Post-traumatic stress disorder

Definition

Post-traumatic stress disorder (PTSD) is a debilitating psychological condition trigged by a traumatic event, such as rape, war, a terrorist act, sudden or violent death of a loved one, natural disaster, or catastrophic accident. It is marked by recurring memories or thoughts of the event, "blunting" of emotions, increased arousal, and sometimes severe personality changes.

Description

Officially termed post-traumatic stress disorder since 1980, descriptions of post-traumatic stress were documented as early as the Civil War and in nineteenth century train crash victims. In the period between World War I and II, a condition known as "shell shock" or "battle fatigue" was recognized. Initially, it was thought that shrapnel entered the brain during battle explosions and caused small brain hemorrhages. When symptoms occurred in war veterans who had not been exposed to explosions, it was then often viewed as a character flaw.

In the 1970s, during and after the Vietnam War, post-traumatic stress received more serious research and documentation. In 1989, the National Center for Post-traumatic Stress Disorder was established in the U.S. Department of Veterans Affairs. Another benchmark was its addition to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) published by the American Psychiatric Association. In the past 20 years, those who have been diagnosed with PTSD have been rape victims, victims of violent crimes, and survivors of natural disasters, terrorist attacks, and random shootings in schools and the workplace.

Although people of all ages, cultures, and socioeconomic backgrounds can develop PTSD if exposed to a life-threatening event, statistics gathered from past events indicate that the risk of PTSD increases in order of the following factors:

• female gender
• middle-aged (40 to 60 years old)
• little or no experience coping with traumatic events
• ethnic minority
• lower socioeconomic status
• children in the home
• women with spouses exhibiting PTSD symptoms
• pre-existing psychiatric conditions
• primary exposure to the event including injury, life-threatening situation, and loss
• living in a traumatized community

For example, over a third of the survivors of the 1995 Murrah Federal Building bombing in Oklahoma City developed PTSD and over half showed signs of anxiety, depression , and alcohol abuse. More than a year later, Oklahomans in general had an increased use of alcohol and tobacco products, as well as PTSD symptoms.

Children are also susceptible to PTSD and their risk is increased exponentially as their exposure to the event increases. Children experiencing abuse, the death of a parent, or those located in a community suffering a traumatic event can develop PTSD. Two years after the Oklahoma City bombing, 16% of children in a 100-mile radius of Oklahoma City with no direct exposure to the bombing had increased symptoms of PTSD. Weak parental response to the event, having a parent suffering from PTSD, and increased exposure to the event via the media all increase the possibility of the child developing PTSD symptoms.

Causes & symptoms

Specific causes for the onset of post-traumatic stress disorder are not clearly defined, although experts suspect it may be influenced both by the severity of the event, by the person's personality and genetic make-up, and by whether or not the event was expected. First response emergency personnel and those directly involved in the event or families who have lost loved ones in the event are most like to experience PTSD.

People exposed to mass destruction or death, toxic contamination, the sudden or violent death of a loved

one, or the loss of home or community, are also at high risk for PTSD. Victims of human-caused trauma have a higher incidence of PTSD than those of natural disasters. Among rape and Holocaust survivors, the rate of PTSD is 50%.

A sampling of the types of traumatic events and the percentage of those exposed to them who develop PTSD includes:

• natural disaster, 4–5%
• mass shooting, 28%
• plane crash into hotel, 29%
• bombing, 34%

For men, events most likely to trigger PTSD are rape, combat exposure, childhood neglect, and childhood physical abuse. For women, these events are rape, sexual molestation, physical attack, threat with a weapon, and childhood physical abuse.

A related condition, Acute Stress Disorder (ASD), which occurs two days to four weeks after a traumatic event, is thought to be an indicator of the occurrence of PTSD. This is especially true if the following factors are present:

• lack of emotional and social support
• the presence of other stressors such as fatigue , cold, hunger, fear, uncertainty, and loss
• continued difficulties at the scene of the event
• lack of information about the event
• lack of self-determination
• treatment given in an authoritarian or impersonal manner
• lack of follow-up

PTSD symptoms are distinct and prolonged stress reactions that naturally occur during a highly stressful event. Common symptoms are:

• hyperalertness
• fear and anxiety
• nightmares and flashbacks
• sight, sound, and smell recollection
• avoidance of recall situations
• anger and irritability
• guilt
• depression
• increased substance abuse
• negative world view
• decreased sexual activity

Symptoms usually begin within three months of the trauma, although sometimes PTSD does not develop until years after the initial trauma occurred. Once the symptoms begin, they may fade away again within six months. Others suffer with the symptoms for far longer and in some cases, the problem may become chronic.

Among the most troubling symptoms of PTSD are flashbacks, which can be triggered by sounds, smells, feelings, or images. During a flashback, the person relives the traumatic event and may completely lose touch with reality, suffering through the trauma for minutes or hours at a time, believing that the traumatizing event is actually happening all over again.

Research conducted in the late 20th century suggests that PTSD sufferers undergo neurological and physiological changes stemming from altered brain activity. A decrease in size of the hippocampus (one of two seahorse-shaped parts of the brain generally believed by scientists to pay an essential role in formation of new memories) may affect the processing and integration of memory while abnormal activation of the amygdala (almondshaped parts of the brain believed to have strong connections to mental and physical reactions) may be tied to fear response. This altered brain activity can lead to hyper-arousal of the sympathetic nervous system, increased sensitivity of the startle reflex, and sleep abnormalities.

The hormone levels of PTSD patients may also show abnormalities: for example, high levels of thyroid, epinephrine, and natural opiates coupled with low levels of cortisol. Blunted, or depressed, responses to a trauma may be the result of the body's increased production of opiates (narcotic-like hormones that induce mental lethargy), which masks the emotional pain .

People with post traumatic stress disorder are also like to suffer from other psychiatric disorders. Eighty-eight percent of men and 79% of women with PTSD meet the diagnostic criteria for other disorders. Physical ailments such as headaches, gastrointestinal ailments, immune system weaknesses, dizziness , chest pain, and general body discomfort are also common in PTSD sufferers.

Diagnosis

Consultation with a mental health professional for diagnosis and a plan of treatment is always advised. Many of the responses to trauma, such as shock, terror, irritability, blame, guilt, grief, sadness, emotional numbing, and feelings of helplessness, are natural reactions. For most people, resilience is an overriding factor and trauma effects diminish within six to sixteen months. It is when these responses continue or become debilitating that PTSD is often diagnosed. The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) outlined three forms of the disorder:

• Acute: onset within six months of the event and lasting less than six months
• Chronic: symptoms lasting six months or more
• Delayed: onset at least six months after the event

As outlined in DSM-IV, the exposure to a traumatic stressor means that an individual experienced, witnessed or was confronted by an event or events involving death or threat of death, serious injury or the threat of bodily harm to oneself or others. The individual's response must involve intense fear, helplessness, or horror. A two-pronged approach to evaluation is considered the best way to make a valid diagnosis because it can gauge under-reporting or over-reporting of symptoms. The two primary forms are structured interviews and self-report questionnaires. Spouses, partners and other family members may be interviewed. Because the evaluation may involve subtle reminders of the trauma in order to gauge a patient's reactions, individuals should ask for a full description of the evaluation process beforehand. Asking what results can be expected from the evaluation is also advised.

A number of structured interview forms have been devised to facilitate the diagnosis of post traumatic stress disorder:

• The Clinician Administered PTSD Scale (CAPS) developed by the National Center for PTSD
• The Structured Clinical Interview for DSM (SCID)
• Anxiety Disorders Interview Schedule-Revised (ADIS)
• PTSD-Interview
• Structured Interview for PTSD (SI-PTSD)
• PTSD Symptom Scale Interview (PSS-I)

Self-reporting checklists provide scores to represent the level of stress experienced. Some of the most commonly used checklists are:

• The PTSD Checklist (PCL), which has one list for civilians and one for military personnel and veterans
• Impact of Event Scale-Revised (IES-R)
• Keane PTSD Scale of the MMPI-2
• The Mississippi Scale for Combat Related PTSD and the Mississippi Scale for Civilians
• The Post Traumatic Diagnostic Scale (PDS)
• The Penn Inventory for Post-Traumatic Stress
• Los Angeles Symptom Checklist (LASC)

Treatment

A definitive treatment does not yet exist for PTSD nor is there a known cure. However, a number of therapies such as cognitive-behavior therapy, group therapy, and exposure therapy are showing promise. Cognitive-behavioral therapy focuses on changing specific actions and thoughts with the help of relaxation training and breathing techniques. In exposure therapy, the person relives the traumatic event repeatedly in a controlled environment and then works through the trauma.

A treatment technique known as eye movement desensitization and reprocessing (EMDR) has been employed with some success to treat PTSD. EMDR involves desensitizing the patient to his or her traumatic memories by associating a series of eye movements with both negative and positive events and emotions. The specific eye movements associated with the negative memories are thought to help the brain process the event and come to terms with the trauma. EDMR should only be performed by a healthcare practitioner, usually a clinical psychologist, certified in the technique.

Relaxation training, which is sometimes called anxiety management training, includes breathing exercises and similar techniques intended to help the patient prevent hyperventilation and relieve the muscle tension associated with the fight-or-flight reaction of anxiety. Yoga, aikido, t'ai chi, and dance therapy help patients work with the physical as well as the emotional tensions that either promote anxiety or are created by the anxiety.

