Post-traumatic Stress Disorder

Original Editor - Samantha Sowder  from Bellarmine University's Pathophysiology of Complex Patient Problems project. Top Contributors - Samantha Sowder, Lucinda hampton, Kim Jackson, Admin, Abigail Litts, Aminat Abolade, Elaine Lonnemann, Naomi O'Reilly, WikiSysop, Wendy Walker, Colleen Baliga, Simisola Ajeyalemi, Amanda Ager and 127.0.0.1

Introduction

Post-traumatic Stress Disorder (PTSD) is an anxiety disorder characterised by psychological symptoms that continue to be experienced long after a traumatic event. Any physical or psychological trauma can trigger PTSD, but there is most often an involvement of actual or threatened serious injury to the person or someone close to them. The most common traumatic events leading to PTSD are combat, natural disasters, forced displacement, abuse and victimisation, including sexual assault and terrorism. The psychological pattern, characterised by persistent and chronic symptoms, that arise in certain individuals in response to such events define this disorder. The three primary symptoms of PTSD are:

• Recollections of the event
• Avoidance of stimuli
• Increased anxiety and irritability

Etiology

Anyone can develop PTSD following a traumatic event, but people are at greater risk if the event involved deliberate harm such as physical or sexual assault or they have had repeated traumatic experiences. eg childhood sexual abuse, living in a war zone, a near-death experience, combat-related trauma, interpersonal conflicts, sexual abuse or after a medical illness.

• Chronic PTSD occurs in patients who are unable to recover from the trauma due to maladaptive responses.
• The most commonly reported PTEs in the pediatric population include physical injuries, domestic violence, and natural disasters.
• Risk Factors - Apart from the event itself, risk factors for developing PTSD include: a past history of trauma or previous mental health problems; ongoing stressful life events after the trauma; an absence of social supports; gender (more prevalent in women); childhood adversities; low socioeconomic status; less education; the nature and the severity of the trauma.

Epidemiology

The prevalence of traumatic events in the lives of individuals ranges from 61% to 80%. After the trauma, PTSD occurs in approximately 5% to 10% of the population and is higher in women than in men. Studies have shown that the rates vary depending upon the specific population being considered.

Current estimates suggest 10% of children less than 18 years of age are diagnosed with PTSD, with girls four times more likely than boys to develop it

Around 12 per cent of Australians will experience PTSD in their lifetime. Serious accidents are one of the leading causes of PTSD in Australia

Rape is the type of trauma most commonly associated with PTSD. Conservative estimates of the number of women raped during the Bosnian war are between 20,000 and 50,000. Estimates of sexual assault rates range from 3% to 6% in Bosnian refugee women, and posttraumatic stress symptoms were found in up to 75% of Bosnian refugees. In Darfur, rates of rape are difficult to establish; however, some estimate that 10,000 girls and women have been raped each year since 2003.

Characteristics

People with PTSD often experience feelings of panic or extreme fear, similar to the fear they felt during the traumatic event. A person with PTSD experiences four main types of difficulties.

• Re-living the traumatic event – The person relives the event through unwanted and recurring memories, often in the form of vivid images and nightmares. There may be intense emotional or physical reactions, such as sweating, heart palpitations or panic when reminded of the event.
• Being overly alert or wound up – The person experiences sleeping difficulties, irritability and lack of concentration, becoming easily startled and constantly on the lookout for signs of danger.
• Avoiding reminders of the event – The person deliberately avoids activities, places, people, thoughts or feelings associated with the event because they bring back painful memories.
• Feeling emotionally numb – The person loses interest in day-to-day activities, feels cut off and detached from friends and family, or feels emotionally flat and numb.

Children and adolescents may have other signs and symptoms than those described above:

• New/unusual bedwetting
• Inability to talk
• Acting out traumatic events during playtime
• Heightened need for attention
• Extreme dependence on parent/adult
• Extreme disruptive behaviors
• Lack of guilt in not preventing harm to others

Associated Co-morbidities 

Research shows that at least 83% of persons in the general population with PTSD have at least one other mental health diagnosis with 16% having one, 17% having two, and 50% having three or more. The following are the co-morbidities most commonly seen in patients with PTSD:

• Substance Abuse
• Depression
• Suicidal Tendencies
• Panic Disorder
• Generalized Anxiety Disorder

The traumatic events that result in the development of PTSD may also result in physical trauma

Diagnostic Tests

The DSM-V criteria for diagnosis of PTSD: Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms; the seventh assesses functioning; and, the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition. Criterion A: Stressor The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence via direct exposure, witnessing, indirectly, or repeated exposure. Criterion B: Intrusion Symptoms The traumatic event is persistently re-experienced in one of the following ways: recurrent memories, traumatic nightmares, dissociative reactions (flashbacks), prolonged distress, or marked physiologic reactivity. Criterion C: Avoidance Persistent effortful avoidance of distressing trauma related stimuli after the event via thoughts/feelings or external reminders. Criterion D: Negative Alterations in Cognition and Mood Negative alterations in cognitions and mood that began or worsened after the traumatic event in two of the following ways: dissociative amnesia, persistent negative beliefs, persistent distorted blame, persistent negative trauma related emotions, markedly diminished interest in significant activities, feeling alienated from others, or constrictive affect. Criterion E: Alterations in Arousal and Reactivity Trauma related alterations in arousal and reactivity that began or worsened after the traumatic event in two of the following ways: irritable or aggressive behavior, self-destructive or reckless behavior, hypervigilance, exaggerated startle response, problems in concentration, or sleep disturbances. Criterion F: Duration Persistence of symptoms (in Criteria B, C, D, and E) for more than one month. Criterion G: Functional Significance Significant symptom related distress or functional impairment (e.g. social, occupational). Criterion H: Exclusion Disturbance is not due to medication, substance use, or other illness.

