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Post-traumatic stress disorder
Specialty	Psychiatry, clinical psychology

Posttraumatic stress disorder (PTSD) is an anxiety disorder that can develop after exposure to one or more terrifying events in which grave physical harm occurred or was threatened. It is a severe and ongoing emotional reaction to an extreme psychological trauma. This stressor may involve someone's actual death or a threat to the patient's or someone else's life, serious physical injury, or threat to physical and/or psychological integrity, to a degree that usual psychological defenses are incapable of coping.

PTSD is a condition distinct from Traumatic stress, which is of less intensity and duration, and combat stress reaction, which is transitory. PTSD has also been recognized in the past as shell shock, traumatic war neurosis, or post-traumatic stress syndrome (PTSS).

Causes

PTSD is believed to be caused by psychological trauma. Possible sources of trauma includes experiencing or witnessing childhood or adult physical, emotional, or sexual abuse, or prolonged or extreme childhood neglect. In addition, experiencing or witnessing an event perceived as life-threatening such as physical assault, adult experiences of sexual assault, accidents, illnesses, medical complications, or the experience of, or employment in occupations exposed to war (such as soldiers) or disaster (such as emergency service workers).

Mechanism

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. In addition, most PTSD also show a low secretion of cortisol and high secretion of catecholamine in urine and the norepinephrine/cortisol ratio is consequently higher than comparable non-diagnosed individuals. 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. Brain catecholamine levels are low, and corticotropin-releasing factor (CRF) concentrations are high. 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. 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. 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.

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. 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 and a review of existing studies on this subject showed no clear relation 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.

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 in comparison with veterans who suffered no such symptoms.

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.

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). 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.

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:

A. Exposure to a traumatic event

B. Persistent reexperience

C. Persistent avoidance of stimuli associated with the trauma

D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep or hypervigilance)

E. Duration of symptoms more than 1 month

F. Significant impairment in social, occupational, or other important areas of functioning

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%.

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. Cognitive therapy shows good results, and group therapy may be helpful in reducing isolation and social stigma. The psychotherapy programs with the strongest demonstrated efficacy are all cognitive behavioral programs and include variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and combinations of these procedures. 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.

Critical incident stress management

Early intervention after a traumatic incident, known as Critical Incident Stress Management (CISM) is often used 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. Six studies have formally looked at the effect of CISM, four finding that although patients and providers thought it was helpful, there was no benefit for preventing PTSD. Two other studies have indicated that CISM actually made things worse. 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.

Eye movement desensitization and reprocessing

Eye Movement Desensitization and Reprocessing (EMDR) is specifically targetted as a treatment for PTSD. 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.

Medication

Propranolol, a beta blocker which appears to 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.

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, and NaSSA's such as mirtazapine) or atypical antipsychotic drugs (such as quetiapine and olanzapine). Recently the anticonvulsant lamotrigine has been reported to be useful in treating some people with PTSD. The US Food and Drug Administration (FDA) recently approved a clinical protocol that combines the drug MDMA with talk therapy sessions.

Other techniques

Relationship based treatments are also often used. These, and other approaches, use attachment theory and an attachment model of treatment. In these cases, the treatment of complex trauma often requires a multi-modal approach.

Epidemiology

PTSD may be experienced following any traumatic experience, or series of experiences which 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.

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.

History

Earliest reports

Reports of battle-associated stress appear as early as the 6th century BC.

Although PTSD-like symptoms have also been recognized in combat veterans of many military conflicts since then, the modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by Vietnam veterans.

The term post-traumatic stress disorder or PTSD was created in the mid 1970s. Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders.

The term was formally recognised in 1980.

(In the Diagnostic and Statistical Manual of the American Psychiatric Association: DSM IV, which is normally considered authoritative, the spelling "posttraumatic stress disorder" is used. Elsewhere, however, "posttraumatic" is almost universally rendered as two words — "post-traumatic stress disorder" or "post traumatic stress disorder" — especially in less formal writing on the subject.)

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.

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..."

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.

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).

Canadian veterans

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

Cultural references

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 begun to engage the issue in their work. Many movies 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.

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. 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.

See also

• Acute stress reaction
• Complex post-traumatic stress disorder
• Dissociative disorders
• Emotional dysregulation
• Post-abduction syndrome
• Post-abortion syndrome
• Psychogenic amnesia
• Psychoneuroimmunology
• Survivor syndrome
• Trauma model of mental disorders

References

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3. National Institute of Mental Health, US National Institutes of Health
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7. Aardal-Eriksson E, Eriksson TE, Thorell LH (2001). "Salivary cortisol, posttraumatic stress symptoms, and general health in the acute phase and during 9-month follow-up". Biol. Psychiatry. 50 (12): 986–93. PMID 11750895.{{cite journal}}: CS1 maint: multiple names: authors list (link)
8. Lindley SE, Carlson EB, Benoit M (2004). "Basal and dexamethasone suppressed salivary cortisol concentrations in a community sample of patients with posttraumatic stress disorder". Biol. Psychiatry. 55 (9): 940–5. doi:10.1016/j.biopsych.2003.12.021. PMID 15110738.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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21. Schatzberg, Alan F. (2007). Manual of Clinical Psychopharmacology. American Psychiatric Pub, Inc. ISBN 1585623172. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
22. "Lamotrigine FAQ". Retrieved 2007-05-01.
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24. A preliminary study of lamotrigine for the treatment of posttraumatic stress disorder, Biol Psychiatry 1999 May 1;45(9):1226-9
25. MAPS FDA and IRB approved MDMA/PTSD protocol
26. Johnson, Susan. Emotionally Focused Couple Therapy with Trauma Survivors : Strengthening Attachment Bonds (Guilford Family Therapy Series). New York: The Guilford Press. ISBN 1-59385-165-0.
27. ^ When trauma tips you over: PTSD Part 1 All in the Mind, Australian Broadcasting Commission, 9 October 2004
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32. Mark Jarzombek, "The Post-traumatic Turn and the Art of Walid Ra'ad and Krzysztof Wodiczko: from Theory to Trope and Beyond," in Trauma and Visuality, Saltzman, Lisa and Eric Rosenberg, editors (University Press of New England, 2006)
33. Elizabeth Cowie, "Perceiving Memory and Tales of the Other: the work of Milica Tomic," Camera Austria, no. , pp. 14-16.

External links

• Template:Dmoz
• Carrot of Hope run by PTSD victims provides info on crisis, service animals, family support, medications and PTSD research. Nonprofit established in Arizona.
• Sidran Institute - Seeks to help people understand, manage, and treat trauma and dissociation.
• Sidran Institute's PTSD Alliance - a multi-disciplinary group of professional and advocacy organizations providing educational resources.
• DailyStrength online support group for PTSD.
• Blaming the Veteran: The Politics of Post-Traumatic Stress Disorder.
• PTSD Genetics
• Patience Press publishes books and literature about PTSD.

• Abnormal psychology
• Anxiety disorders
• Counseling
• Military personnel
• Stress
• Traumatology