Other alternative or complementary therapies are based on physiological and/or energetic understanding of how the trauma is imprinted in the body. These therapies affect a release of stored emotions and resolution of them by working with the body rather than merely talking through the experience. One example of such a therapy is Somatic Experiencing (SE), developed by Dr. Peter Levine. SE is a short-term, biological, body-oriented approach to PTSD or other trauma. This approach heals by emphasizing physiological and emotional responses, without re-traumatizing the person, without placing the person on medication, and without the long hours of conventional therapy.

When used in conjunction with therapies that address the underlying cause of PTSD, relaxation therapies such as hydrotherapy, massage therapy, and aromatherapy are useful to some patients in easing PTSD symptoms. Essential oils of lavender, chamomile , neroli, sweet marjoram, and ylang-ylang are commonly recommended by aromatherapists for stress relief and anxietyreduction.

Research into the prevention of PTSD is also undergoing intensive research. The National Mental Health Association provides RAPID grants that allow researchers to visit disaster scenes to study acute effects and the effectiveness of early intervention. Rapid disaster relief and positive community response appear to be key. Not identifying individual survivors as "victims" also seems to help. Debriefing survivors as quickly as possible after the event can stem the development of PTSD symptoms.

Allopathic treatment

As of mid-2004, allopathic (medical practice that combats disease with remedies to produce effects different from those produced by the disease) treatment consists of a combination of medication along with supportive and cognitive-behavioral therapies. Effective medications include anxiety-reducing medications and antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft). In 2001, the U.S. Food and Drug Administration (FDA) approved Zoloft as a long-term treatment for PTSD. In a controlled study, Zoloft was effective in safely improving symptoms of PTSD over a period of 28 weeks and reducing the risk of relapse. Sleep problems can be lessened by brief treatment with an anti-anxiety drug such as a benzodiazepine like alprazolam (Xanax). However, long-tem use of these drugs can lead to disturbing side effects, such as increased anger. The new research into the biological changes manifested in PTSD patients is leading to additional research on drugs used to monitor hormone levels and brain activity.

Expected results

With appropriate medication, emotional support, and counseling, most people show significant improvement. Behavior therapies can help reduce negative thought patterns and self talk. The patient typically moves back and forth through three recovery phases:

• Phase One, Safety: the elimination and/or management of dangerous behaviors and/or relationships. Becoming less fearful of thoughts, feelings, and dissociative (separated from the main stream of consciousness) episodes
• Phase Two: resolution of traumatic memory processing. Developing a narrative account of the trauma without becoming re-traumatized
• Phase Three: personality re-integration and rehabilitation

Successful treatment depends in part on whether or not the trauma was unexpected, the severity of the trauma, if the trauma was chronic (such as for victims of sexual abuse), and the person's inherent personality and genetic makeup. However, prolonged exposure to severe trauma such as experienced by victims of prolonged physical or sexual abuse and survivors of the Holocaust may cause permanent psychological scars.

Resources

BOOKS

Knaster, Mirka. Discovering the Body's Wisdom: A Guide to Exploring Bodyways. New York: Bantam Books, 1996.

Shapiro, Francine, Ph.D., and Margot Silk Forrest. The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma. New York: Basic Books, 1997.

PERIODICALS

DiGiovanni, C. "Domestic Terrorism with Chemical or Biological Agents: Psychiatric Aspects." American Journal of Psychiatry (1999): 1500 – 1505.

Kessler, R., et al. "Post-traumatic Stress Disorder in the National Comorbidity Survey." Archives of General Psychiatry (1996): 1048 – 1060.

North, C., S. Nixon, S. Hariat, S. Mallonee et al. "Psychiatric Disorders Among Survivors of the Oklahoma City Bombing." Journal of the American Medical Association (1999): 755 – 762.

Pfefferbaum, B., R. Gurwitch, N. McDonald et al. "Posttraumatic Stress Among Children After the Death of a Friend or Acquaintance in a Terrorist Bombing." Psychiatric Services (2000): 386 – 388.

"Sertraline HCI Approved for Long-Term Use." Women's Health Weekly (September 20, 2001).

Sloan, M. "Response to Media Coverage of Terrorism." Journal of Conflict Resolution (2000): 508 – 522.

Smith, D, E., Christiansen, R. Vincent, and N. Hann. "Population Effects of the Bombing of Oklahoma City." Journal of Oklahoma State Medical Association (1999): 193 – 198.

ORGANIZATIONS

American Psychiatric Association. 1000 Wilson Blvd., Ste. 1825, Arlington, VA 22209-3901. (703) 907-7300. http://www.psych.org.

Anxiety Disorders Association of America. 8730 Georgia Ave., Ste. 600, Silver Spring, MD 20910. (240) 485-1001. <http://www.adaa.org>.

Freedom From Fear. 308 Seaview Ave., Staten Island, NY 10305. (718) 351-1717. <http://www.freedomfromfear.com>.

International Society for Traumatic Stress Studies, 60 Revere Dr., Ste. 500, Northbrook, IL 60062. (847) 480-9028. <http://www.istss.org>.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166. <http://www.lexington-on-line.com>.

National Institute of Mental Health. 6001 Executive Blvd, Rm. 8184, MSC 9663, Bethesda, MD 20892. (866) 615-6464. <http://www.nimh.nih.org>.

National Mental Health Association. 2001 N. Beauregard St., 12th floor, Alexandria, VA 22311. (800) 969-NMHA. <http://www.nmha.org>.

OTHER

"Effects of Traumatic Stress in a Disaster Situation." National Center for PTSD. [cited May 2, 2004]. <http://www.ncptsd.org/facts/disasters/fs_effects_disaster.html>.

"How is PTSD Measured?" National Center for PTSD. [cited May 2, 2004]. <http://www.ncptsd.org/facts/treatment/fs/lay/assess.html>.

Mary McNulty

Post-Traumatic Stress Disorder

Definition

Description

Demographics

Causes and symptoms

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Post-traumatic stress disorder (PTSD) is a complex anxiety disorder that may occur when a person experiences or witnesses an event perceived as a threat and in which he or she experiences fear, terror, or helplessness. PTSD is sometimes summarized as “a normal reaction to abnormal events.”

Description

PTSD depends on a factor outside the individual, namely, a traumatic stressor. A patient cannot be given a diagnosis of PTSD unless he or she has been exposed to an event that is considered traumatic. These events include such obvious traumas as rape, military combat, torture, genocide, natural disasters, and transportation or workplace disasters. In addition, it is now recognized that repeated traumas or traumas of long duration as child abuse , domestic violence, stalking, cult membership, and hostage situations may also produce the symptoms of PTSD in survivors.

A person suffering from PTSD experiences flashbacks, nightmares, or daydreams in which the traumatic event is experienced again. The person may also experience abnormally intense startle responses, insomnia, and may have difficulty concentrating. Trauma survivors with PTSD have been effectively treated with group therapy or individual psychological therapy, and other therapies have helped individuals, as well. Some affected individuals have found support groups or peer counseling groups helpful. Treatment may require several years, and in some cases, PTSD may affect a person for the rest of his or her life.

Demographics

General United States population

PTSD is much more widespread in the general population than was thought when it was first introduced as a diagnostic category. The National Comor-bidity Survey, a major epidemiological study conducted between 1990 and 1992, estimates that the lifetime prevalence among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to be diagnosed with PTSD at some point in their lives. These figures represent only a small proportion of adults who have experienced at least one traumatic event—60.7% of men and 51.2% of women respectively. More than 10% of the men and 6% of the women reported experiencing four or more types of trauma in their lives. The most frequently mentioned traumas are:

• witnessing someone being badly hurt or killed
• involvement in a fire, flood, earthquake, severe hurricane, or other natural disaster
• involvement in a life-threatening accident (workplace explosion or transportation accident)
• military combat

The traumatic events most frequently mentioned by men diagnosed with PTSD are rape, combat exposure, childhood neglect, and childhood physical abuse. For women diagnosed with PTSD, the most common traumas are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.

High-risk populations

Some subpopulations in the United States are at greater risk of developing PTSD. The lifetime prevalence of PTSD among persons living in depressed urban areas or on Native American reservations is estimated at 23%. For victims of violent crimes, the estimated rate is 58%.

Military veterans

Information about PTSD in veterans of the Vietnam era is derived from the National Vietnam Veterans Readjustment Survey (NVVRS), conducted between 1986 and 1988. The estimated lifetime prevalence of PTSD among American veterans of this war is 30.9% for men and 26.9% for women. An additional 22.5% of the men and 21.2% of the women have been diagnosed with partial PTSD at some point in their lives. The lifetime prevalence of PTSD among veterans of World War II and the Korean War is estimated at 20%.

Cross-cultural issues

Further research needs to be done on the effects of ethnicity and culture on post-traumatic symptoms. As of 2001, most PTSD research has been done by Western clinicians working with patients from a similar background. Researchers do not yet know whether persons from non-Western societies have the same psychological reactions to specific traumas or whether they develop the same symptom patterns.

Causes and symptoms

Causes

When PTSD was first suggested as a diagnostic category for DSM-III in 1980, it was controversial precisely because of the central role of outside stres-sors as causes of the disorder. Psychiatry has generally emphasized the internal abnormalities of individuals as the source of mental disorders; prior to the 1970s, war veterans, rape victims, and other trauma survivors were often blamed for their symptoms and regarded as cowards, moral weaklings, or masochists. The high rate of psychiatric casualties among Vietnam veterans, however, led to studies conducted by the Veterans Administration. These studies helped to establish PTSD as a legitimate diagnostic entity with a complex set of causes.