Increased arousal may be measured through studies of autonomic functioning such as heart rate, electromyography, and sweat gland activity.

Complications

Posttraumatic stress disorder has a devastating impact on those suffering and their families. Psychiatric and medical comorbidities are common with PTSD such as:

• Mood disorders
• Anxiety and panic disorders
• Neurological disorders including dementia
• Substance abuse disorder

Patients with PTSD are associated with substantial disability, and the presence of comorbidities can cause the chronicity of the condition. Studies have shown that 51.9% of men with PTSD concomitantly abuse alcohol and have reported early age of onset of alcohol dependence, increased cravings, and legal problems owing to alcohol abuse. There is an overall increased risk of suicide ideation and attempts. Dementia may also occur due to traumatic injury or alterations in the functioning of the brain.

Research shows that people with PTSD are at an increased risk of developing diseases of the nervous system, circulatory systems, digestive system, musculoskeletal system, and ill-defined conditions. Furthermore, veterans with PTSD have a higher prevalence of physical illnesses in these areas when compared to veterans without PTSD. 

Treatment

We have come a long way in improving treatments for PTSD and now have a large body of research evidence to guide our decisions.

The most effective treatment is trauma-focused psychological therapy. There are a few different forms, including cognitive behavioural therapies (CBT), as well as something called eye movement desensitisation and reprocessing (EMDR). The thing they share in common is providing the survivor with an opportunity to confront the painful memories, and to “work through” the experience in a safe and controlled environment. This therapy is not easy for either the patient or the therapist, but it is very effective in most cases.

Selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) are the first-line drug of choice for the treatment of PTSD. However, their efficacy in children and adolescents is still to be proven. Insomnia is common in patients with PTSD, which may be treated by educating the patient regarding following adequate sleep hygiene.

Physiotherapy Management 

A physiotherapist is not involved in the primary treatment of PTSD. However, patients with PTSD may have experienced an injury during their traumatic event, i.e. military personnel, emergency personnel, first responders, etc, who need physiotherapy interventions. Acknowledging that the development of PTSD can occur quickly, or with a delayed onset, understanding the associated risk factors, and recognizing signs and symptoms allows for physiotherapists to better address the needs of their patients. A patient exhibiting warning signs of PTSD may indicate the need for onward referral to a mental health professional. Also, collaboration with mental health professionals may be necessary to ensure the highest quality of care for these patients.

Treating a patient who presents with a co-morbidity of PTSD, or who is exhibiting signs and symptoms of the disorder, may pose challenges throughout the course of therapy. Challenges may include patient’s response to treatment, patient's relationship with the physiotherapist, compliance, fear of symptoms, etc.

“Clinically, it could be hypothesized that exposing patients with PTSD to the physiological symptoms they fear, such as rapid heart rate, in the context of physical activity increases tolerance for such symptoms. This repeated exposure may reinforce that the feared physiological sensations may be uncomfortable, but do not pose a serious threat and consequently could facilitate habituation.” One study found that yoga intervention in women with PTSD improved exercise motivation. Aquatic therapy can be an effective intervention in patients with PTSD based on the similar sensory deficits as children with sensory integration disorder, but further research is needed to determine its effectiveness. Having a list of resources related to PTSD available in the physiotherapy setting may also be beneficial.

Differential Diagnosis

Other disorders besides PTSD can present with the same symptoms and be triggered by a traumatic event. In addition, all of the following may exist simultaneously with PTSD.

• Depression - Predominantly Low Mood
• Generalized Anxiety Disorder; Mimics symptoms of hyperarousal
• Specific Phobias i.e. agoraphobia
• Dissociative Disorders; Involve breakdown of memory, awareness, identity, or perception
• Psychosis i.e. hallucinations, delusions, etc.
• Personality Disorder; Changes in personality traits with prolonged extreme stressor
• Adjustment Disorder; Less severe stressor with different pattern of symptoms
• Obsessive Compulsive Disorder; Any repetitive or intruding thoughts that are not related to trauma
• Panic Disorder; Anxiety attacks are not a result of re-living trauma
  

Case Reports

• PTSD and Early Childhood Trauma [17][18][16][16][16][15][15][15][14][14][15][15]
• PTSD treatment in Battered Women
• Virtual Reality Exposure Therapy for Vietnam Veterans
• PTSD Treatment Cochrane Review [20][15][13][14][14][18][18][18][17][17][18][18]

Resources

• National Institute of Mental Health: PTSD
• Medline Plus: PTSD
• National Center For PTSD: US Department of Veterans Affairs
• Gift from Within: Non-profit Organization

References

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