings of guilt, which can lead to, for example, a depression disorder. Also various other disorders can take place as an effect of the different lifestyle. An example is the development of a social phobia or panic disorder [1, 5].

War is known for its high rates of potential traumatic events. Fire fights, terrorist attacks, losing comrades and taking care of dead bodies are only some of the events a soldier can experience during war. A study [9] among ‘Operation Iraqi Freedom’ veterans showed that PTSD symptoms affected up to 18% of the returning soldiers. Another study [10], also concerned with returning soldiers from Iraq, has shown that over 66% of the soldiers were at least exposed to potential stressors. In the same study it is said that almost 17% of active duty soldiers and over 24% of reserve soldiers screened positive for PTSD. When soldiers or other military personnel get deployed multiple times, the chances of developing a PTSD even get 1.5 times higher [11].

Currently 18% of the American (adult) population suffers from some form of anxiety disorder [12]. Of this group about 8% has a particular PTSD. Studies [13] have shown that a huge amount of people do not seek treatment. Unless the disorder causes drastic changes in their lifestyle such that it causes huge amounts of hardship, people tend to rather avoid the various stimuli than seek for appropriate treatment [1].

One of the reasons mentioned in a study among Iraqi veterans [9] is the stigmatization attached to the treatment. People may be afraid to lose their jobs when their boss finds out about their problems, or they are afraid others might think different of them.

Several new methods to treat people with a PTSD are being developed to deal with these kinds of problems. The previous mentioned paper states that the use of Virtual Reality as a post-combat exercise can be a good option for returning soldiers. The attitude among soldiers towards Virtual Reality exposure is different compared to other more standard types of treatment. Virtual Reality through a network or letting patients finish (writing) assignments or exercises at home through the internet may be other possible options for treatment.

References

1. Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

2. Harvey, A.G., R.A. Bryant, and N. Tarrier, Cognitive behaviour therapy for posttraumatic stress disorder. Clinical Psychology Review, 2003. 23(3): p. 501-522.

3. Bush, J., Viability of virtual reality exposure therapy as a treatment alternative. Computers in Human Behavior, 2008. 24(3): p. 1032-1040.

4. Difede, J., et al., Virtual reality exposure therapy for the treatment of Posttraumatic stress disorder following September 11, 2001. Journal of Clinical Psychiatry, 2007. 68(11): p. 1639-1647.

5. AmericanPsychiatricAssociation, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 1995.

6. Raudis, S. and V. Yustitskis, The Yerkes-Dodson law: The link between stimulation and learning success. Voprosy Psikhologii, 2008(3): p. 119-+.

7. Foa, E.B. and M.J. Kozak, EMOTIONAL PROCESSING OF FEAR - EXPOSURE TO CORRECTIVE INFORMATION. Psychological Bulletin, 1986. 99(1): p. 20-35.

8. Foa, E.B., et al., THE IMPACT OF FEAR ACTIVATION AND ANGER ON THE EFFICACY OF EXPOSURE TREATMENT FOR POSTTRAUMATIC-STRESS-DISORDER. Behavior Therapy, 1995. 26(3): p. 487-499.

9. Hoge, C.W., et al., Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 2004. 351(1): p. 13-22.

10. Milliken, C.S., J.L. Auchterlonie, and C.W. Hoge, Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Jama-Journal of the American Medical Association, 2007. 298(18): p. 2141-2148.

11. IV, M., Operation Iraqi Freedom 05-07. 2006, Washington DC.

12. Health, N.I.o.M., Anxiety disorders. 2006.

13. Garcia-Palacios, A., et al., Virtual reality in the treatment of spider phobia: a controlled study. Behaviour Research and Therapy, 2002. 40(9): p. 983-993.