BIOCHEMICAL/PHYSIOLOGICAL CAUSES

Present neu-robiological research indicates that traumatic events cause lasting changes in the human nervous system, including abnormal secretions of stress hormones. In addition, in PTSD patients, researchers have found changes in the amygdala and the hippocampus—the parts of the brain that form links between fear and memory. Experiments with ketamine, a drug that inactivates one of the neurotransmitter chemicals in the central nervous system, suggest that trauma works in a similar way to damage associative pathways in the brain. Positron emission tomography (PET) scans of PTSD patients suggest that trauma affects the parts of the brain that govern speech and language.

SOCIOCULTURAL CAUSES

Studies of specific populations of PTSD patients (combat veterans, survivors of rape or genocide, former political hostages or prisoners, etc.) have shed light on the social and cultural causes of PTSD. In general, societies that are highly authoritarian, glorify violence, or sexualize violence have high rates of PTSD even among civilians.

OCCUPATIONAL FACTORS

Persons whose work exposes them to traumatic events or who treat trauma survivors may develop secondary PTSD (also known as compassion fatigue or burnout). These occupations

include specialists in emergency medicine, police officers, firefighters, search-and-rescue personnel, psychotherapists, disaster investigators, etc. The degree of risk for PTSD is related to three factors: the amount and intensity of exposure to the suffering of trauma victims, the worker’s degree of empathy and sensitivity, and unresolved issues from the worker’s personal history.

PERSONAL VARIABLES

Although the most important causal factor in PTSD is the traumatic event itself, individuals differ in the intensity of their cognitive and emotional responses to trauma; some persons appear to be more vulnerable than others. In some cases, this greater vulnerability is related to temperament or natural disposition, with shy or introverted people being at greater risk. In other cases, the person’s vulnerability results from chronic illness, a physical disability, or previous traumatization—particularly abuse in childhood. As of 2007, researchers have not found any correlation between race and biological vulnerability to PTSD.

Symptoms

DSM-IV-TR specifies six diagnostic criteria for PTSD:

• Traumatic stressor: The patient has been exposed to a catastrophic event involving actual or threatened death or injury, or a threat to the physical integrity of the self or others. During exposure to the trauma, the person’s emotional response was marked by intense fear, feelings of helplessness, or horror. In general, stressors caused intentionally by human beings (genocide, rape, torture, abuse, etc.) are experienced as more traumatic than accidents, natural disasters, or “acts of God.”
• Intrusive symptoms: The patient experiences flashbacks, traumatic daydreams, or nightmares, in which he or she relives the trauma as if it were recurring in the present. Intrusive symptoms result from an abnormal process of memory formation. Traumatic memories have two distinctive characteristics: 1) they can be triggered by stimuli that remind the patient of the traumatic event; 2) they have a “frozen” or wordless quality, consisting of images and sensations rather than verbal descriptions.
• Avoidant symptoms: The patient attempts to reduce the possibility of exposure to anything that might trigger memories of the trauma, and to minimize his or her reactions to such memories. This cluster of symptoms includes feeling disconnected from other people, psychic numbing, and avoidance of places, persons, or things associated with the trauma. Patients with PTSD are at increased risk of substance abuse as a form of self-medication to numb painful memories.
• Hyperarousal: Hyperarousal is a condition in which the patient’s nervous system is always on “red alert” for the return of danger. This symptom cluster includes hypervigilance, insomnia, difficulty concentrating, general irritability, and an extreme startle response. Some clinicians think that this abnormally intense startle response may be the most characteristic symptom of PTSD.
• Duration of symptoms: The symptoms must persist for at least one month.
• Significance: The patient suffers from significant social, interpersonal, or work-related problems as a result of the PTSD symptoms. A common social symptom of PTSD is a feeling of disconnection from other people (including loved ones), from the larger society, and from spiritual or other significant sources of meaning.

Diagnosis

The diagnosis of PTSD is complicated by several factors.

Time of onset/symptom duration

In the case of a known trauma of recent occurrence— most often a civilian disaster or war—the diagnosis of PTSD is relatively straightforward, based on the criteria listed above.

DSM-IVintroduced a new diagnostic category, acute stress disorder, to differentiate between time-limited and longer-term stress reactions. In acute stress disorder, the hyperarousal and intrusive symptoms last between two days and four weeks. If the symptoms last beyond four weeks, and all of the above criteria are met, the diagnosis is changed to PTSD.

The diagnosis of PTSD is more difficult in cases of delayed reaction to trauma. Some individuals do not develop symptoms of PTSD until months or even years after the traumatic event. DSM-IV-TR specifies an interval of at least six months between the event and the development of symptoms for a diagnosis of PTSD With Delayed Onset. Delayed symptoms are often triggered by a situation that resembles the original trauma, as when a person raped in childhood experiences workplace sexual harassment.

Individual variations in response to stressors

DSM-IIIand its successors included the category of adjustment disorder to differentiate abnormal reactions

to such painful but relatively common life events (“ordinary stressors”) as divorce, job loss, or bereavement from symptoms resulting from overwhelming trauma. The differential diagnosis (the process of determining that the diagnosis is one disorder although it may resemble another) is complicated, however, by the fact that “ordinary stressors” sometimes reawaken unresolved childhood trauma, producing the delayed-reaction variant of PTSD.

Dual diagnoses

Most patients with PTSD (as many as 80%) have been diagnosed with one of the anxiety (30–60%), dissociative, mood (26–85%), or somatoform disorders as well as with PTSD. Between 40% and 60% of persons with delayed-reaction PTSD are diagnosed with a personality disorder, most often borderline personality disorder . Another common dual diagnosis is PTSD/substance abuse disorder. Between 60% and 80% of patients who develop PTSD turn to alcohol or narcotics in order to avoid or numb painful memories. According to the NVVRS, the estimated lifetime prevalence of alcohol abuse among male Vietnam veterans is 39.2%, and the estimated lifetime prevalence of drug abuse is 5.7%. Dual diagnoses complicate treatment because the therapist must decide whether to treat the disorders in sequence or concurrently. PTSD patients diagnosed with personality disorders are regarded as the most difficult to treat.

Psychological measures

As of 2007, there are no physical tests to establish a diagnosis of PTSD. The diagnosis is usually made on the basis of the patient’s history and results from one or more short-answer interviews or symptom inventories. The instruments most often used to evaluate patients for PTSD include the Anxiety Disorders Interview Scale (ADIS), the Beck Depression Inventory , the Clinician-Administered PTSD Scale (CAPS), the Disorders of Extreme Stress Inventory (DESI), the Dissociative Experiences Scale (DES), the Hamilton Anxiety Scale , and the Impact of Event Scale (IES).

Treatments

Psychological and social interventions

In general, there have been few well-controlled clinical trials of treatment options for PTSD, particularly for severely affected patients.

Critical incident stress debriefing (CISD) is a treatment offered to patients within 48 hours following a civilian disaster or war zone trauma. It is intended to weaken the acute symptoms of the trauma and to forestall the development of full-blown PTSD. CISD usually consists of four phases:

• description of the traumatic event
• sharing of survivors’ emotional reactions to the event
• open discussion of symptoms caused by the event
• reassurance that the symptoms are normal responses to trauma, followed by discussion of coping strategies

Critical incident stress management is a system of interventions designed to help emergency/disaster response workers, public safety personnel, and therapists deal with stress reactions before they develop secondary PTSD.

Other mainstream treatment methods used with patients who have already developed PTSD include:

• Cognitive-behavioral therapy. There are two treatment approaches to PTSD included under this heading: exposure therapy, which seeks to desensitize the patient to reminders of the trauma; and anxiety management training, which teaches the patient strategies for reducing anxiety. These strategies may include relaxation training, biofeedback, social skills training, distraction techniques, or cognitive restructuring.
• Psychodynamic psychotherapy. This method helps the patient recover a sense of self and learn new coping strategies and ways to deal with intense emotions related to the trauma. Typically, it consists of three phases: 1) establishing a sense of safety for the patient; 2) exploring the trauma itself in depth; 3) helping the patient re-establish connections with family, friends, the wider society, and other sources of meaning.
• Discussion groups or peer-counseling groups. These groups are usually formed for survivors of specific traumas, such as combat, rape/incest, and natural disasters. They help patients to recognize that other survivors of the shared experience have had the same emotions and reacted to the trauma in similar ways. They appear to be especially beneficial for patients with guilt issues about their behavior during the trauma (e.g., submitting to rape to save one’s life, or surviving the event when others did not).
• Family therapy. This form of treatment is recommended for PTSD patients whose family life has been affected by the PTSD symptoms.

Medications

In general, medications are used most often in patients with severe PTSD to treat the intrusive symptoms of the disorder as well as feelings of anxiety and depression . These drugs are usually given as one part of a treatment plan that includes psychotherapy or group

therapy. As of 2007, there is no single medication that appears to be a “magic bullet” for PTSD. The selective serotonin reuptake inhibitors (SSRIs ) appear to help the core symptoms when given in higher doses for five to eight weeks, while the tricyclic antidepressants (TCAs) or the monoamine oxidase inhibitors (MAOIs) are most useful in treating anxiety and depression.

Alternative therapies

Some alternative therapies for PTSD include:

• Spiritual/religious counseling. Because traumatic experiences often affect patients’ spiritual views and beliefs, counseling with a trusted religious or spiritual advisor may be part of a treatment plan. A growing number of pastoral counselors in the major Christian and Jewish bodies have advanced credentials in trauma therapy.
• Yoga and various forms of bodywork are often recommended as ways of releasing physical tension or muscle soreness caused by anxiety or hypervigilance.
• Martial arts training can be helpful in restoring the patient’s sense of personal effectiveness and safety. Some martial arts programs, such as Model Mugging, are designed especially for survivors of rape and other violent crimes.
• Art therapy, journaling, dance therapy, and creative writing groups offer safe outlets for the strong emotions that follow traumatic experiences.

Recent controversial therapies

Since the mid-1980s, several controversial methods of treatment for PTSD have been introduced. Some have been developed by mainstream medical researchers while others are derived from various forms of alternative medicine. They include:

• Eye Movement Desensitization and Reprocessing. This is a technique in which the patient reimagines the trauma while focusing visually on movements of the therapist’s finger. It is claimed that the movements of the patient’s eyes reprogram the brain and allow emotional healing.
• Tapas Acupressure Technique (TAT). TAT was derived from traditional Chinese medicine (TCM), and its practitioners maintain that a large number of acupuncture meridians enter the brain at certain points on the face, especially around the eyes. Pressure on these points is thought to release traumatic stress.
• Thought Field Therapy. This therapy combines the acupuncture meridians of TCM with analysis of the patient’s voice over the telephone. The therapist then provides an individualized treatment for the patient.
• Traumatic Incident Reduction. This is a technique in which the patient treats the trauma like a videotape and “runs through” it repeatedly with the therapist until all negative emotions have been discharged.
• Emotional Freedom Techniques (EFT). EFT is similar to TAT in that it uses the body’s acupuncture meridians, but it emphasizes the body’s entire “energy field” rather than just the face.
• Counting Technique. Developed by a physician, this treatment consists of a preparation phase, a counting phase in which the therapist counts from 1 to 100 while the patient reimagines the trauma, and a review phase. Like Traumatic Incident Reduction, it is intended to reduce the patient’s hyperarousal.

Prognosis

Trauma survivors who receive critical incident stress debriefing as soon as possible after the event have the best prognosis for full recovery. For patients who develop full-blown PTSD, a combination of peer-group meetings and individual psychotherapy are often effective. Treatment may require several years, however, and the patient is likely to experience relapses.

There are no studies of untreated PTSD, but long-term studies of patients with delayed-reaction PTSD or delayed diagnosis of the disorder indicate that treatment of patients in these groups is much more difficult and complicated.

In some patients, PTSD becomes a chronic mental disorder that can persist for decades, or the remainder of the patient’s life. Patients with chronic PTSD often have a cyclical history of symptom remissions and relapses. This group has the poorest prognosis for recovery; some patients do not respond to any of the currently available treatments for PTSD.

Prevention

Some forms of trauma, such as natural disasters and accidents, can never be completely eliminated from human life. Traumas caused by human intention would require major social changes to reduce their frequency and severity, but given the increasing prevalence of PTSD around the world, these long-term changes are worth the effort. In the short term, educating people— particularly those in the helping professions—about the signs of critical incident stress may prevent some cases of exposure to trauma from developing into fullblown PTSD.

See alsoAnxiety reduction techniques; Bodywork therapies; Creative therapies; Exposure; Somatization and somatoform disorders.

KEY TERMS

Acute stress disorder —Symptoms occurring in an individual following a traumatic event to oneself or surrounding environment. Symptoms include a continued response of intense fear, helplessness, or terror within four weeks of the event, extreme nervousness, sleep disorders, increased anxiety, poor concentration, absence of emotional response to surroundings, and sometimes a dissociative amnesia—not recalling the significance of the trauma. Symptoms last a minimum of two days and maximum of four weeks. Can become post-traumatic stress disorder.

Adjustment disorder —A disorder defined by the development of significant emotional or behavioral symptoms in response to a stressful event or series of events. Symptoms may include depressed mood, anxiety, and impairment of social and occupational functioning.

Borderline personality disorder —A severe and usually life-long mental disorder characterized by violent mood swings and severe difficulties in sustaining interpersonal relationships.

Somatoform —Referring to physical symptoms with a psychological origin.

Substance abuse disorder —Disorder that is characterized by: an individual’s need for more of a drug or alcohol than intended, an inability to stop using by choice, and an ongoing difficulty in recovering from the effects of the substance.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington D.C.: American Psychiatric Association, 2000.

Foa, Edna B., Terence M. Keane, & Matthew J. Friedman, eds. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York: The Guilford Press, 2004.

Freeman, Arthur, and others. Clinical Applicatoins of Cognitive Therapy. 2nd ed. New York: Kluwer Academic/Plenum Publishers, 2004.

Friedman, Matthew J. Post-traumatic and Acute Stress Disorders: The Latest Assessment and Treatment Strategies. Kansas City, MO: Compact Clinicals, 2005.

VandenBos, Gary R., ed. APA Dictionary of Psychology. Washington D.C.: American Psychological Association, 2007.

PERIODICALS

Declercq, Frédéric, and Jochem Willemsen. “Distress and Post-Traumatic Stress Disorders in High Risk Professionals: Adult Attachment Style and the Dimensions of Anxiety and Avoidance.” Clinical Psychology & Psychotherapy 13(4), Jul–Aug 2006: 256–63.

van Liempt, Saskia, and others. “Pharmacotherapy for Disordered Sleep in Post-Traumatic Stress Disorder: A Systematic Review.” International Clinical Psychopharmacology 21(4), July 2006: 193–202.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. http://www.psych.org

Anxiety Disorders Association of America, Inc. 11900 Par-klawn Drive, Suite 100, Rockville, MD 20852. (301) 231-9350. http://www.adaa.org

International Critical Incident Stress Foundation, Inc. 10176 Baltimore National Pike, Unit 201, Ellicott City, MD 21042. (410) 750-9600. Emergency: (410) 313-2473. http://www.icisf.org

International Society for Traumatic Stress Studies. 60 Revere Drive, Suite 500, Northbrook, IL 60062. (847) 480-9028. http://www.istss.org

National Center for PTSD. 1116D V.A. Medical Center, 215 N. Main Street, White River Junction, VT 05009-0001. (802) 296-5132. http://www.ncptsd.org

National Institute of Mental Health. 6001 Executive Boulevard, Rm. 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. http://www.nimh.nih.gov

Rebecca Frey, Ph.D.

Post-traumatic stress disorder

Definition

Post-traumatic stress disorder, often abbreviated as PTSD, is a complex disorder in which the affected person's memory, emotional responses, intellectual processes, and nervous system have all been disrupted by one or more traumatic experiences. It is sometimes summarized as "a normal reaction to abnormal events." The DSM-IV-TR (the professional's diagnostic manual) classifies PSTD as an anxiety disorder.

Description

PTSD has a unique position as the only psychiatric diagnosis (along with acute stress disorder ) that depends on a factor outside the individual, namely, a traumatic stressor. A patient cannot be given a diagnosis of PTSD unless he or she has been exposed to an event that is considered traumatic. These events include such obvious traumas as rape, military combat, torture, genocide, natural disasters, and transportation or workplace disasters. In addition, it is now recognized that repeated traumas or such traumas of long duration as child abuse , domestic violence, stalking, cult membership, and hostage situations may also produce the symptoms of PTSD in survivors.

A person suffering from PTSD experiences flashbacks, nightmares, or daydreams in which the traumatic event is experienced again. The person may also experience abnormally intense startle responses, insomnia , and may have difficulty concentrating. Trauma survivors with PTSD have been effectively treated with group therapy or individual psychological therapy, and other therapies have helped individuals, as well. Some affected individuals have found support groups or peer counseling groups helpful. Treatment may require several years, and in some cases, PTSD may affect a person for the rest of his or her life.

Demographics

General United States population

PTSD is much more widespread in the general population than was thought when it was first introduced as a diagnostic category. The National Comorbidity Survey, a major epidemiological study conducted between 1990 and 1992, estimates that the lifetime prevalence among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to be diagnosed with PTSD at some point in their lives. These figures represent only a small proportion of adults who have experienced at least one traumatic event—60.7% of men and 51.2% of women respectively. More than 10% of the men and 6% of the women reported experiencing four or more types of trauma in their lives. The most frequently mentioned traumas are:

• witnessing someone being badly hurt or killed
• involvement in a fire, flood, earthquake, severe hurricane, or other natural disaster
• involvement in a life-threatening accident (workplace explosion or transportation accident)
• military combat

The traumatic events most frequently mentioned by men diagnosed with PTSD are rape, combat exposure, childhood neglect , and childhood physical abuse. For women diagnosed with PTSD, the most common traumas are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.

High-risk populations

Some subpopulations in the United States are at greater risk of developing PTSD. The lifetime prevalence of PTSD among persons living in depressed urban areas or on Native American reservations is estimated at 23%. For victims of violent crimes, the estimated rate is 58%.

Military veterans

Information about PTSD in veterans of the Vietnam era is derived from the National Vietnam Veterans Readjustment Survey (NVVRS), conducted between 1986 and 1988. The estimated lifetime prevalence of PTSD among American veterans of this war is 30.9% for men and 26.9% for women. An additional 22.5% of the men and 21.2% of the women have been diagnosed with partial PTSD at some point in their lives. The lifetime prevalence of PTSD among veterans of World War II and the Korean War is estimated at 20%.

Cross-cultural issues

Further research needs to be done on the effects of ethnicity and culture on post-traumatic symptoms. As of 2001, most PTSD research has been done by Western clinicians working with patients from a similar background. Researchers do not yet know whether persons from non-Western societies have the same psychological reactions to specific traumas or whether they develop the same symptom patterns.

Causes and symptoms

Causes

When PTSD was first suggested as a diagnostic category for DSM-III in 1980, it was controversial precisely because of the central role of outside stressors as causes of the disorder. Psychiatry has generally emphasized the internal weaknesses or deficiencies of individuals as the source of mental disorders; prior to the 1970s, war veterans, rape victims, and other trauma survivors were often blamed for their symptoms and regarded as cowards, moral weaklings, or masochists. The high rate of psychiatric casualties among Vietnam veterans, however, led to studies conducted by the Veterans Administration. These studies helped to establish PTSD as a legitimate diagnostic entity with a complex set of causes.

BIOCHEMICAL/PHYSIOLOGICAL CAUSES. Present neurobiological research indicates that traumatic events cause lasting changes in the human nervous system, including abnormal secretions of stress hormones. In addition, in PTSD patients, researchers have found changes in the amygdala and the hippocampus—the parts of the brain that form links between fear and memory. Experiments with ketamine, a drug that inactivates one of the neurotransmitter chemicals in the central nervous system, suggest that trauma works in a similar way to damage associative pathways in the brain. Positron emission tomography (PET) scans of PTSD patients suggest that trauma affects the parts of the brain that govern speech and language.

SOCIOCULTURAL CAUSES. Studies of specific populations of PTSD patients (combat veterans, survivors of rape or genocide, former political hostages or prisoners, etc.) have shed light on the social and cultural causes of PTSD. In general, societies that are highly authoritarian, glorify violence, or sexualize violence have high rates of PTSD even among civilians.

OCCUPATIONAL FACTORS. Persons whose work exposes them to traumatic events or who treat trauma survivors may develop secondary PTSD (also known as compassion fatigue or burnout). These occupations include specialists in emergency medicine, police officers, firefighters, search-and-rescue personnel, psychotherapists, disaster investigators, etc. The degree of risk for PTSD is related to three factors: the amount and intensity of exposure to the suffering of trauma victims; the worker's degree of empathy and sensitivity; and unresolved issues from the worker's personal history.

PERSONAL VARIABLES. Although the most important causal factor in PTSD is the traumatic event itself, individuals differ in the intensity of their cognitive and emotional responses to trauma; some persons appear to be more vulnerable than others. In some cases, this greater vulnerability is related to temperament or natural disposition, with shy or introverted people being at greater risk. In other cases, the person's vulnerability results from chronic illness, a physical disability, or previous traumatization—particularly abuse in childhood. As of 2001, researchers have not found any correlation between race and biological vulnerability to PTSD.

Symptoms

DSM-IV-TR specifies six diagnostic criteria for PTSD:

• Traumatic stressor: The patient has been exposed to a catastrophic event involving actual or threatened death or injury, or a threat to the physical integrity of the self or others. During exposure to the trauma, the person's emotional response was marked by intense fear, feelings of helplessness, or horror. In general, stressors caused intentionally by human beings (genocide, rape, torture, abuse, etc.) are experienced as more traumatic than accidents, natural disasters, or "acts of God."
• Intrusive symptoms: The patient experiences flashbacks, traumatic daydreams, or nightmares, in which he or she relives the trauma as if it were recurring in the present. Intrusive symptoms result from an abnormal process of memory formation. Traumatic memories have two distinctive characteristics: 1) they can be triggered by stimuli that remind the patient of the traumatic event; 2) they have a "frozen" or wordless quality, consisting of images and sensations rather than verbal descriptions.
• Avoidant symptoms: The patient attempts to reduce the possibility of exposure to anything that might trigger memories of the trauma, and to minimize his or her reactions to such memories. This cluster of symptoms includes feeling disconnected from other people, psychic numbing, and avoidance of places, persons, or things associated with the trauma. Patients with PTSD are at increased risk of substance abuse as a form of self-medication to numb painful memories.
• Hyperarousal: Hyperarousal is a condition in which the patient's nervous system is always on "red alert" for the return of danger. This symptom cluster includes hypervigilance, insomnia, difficulty concentrating, general irritability, and an extreme startle response. Some clinicians think that this abnormally intense startle response may be the most characteristic symptom of PTSD.
• Duration of symptoms: The symptoms must persist for at least one month.
• Significance: The patient suffers from significant social, interpersonal, or work-related problems as a result of the PTSD symptoms. A common social symptom of PTSD is a feeling of disconnection from other people (including loved ones), from the larger society, and from spiritual or other significant sources of meaning.

Diagnosis

The diagnosis of PTSD is complicated by several factors.

Time of onset/symptom duration

In the case of a known trauma of recent occurrence—most often a civilian disaster or war—the diagnosis of PTSD is relatively straightforward, based on the criteria listed above.

DSM-IV introduced a new diagnostic category, acute stress disorder, to differentiate between time-limited and longer-term stress reactions. In acute stress disorder, the hyperarousal and intrusive symptoms last between two days and four weeks. If the symptoms last beyond four weeks, and all of the above criteria are met, the diagnosis is changed to PTSD.

The diagnosis of PTSD is more difficult in cases of delayed reaction to trauma. Some individuals do not develop symptoms of PTSD until months or even years after the traumatic event. DSM-IV-TR specifies an interval of at least six months between the event and the development of symptoms for a diagnosis of PTSD with delayed onset. Delayed symptoms are often triggered by a situation that resembles the original trauma, as when a person raped in childhood experiences workplace sexual harassment.

Individual variations in response to stressors

DSM-III and its successors included the category of adjustment disorder to differentiate abnormal reactions to such painful but relatively common life events ("ordinary stressors") as divorce, job loss, or bereavement from symptoms resulting from overwhelming trauma. The differential diagnosis (the process of determining that the diagnosis is one disorder although it may resemble another) is complicated, however, by the fact that "ordinary stressors" sometimes reawaken unresolved childhood trauma, producing the delayed-reaction variant of PTSD.

Dual diagnoses

Most patients with PTSD (as many as 80%) have been diagnosed with one of the anxiety (30–60%), dissociative, mood (26–85%), or somatoform disorders as well as with PTSD. Between 40–60% of persons with delayed-reaction PTSD are diagnosed with a personality disorder, most often borderline personality disorder . Another common dual diagnosis is PTSD/substance abuse disorder. Between 60%–80% of patients who develop PTSD turn to alcohol or narcotics in order to avoid or numb painful memories. According to the NVVRS, the estimated lifetime prevalence of alcohol abuse among male Vietnam veterans is 39.2%, and the estimated lifetime prevalence of drug abuse is 5.7%. Dual diagnoses complicate treatment because the therapist must decide whether to treat the disorders in sequence or concurrently. PTSD patients diagnosed with personality disorders are regarded as the most difficult to treat.

Psychological measures

As of 2002, there are no physical tests to establish a diagnosis of PTSD. The diagnosis is usually made on the basis of the patient's history and results from one or more short-answer interviews or symptom inventories. The instruments most often used to evaluate patients for PTSD include the Anxiety Disorders Interview Scale (ADIS), the Beck Depression Inventory , the Clinician-Administered PTSD Scale (CAPS), the Disorders of Extreme Stress Inventory (DESI), the Dissociative Experiences Scale (DES), the Hamilton Anxiety Scale , and the Impact of Event Scale (IES).

Treatments

Psychological and social interventions

In general, there have been few well-controlled clinical trials of treatment options for PTSD, particularly for severely affected patients.

Critical incident stress debriefing (CISD) is a treatment offered to patients within 48 hours following a civilian disaster or war zone trauma. It is intended to weaken the acute symptoms of the trauma and to forestall the development of full-blown PTSD. CISD usually consists of four phases:

• description of the traumatic event
• sharing of survivors' emotional reactions to the event
• open discussion of symptoms caused by the event
• reassurance that the symptoms are normal responses to trauma, followed by discussion of coping strategies

Critical incident stress management is a system of interventions designed to help emergency/disaster response workers, public safety personnel, and therapists deal with stress reactions before they develop secondary PTSD.

Other mainstream treatment methods used with patients who have already developed PTSD include:

• Cognitive-behavioral therapy . There are two treatment approaches to PTSD included under this heading: exposure therapy, which seeks to desensitize the patient to reminders of the trauma; and anxiety management training, which teaches the patient strategies for reducing anxiety. These strategies may include relaxation training, biofeedback , social skills training , distraction techniques, or cognitive restructuring.
• Psychodynamic psychotherapy . This method helps the patient recover a sense of self and learn new coping strategies and ways to deal with intense emotions related to the trauma. Typically, it consists of three phases:1) establishing a sense of safety for the patient; 2) exploring the trauma itself in depth; 3) helping the patient re-establish connections with family, friends, the wider society, and other sources of meaning.
• Discussion groups or peer-counseling groups. These groups are usually formed for survivors of specific traumas, such as combat, rape/incest, and natural disasters. They help patients to recognize that other survivors of the shared experience have had the same emotions and reacted to the trauma in similar ways. They appear to be especially beneficial for patients with guilt issues about their behavior during the trauma (such as submitting to rape to save one's life, or surviving the event when others did not).
• Family therapy . This form of treatment is recommended for PTSD patients whose family life has been affected by the PTSD symptoms.

Medications

In general, medications are used most often in patients with severe PTSD to treat the intrusive symptoms of the disorder as well as feelings of anxiety and depression. These drugs are usually given as one part of a treatment plan that includes psychotherapy or group therapy . As of 2002, there is no single medication that appears to be a "magic bullet" for PTSD. The selective serotonin reuptake inhibitors (SSRIs) appear to help the core symptoms when given in higher doses for five to eight weeks, while the tricyclic antidepressants (TCAs) or the monoamine oxidase inhibitors (MAOIs) are most useful in treating anxiety and depression.

Alternative therapies

Some alternative therapies for PTSD include:

• Spiritual/religious counseling. Because traumatic experiences often affect patients' spiritual views and beliefs, counseling with a trusted religious or spiritual advisor may be part of a treatment plan. A growing number of pastoral counselors in the major Christian and Jewish bodies have advanced credentials in trauma therapy.
• Yoga and various forms of bodywork are often recommended as ways of releasing physical tension or muscle soreness caused by anxiety or hypervigilance.
• Martial arts training can be helpful in restoring the patient's sense of personal effectiveness and safety. Some martial arts programs, such as Model Mugging, are designed especially for survivors of rape and other violent crimes.
• Art therapy, journaling, dance therapy, and creative writing groups offer safe outlets for the strong emotions that follow traumatic experiences.

Recent controversial therapies

Since the mid-1980s, several controversial methods of treatment for PTSD have been introduced. Some have been developed by mainstream medical researchers while others are derived from various forms of alternative medicine. They include:

• Eye Movement Desensitization and Reprocessing. This is a technique in which the patient reimagines the trauma while focusing visually on movements of the therapist's finger. It is claimed that the movements of the patient's eyes reprogram the brain and allow emotional healing.
• Tapas Acupressure Technique (TAT). TAT was derived from traditional Chinese medicine (TCM), and its practitioners maintain that a large number of acupuncture meridians enter the brain at certain points on the face, especially around the eyes. Pressure on these points is thought to release traumatic stress.
• Thought Field Therapy. This therapy combines the acupuncture meridians of TCM with analysis of the patient's voice over the telephone. The therapist then provides an individualized treatment for the patient.
• Traumatic Incident Reduction. This is a technique in which the patient treats the trauma like a videotape and "runs through" it repeatedly with the therapist until all negative emotions have been discharged.
• Emotional Freedom Techniques (EFT). EFT is similar to TAT in that it uses the body's acupuncture meridians, but it emphasizes the body's entire "energy field" rather than just the face.
• Counting Technique. Developed by a physician, this treatment consists of a preparation phase, a counting phase in which the therapist counts from 1 to 100 while the patient reimagines the trauma, and a review phase. Like Traumatic Incident Reduction, it is intended to reduce the patient's hyperarousal.

Prognosis

Trauma survivors who receive critical incident stress debriefing as soon as possible after the event have the best prognosis for full recovery. For patients who develop full-blown PTSD, a combination of peer-group meetings and individual psychotherapy are often effective. Treatment may require several years, however, and the patient is likely to experience relapses.

There are no studies of untreated PTSD, but long-term studies of patients with delayed-reaction PTSD or delayed diagnosis of the disorder indicate that treatment of patients in these groups is much more difficult and complicated.

In some patients, PTSD becomes a chronic mental disorder that can persist for decades, or the remainder of the patient's life. Patients with chronic PTSD often have a cyclical history of symptom remissions and relapses. This group has the poorest prognosis for recovery; some patients do not respond to any of the currently available treatments for PTSD.

Prevention

Some forms of trauma, such as natural disasters and accidents, can never be completely eliminated from human life. Traumas caused by human intention would require major social changes to reduce their frequency and severity, but given the increasing prevalence of PTSD around the world, these long-term changes are worth the effort. In the short term, educating people—particularly those in the helping professions—about the signs of critical incident stress may prevent some cases of exposure to trauma from developing into full-blown PTSD.

See also Anxiety reduction techniques; Bodywork therapies; Creative therapies; Exposure treatment; Somatization and Somatoform disorders

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.

Beers, Mark H., M.D., and Robert Berkow, M.D., eds. "Posttraumatic Stress Disorder." In The Merck Manual of Diagnosis and Therapy, 17th edition. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Herman, Judith, M.D. Trauma and Recovery. 2nd ed., revised. New York: Basic Books, 1997.

Laub, Dori, M.D. "An Event Without A Witness: Truth, Testimony and Survival." In Testimony: Crises of Witnessing in Literature, Psychoanalysis, and History, written by Dori Laub, M.D. and Shoshana Felman. New York: Routledge, 1992.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington D.C. 20005. <http://www.psych.org>.

Anxiety Disorders Association of America, Inc. 11900 Parklawn Drive, Suite 100, Rockville, MD 20852. (301) 231-9350. <http://www.adaa.org>.

International Critical Incident Stress Foundation, Inc. 10176 Baltimore National Pike, Unit 201, Ellicott City, MD21042. (410) 750-9600. Emergency: (410) 313-2473. <http://www.icisf.org>.

International Society for Traumatic Stress Studies. 60 Revere Drive, Suite 500, Northbrook, IL 60062. (847) 480-9028. <http://www.istss.org>.

National Center for PTSD. 1116D V.A. Medical Center, 215 N. Main Street, White River Junction, VT 05009-0001.(802) 296-5132. <http://www.ncptsd.org>.

National Institute of Mental Health. 6001 Executive Boulevard, Rm. 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <http://www.nimh.nih.gov>.

Rebecca J. Frey, Ph.D.

Posttraumatic Stress Disorder (PTSD)

The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to a traumatic event that arouses "intense fear, helplessness, or horror," or in children, "disorganized or agitated behavior" (American Psychiatric Association 1994, p. 428). A host of stressors, both natural and manmade, can be traumatizing. Naturally occurring stressors include, for example, natural disasters and medical illnesses. Man-made events include accidents and acts of violence. Some of these are single events with acute effects; others involve repeated or chronic exposure. Exposure can occur through direct experience with personal victimization or through witnessing or learning about a traumatic event.

Symptoms are categorized into three clusters: persistent re-experiencing of the stressor, persistent avoidance of reminders and emotional numbing, and persistent symptoms of increased arousal (American Psychiatric Association 1994). Intrusive re-experiencing may involve intrusive distressing recollections or dreams about the trauma, "acting or feeling" as if the event were recurring, and intense distress or physiological reactivity when exposed to reminders (American Psychiatric Association 1994, p. 428). In children, re-experiencing may be evident in repetitive play with themes of the traumatic experience, generalized nightmares, and trauma-specific reenactment. At least one re-experiencing symptom is required for the diagnosis.

The avoidance/numbing cluster includes both purposeful actions and unconscious mechanisms: efforts to avoid thoughts, feelings, or conversations related to the trauma; efforts to avoid activities, places, or people reminiscent of the trauma; inability to recall important aspects of the trauma; greatly decreased interest in important activities; feeling detached or estranged; restricted affect; and a "sense of a foreshortened future" (American Psychiatric Association 1994, p. 428). At least three avoidance/numbing symptoms, not present before the trauma, are required for the diagnosis.

The arousal cluster requires increased generalized arousal, including sleep disturbance, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. At least two arousal symptoms, not present before the trauma, are required.

To qualify for a diagnosis, symptoms must continue for more than one month; they may persist for months to years. Symptoms usually begin within three months after exposure, but may be delayed, and specific symptoms and their intensity or severity may vary over time (American Psychiatric Association 1994). The symptoms must cause "clinically significant distress" or impaired functioning (American Psychiatric Association 1994, p. 429), which may be evident at home, work, or school, or in other settings and in interpersonal relationships. Endorsement of some PTSD symptoms may be normal following trauma exposure, partial symptomatology may be disabling, and the full symptom complex may develop over time. Treatment may be necessary even if all criteria are not met.

Prevalence, Epidemiology, and Comorbidity

Exposure to traumatic events and situations is increasingly common, especially in some environments. The estimated lifetime prevalence of PTSD in the general U.S. population ranges from 1 percent to 14 percent (American Psychiatric Association 1994). Rose Giaconia and colleagues (1995) found that by the age of eighteen years, more than two-fifths of youths in a community sample had been exposed to trauma severe enough to qualify for diagnosis, and over 6 percent met criteria for a lifetime diagnosis of PTSD. Co-morbid conditions are common with PTSD. They include anxiety, somatization (when psychological distress is translated to physical complaints or ailments), and substance-use disorders (American Psychiatric Association 1994; Giaconia et al. 1995).

Etiology

PTSD "is defined by its cause" (Davidson 1995, p. 1230) requiring exposure to a traumatic event or stressor that results in physiological changes associated with the fight-or-flight response, a complex interplay among several systems of the body that leads to increased blood pressure, pulse, and respiratory rate; increased blood supply to the muscles; and vigilance (Guyton and Hall 1997; Perry and Pollard 1998). This response dissipates with time except in cases of severe, prolonged, or chronic stress, in which it may persist and may have potentially detrimental consequences, especially for the developing child (Perry and Pollard 1998).

Risk Indicators and Factors That Promote Resilience

The factors that contribute to posttraumatic stress may be categorized into those occurring before, during, and after exposure to the stressor. Prestressor factors include characteristics of the victim, family, and sociocultural environment. Stressor factors include aspects of the event and exposure. Poststressor factors include aspects of the recovery environment, coping, and treatment.

Pre-event factors. Rates of PTSD are higher in women than men (Ballenger et al. 2000), though gender differences are less clear in children (Foy et al. 1996; Pfefferbaum 1997). The influence of age and ethnicity is not well established. Age and developmental differences may be evident in the symptoms of the disorder, and may reflect prior experience, coping, and the availability of support. Ethnic minorities may be at risk for trauma exposure, but this may reflect differences in socioeconomic status or family influences rather than ethnicity. Other individual factors important in trauma response are preexisting psychopathology and prior exposure to trauma (American Psychiatric Association 1994; Asarnow et al. 1999; Ballenger et al. 2000; Davidson 1995).

Prestressor family and social factors that may influence outcome include relationships within the family and social environment, family organization, and the family's long-term adaptation (Boney-McCoy and Finkelhor 1996; McFarlane 1987; Solomon 1989). Positive family relationships are generally considered protective for traumatized children. Specifically, problems in children appear to be associated with irritable, depressed, and overprotective families (Green et al. 1991; McFarlane 1987). Family adaptability—the capacity for change—and family cohesion—the flexibility of emotional bonds—are likely to affect trauma response. Both extremes of cohesion, too distant and too close, create risk for maladaptive outcome (Laor et al. 1996), although more research is needed to help clarify these family factors.

PTSD has been described in individuals from many cultures. In fact, one would expect high rates of exposure to trauma and PTSD in individuals from those parts of the world where war, crime, and poverty prevail and in refugee populations (American Psychiatric Association 1994). Race, ethnicity, and culture shape conceptualization of events, reactions to trauma, expectations, and treatment (Parson 1994). The biologic response to trauma appears to be consistent across cultures, while the psychosocial aspects of symptom expression are influenced by pre-event, stressor, and poststressor factors (Parson 1994). Of particular concern when Western concepts of trauma are applied in non-Western cultural contexts are potential differences in notions of illness and health, symptom expression, and the phenomenology of the disorder (Marsella et al. 1994).

Stressor factors. Characteristics of the stressor and one's exposure to it influence response. For example, man-made events are thought to be more traumatizing than natural ones (American Psychiatric Association 1994). Exposure can be direct or indirect. Direct exposure involves physical presence or direct victimization; indirect exposure occurs through witnessing or learning of an event experienced by a family member or close associate (American Psychiatric Association 1994). Severity, duration, and proximity are the most important aspects of exposure in predicting the likelihood of developing the disorder (American Psychiatric Association 1994). The role of interpersonal exposure through relationship to direct victims has also been established (American Psychiatric Association 1994). Television viewing as a form of indirect exposure may be associated with posttraumatic stress reactions (Pfefferbaum et al. 2001; Schuster et al. 2001), but no studies link television exposure to the diagnosis of PTSD. One's reaction at the time of the trauma is an important predictor of post-traumatic stress (Asarnow et al. 1999; Ballenger et al. 2000; Schwarz and Kowalski 1991).

Poststressor factors. Family and social factors may influence adjustment following exposure to trauma. For example, within a family, there may be an association between child and parent symptomatology (Foy et al. 1996; Green et al. 1991; Laor et al. 1996; McFarlane 1987) that in some cases may reflect similar exposure. Parental symptoms and poor parental functioning constitute important risk factors for symptom development in traumatized children (Green et al. 1991; McFarlane 1987). Consistency in reaction and mood between parents (Handford et al. 1986), and the quality of the parent-child relationship (Boney-McCoy and Finkelhor 1996) may also affect the intensity of the child's reaction.

When a traumatic event affects large numbers, social factors, such as community disruption, competition for resources, and community response, may influence adjustment (Pfefferbaum 1998; Quarantelli and Dynes 1985; Solomon 1989). Secondary adversities associated with a traumatic event such as displacement and relocation, property and economic loss, family and social problems, and loss of interpersonal support networks affect recovery (Freedy et al. 1992; Laor et al. 1996; Pfefferbaum 1998; Shaw et al. 1995). Traumatic reminders—stimulus cues that activate symptoms—may also interfere with recovery.

Assessment and Treatment

Assessment. Clinical assessment of posttraumatic stress involves the traditional methods of evaluation. The history of exposure, prior trauma, and pre-existing and co-morbid conditions must be assessed. In some situations, such as natural disasters or reported criminal victimization, exposure to trauma is obvious, and the clinician quite naturally inquires about the signs and symptoms of PTSD. In other situations, however, exposure is obscure, and the need for evaluation may be less obvious. Children may not spontaneously report their symptoms, and adults may underestimate trauma in children (Almqvist and Brandell-Forsberg 1997; Handford et al. 1986; Yule and Williams 1990), making it essential to ask children themselves about their experiences and reactions. In addition, children may have difficulty understanding concepts such as avoidance and numbing; therefore, evaluation of them should include observation and reports by parents, teachers, and/or other adults.

Treatment. Treatment involves transforming the individual's self-concept from victim to survivor as the trauma is resolved in a safe setting in which painful and overwhelming experiences can be explored (Amaya-Jackson and March 1995; Gillis 1993; Hollander et al. 1999). Avoidance, a core symptom of PTSD, may prevent the victim from seeking or continuing treatment (Ehlers 2000). The therapist, therefore, must consider omitted information and associated feelings and affects. Avoidance can be protective, decreasing suffering temporarily, but it may be interrupted by intrusive experiences and heightened arousal that occur spontaneously or with exposure to traumatic cues. Educational information is an important aspect of the treatment of PTSD, especially when anxiety and avoidance discourage the patient from seeking or continuing treatment. Prior traumatic experiences must be explored and co-morbid symptoms such as anxiety and depression must be identified and treated. A variety of modalities are used to treat PTSD, although the comparative effectiveness of various modalities has received little attention.

Psychotherapeutic and cognitive-behavioral approaches. The literature suggests that crisis intervention, individual and group therapy, play therapy for children, therapeutic exposure, desensitization, relaxation, other cognitive-behavioral techniques, and pharmacotherapy are beneficial in treating PTSD (Davidson 1995; Terr 1989). Exposure therapy that involves repeated review of the traumatic experience is a component of many approaches. Use of projective techniques such as play in children and art may provide access to traumatic themes without threatening the victim's defensive structure. Relaxation techniques may decrease arousal, tension, physical symptoms, anxiety, and sleep disturbance (Hollander et al. 1999). Hypnosis can also be effective (Davidson 1995; Ehlers 2000; Hollander et al. 1999; Terr 1989).

Pharmacotherapy. Pharmacotherapy is an adjunctive treatment that may be needed if symptoms are disabling (Amaya-Jackson and March 1995; Hollander et al. 1999; Marmar et al. 1994). A variety of drugs are potentially effective, most notably anxiolytics (agents that dispel anxiety) and antidepressants. Specific symptoms and the stage of the illness determine whether to use a drug, what drug to use, and the duration of use. Positive symptoms of re-experiencing and arousal may be more responsive to medication than negative symptoms of avoidance (Marmar et al. 1994). Co-morbid conditions should be considered in selecting an agent.

Family therapy. Family work is an excellent means of providing education about trauma and what to expect over time. Parents of traumatized children may benefit from psychoeducation about their children's symptoms and how to effectively manage them. Often, more than one family member will be traumatized though individual exposure and the course of the illness and recovery may differ. Parental trauma may be so great that the needs of a young child may be overlooked. Helping parents resolve their own emotional distress can increase their perceptiveness and responsiveness to their children. The focus of family work includes validating the experiences and emotional reactions of each family member, helping family members regain a sense of security, anticipating situations in which additional support will be needed, and exploring ways to decrease traumatic reminders and secondary stresses.

Group treatment. Group work is ideal for educating victims about symptoms and the posttraumatic course. Sharing with others who have experienced the same or similar trauma can be reassuring, but some are uncomfortable sharing in a group. Group discussions may be re-traumatizing through re-exposure to one's own experiences or through exposure to the experiences of others. Group work also provides an expedient means of reaching individuals in need of more intensive individual assistance.

School-based efforts. School-based interventions are effective for traumatized children or children at risk for trauma. They provide access in developmentally appropriate settings that encourage normality and minimize stigma.

Long-term treatment and pulsed interventions. Long-term treatment may be necessary for those with intense or enduring exposure and symptoms, pre-existing or co-morbid conditions, prior or subsequent trauma, or family problems. Treatment during the acute phase of trauma may be followed by planned interventions at strategic points. These may be especially important following mass casualty events when many have been exposed and can be reached for follow-up in groups. Periodic, brief interventions are useful during developmental transitions and at anniversaries.

Conclusion

The diagnosis of PTSD requires exposure to a traumatic stressor and can be challenging to make if exposure is not obvious or if the victim does not reveal it. Symptoms fall into three clusters—intrusive re-experiencing, avoidance/numbing, and arousal. An array of treatment modalities is used to treat the disorder, although the comparative effectiveness of these modalities has not been well examined.

See also:Anxiety Disorders; Attachment: Parent-Child Relationships; Child Abuse: Physical Abuse and Neglect; Child Abuse: Sexual Abuse; Codependency; Developmental Psychopathology; Incest; Interparental Violence—Effects on Children; Rape; Spouse Abuse: Prevalence; Spouse Abuse: Theoretical Explanations; War/Political Violence

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betty pfefferbaum

Post-Traumatic Stress Disorder

Definition

Post-traumatic stress disorder (PTSD) is a debilitating psychological condition triggered by a major traumatic event, such as rape, war, a terrorist act, death of a loved one, a natural disaster, or a catastrophic accident. It is marked by upsetting memories or thoughts of the ordeal, "blunting" of emotions, increased arousal, and sometimes severe personality changes.

Description

Officially termed post-traumatic stress disorder since 1980, PTSD was once known as shell shock or battle fatigue because of its more common manifestation in war veterans. However in the past 20 years, PTSD has been diagnosed in rape victims and victims of violent crime; survivors of natural disasters; the families of loved ones lost in the downing of Flight 103 over Lockerbie, Scotland; and survivors of the 1993 World Trade Center bombing, the 1995 Oklahoma City bombing, the random school and workplace shootings, and the release of poisonous gas in a Japanese subway; and, most recently, in the September 11, 2001, World Trade Center and Pentagon terrorist attacks. PTSD can affect adults of all ages. Statistics gathered from past events indicate that the risk of PTSD increases in order of the following factors.

• female gender
• middle-aged (40 to 60 years old)
• little or no experience coping with traumatic events
• ethnic minority
• lower socioeconomic status (SES)
• children in the home
• women with spouses exhibiting PTSD symptoms
• pre-existing psychiatric conditions
• primary exposure to the event including injury, life-threatening situation, and loss
• living in traumatized community

For example, over a third of the Oklahoma City bombing survivors developed PTSD and over half showed signs of anxiety, depression, and alcohol abuse. Over one year later, Oklahomans in general had a increased use of alcohol and tobacco products, as well as PTSD symptoms.

Children are also susceptible to PTSD and their risk is increased exponentially as their exposure to the event increases. Children experiencing abuse, the death of a parent, or those located in a community suffering a traumatic event can develop PTSD. Two years after the Oklahoma City bombing, 16% of children in a 100 mile radius of Oklahoma City with no direct exposure to the bombing had increased symptoms of PTSD. Weak parental response to the event, having a parent suffering from PTSD symptoms, and increased exposure to the event via the media all increase the possibility of the child developing PTSD symptoms.

Causes and symptoms

Specific causes for the onset of PTSD following a trauma aren't clearly defined, although experts suspect it may be influenced both by the severity of the event, by the person's personality and genetic make-up, and by whether or not the trauma was expected. First response emergency personnel and individuals directly involved in the event or those children and families who have lost loved ones are more likely to experience PTSD. Natural disasters account for about a 5% rate of PTSD, while there is a 50% rate of PTSD among rape and Holocaust survivors.

Media coverage plays a new role in both adult and pediatric onset of PTSD symptoms. The heightened level of news footage of actual traumatic events, such as the Oklahoma City bombing and the terrorist attack on the World Trade Center and the Pentagon, increases the exposure to the violence, injury, and death associated with the event and may reinforce PTSD symptoms in individuals, especially young children who cannot distinguish between the actual event and the repeated viewing of the event in the media.

PTSD symptoms are distinct and prolonged stress reactions that naturally occur during a highly stressful event. Common symptoms are:

• hyperalertness
• fear and anxiety
• nightmares and flashbacks
• sight, sound, and smell recollection
• avoidance of recall situations
• anger and irritability
• guilt
• depression
• increased substance abuse
• negative world view
• decreased sexual activity

Symptoms usually begin within three months of the trauma, although sometimes PTSD doesn't develop until years after the initial trauma occurred. Once the symptoms begin, they may fade away again within six months. Others suffer with the symptoms for far longer and in some cases, the problem may become chronic.

Among the most troubling symptoms of PTSD are flashbacks, which can be triggered by sounds, smells, feelings, or images. During a flashback, the person relives the traumatic event and may completely lose touch with reality, suffering through the trauma for minutes or hours at a time, believing that the traumatizing event is actually happening all over again.

For a diagnosis of PTSD, symptoms must include at least one of the following so-called "intrusive" symptoms:

• flashbacks
• sleep disorders: nightmares or night terrors
• intense distress when exposed to events that are associated with the trauma

In addition, the person must have at least three of the following "avoidance" symptoms that affect interactions with others:

• trying to avoid thinking or feeling about the trauma
• inability to remember the event
• inability to experience emotion, as well as a loss of interest in former pleasures (psychic numbing or blunting)
• a sense of a shortened future

Finally, there must be evidence of increased arousal, including at least two of the following:

• problems falling asleep
• startle reactions: hyperalertness and strong reactions to unexpected noises
• memory problems
• concentration problems
• moodiness
• violence

In addition to the above symptoms, children with PTSD may experience learning disabilities and memory or attention problems. They may become more dependent, anxious, or even self-abusing.

Recovery may be slowed by injuries, damage to property, loss of employment, or other major problems in the community due to disaster.

Diagnosis

Not every person who experiences a traumatic event will experience PTSD. A mental health professional will diagnose the condition if the symptoms of stress last for more than a month after a traumatic event. While a formal diagnosis of PTSD is made only in the wake of a severe trauma, it is possible to have a mild PTSD-like reaction following less severe stress.

Treatment

Several factors have shown to be important in the treatment of post-traumatic stress. These include proximity of the treatment to the site of the event, immediate intervention of therapy as soon as possible, and the expectation that the individual will eventually return to more normal functions. The most helpful treatment of prolonged PTSD appears to be a combination of medication along with supportive and cognitive-behavioral therapies.

Emergency care

Immediate intervention is important for individuals directly affected by the traumatic event. Emergency care workers focus on achieving the following during the hours and days following the trauma.

• protect survivors from further danger
• treat immediate injuries
• provide food, shelter, fluids, and clothing
• provide safe zone
• locate separated loved ones
• reconnect loved ones
• provide normal social contact
• help reestablish routines
• help resolve transportation, housing, or other issues caused by disaster
• provide grief counseling, stress reduction, and other consultation to enable survivors and families to return to normal life

As well as providing care to others, emergency personnel often need the same support as the survivors. Operational debriefing is used to organize the emergency response and to disseminate information and sense of purpose to the first responders. Critical Incident Stress Debriefing (CISD) is a formal group invention designed to include various crisis intervention, such as information disbursement, one-on-one counseling, consultation, family crisis intervention, and referrals. CISD is not useful for survivors and is an interim support for first responders until they are able to receive therapy.

Medications

Medications used to reduce the symptoms of PTSD include anxiety-reducing medications and antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline HCl (Zoloft). In 2001, the U.S. Food and Drug Administration (FDA) approved Zoloft as a long-term treatment for PTSD. In a controlled study, Zoloft was effective in safely improving symptoms of PTSD over a period of 28 weeks and reducing the risk of relapse.

Sleep problems can be lessened with brief treatment with an anti-anxiety drug, such as a benzodiazepine like alprazolam (Xanax), but long-term usage can lead to disturbing side effects, such as increased anger, drug tolerance, dependency, and abuse.

Therapy

Several types of therapy may be useful and they are often combined in a multi-faceted approach to understand and treat this condition.

• Cognitive-behavioral therapy focuses on changing specific actions and thoughts through repetitive review of traumatic events, identification of negative behaviors and thoughts, and stress management.
• Group therapy has been useful in decreasing psychological distress, depression, and anxiety in some PTSD sufferers such as sexually abused women and war veterans.
• Psychological debriefing has been widely used to treat victims of natural disasters and other traumatic events such as bombings and workplace shootings, however, recent research shows that psychological debriefing may increase the stress response. Since this type of debriefing focuses on the emotional response of the survivor, it is not recommended for individuals experiencing an extreme level of grief.

Alternative treatment

Several means of alternative treatment may be helpful in combination with conventional therapy for reduction of the symptoms of post-traumatic stress disorder. These include relaxation training, breathing techniques, spiritual treatment, and drama therapy where the event is re-enacted.

Prognosis

The severity of the illness depends in part on whether the trauma was unexpected, the severity of the trauma, how chronic the trauma was (such as for victims of sexual abuse), and the person's readiness to embrace the recovery process. With appropriate medication, emotional support, counseling, and follow-up care, most people show significant improvement. However, prolonged exposure to severe trauma, such as experienced by victims of prolonged physical or sexual abuse and survivors of the Holocaust, may cause permanent psychological scars.

Prevention

More studies are needed to determine if PTSD can actually be prevented. Some measures that have been explored include controlling exposure to traumatic events through safety and security measures, psychological preparation for individuals who will be exposed to traumatic events (i.e. policemen, paramedics, soldiers), and stress inoculation training (rehearsal of the event with small doses of the stressful situation).

Resources

PERIODICALS

DiGiovanni, C. "Domestic Terrorism with Chemical or Biological Agents: Psychiatric Aspects." American Journal of Psychiatry 156 (1999): 1500-1505.

North, C., S. Nixon, S. Hariat, S. Mallonee, et al. "Psychiatric Disorders Among Survivors of the Oklahoma City Bombing." Journal of the American Medical Association 282 (1999): 755-762.

Pfefferbaum, B., R. Gurwitch, N. McDonald, et al. "Posttraumatic Stress Among Children After the Death of a Friend or Acquaintance in a Terrorist Bombing." Psychiatric Services 51 (2000): 386-388.

"Sertraline HCl Approved for Long-Term Use." Women's Health Weekly September 20, 2001.

Sloan, M. "Response to Media Coverage of Terrorism" Journal of Conflict Resolution 44 (2000): 508-522.

Smith, D, E. Christiansen, R. Vincent, and N. Hann. "Population Effects of the Bombing of Oklahoma City." Journal of Oklahoma State Medical Association 92 (1999): 193-198.

ORGANIZATIONS

American Psychiatric Association. 1400 K St., NW, Washington, DC 20005.

Anxiety Disorders Association of America. 11900 Parklawn Dr., Ste. 100, Rockville, MD 20852. (301) 231-9350.

Freedom From Fear. 308 Seaview Ave., Staten Island, NY 10305. (718) 351-1717.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166.

National Center for Post-Traumatic Stress Disorder. 〈http://www.dartmouth.edu/dms/ptsd〉.

National Institute of Mental Health. Rm 15C-05, 5600 Fishers Lane, Rockville, MD 20857.

Society for Traumatic Stress Studies, 60 Revere Dr., Ste. 500, Northbrook, IL 60062. (708) 480-9080.

KEY TERMS

Benzodiazepine— A class of drugs that have a hypnotic and sedative action, used mainly as tranquilizers to control symptoms of anxiety.

Cognitive-behavioral therapy— A type of psychotherapy used to treat anxiety disorders (including PTSD) that emphasizes behavioral change, together with alteration of negative thought patterns.

Selective serotonin reuptake inhibitor (SSRI)— A class of antidepressants that work by blocking the reabsorption of serotonin in the brain, raising the levels of serotonin. SSRIs include Prozac, Zoloft, and Paxil.