POST-TRAUMATIC STRESS DISORDER (PTSD)

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1 POST-TRAUMATIC STRESS DISORDER (PTSD) Post-Traumatic Stress Disorder (PTSD) arises as an immediate, delayed and/or protracted response to a traumatic or stressful event of an exceptionally threatening or catastrophic nature. The person encountering the stress does not have to be the one who was threatened directly. This stress can also be experienced by witnesses to a traumatic incident. Examples of life-threatening traumas that can cause post-traumatic stress symptoms include natural disasters, serious accidents and acts of violence. It has been suggested that the disorder tends to be more severe when the stressor involves deliberate human malice as opposed to a "twist of fate". Symptoms such as flashbacks must last for at least a month after a traumatic event for a diagnosis of PTSD to be made. Post-Traumatic Stress Disorder (PTSD) arises as an immediate, delayed and/or protracted response to a traumatic or stressful event of an exceptionally threatening or catastrophic nature. These include natural disasters, acts of terrorism such as bomb blasts, hijackings and physical assault such as rape. The trauma involves direct personal experience of an event that involves actual or threatened death or serious injury, or a threat to one's physical integrity, or witnessing an event that involves death, injury, or a threat to the physical integrity of another person. Stressors that might trigger PTSD must be outside the range of typical human experience. Problems such as grieving the loss of a loved one or marital conflict are not considered severe enough to lead to PTSD. People who have PTSD are those who: Have experienced, witnessed or were confronted with a traumatic event that involved the threat of death or serious injury to themselves or others, causing them to respond with intense fear, helplessness or horror. Persistently re-experience the event through intrusive thoughts, dreams, acting or feeling as if the event were reoccurring, and/or intense distress and emotion when exposed to cues that symbolise or resemble the event. Avoid stimuli associated with the event and attempt to numb their general responsiveness by avoiding thoughts, feelings, conversation, activities, places or people associated with the trauma. An inability to recall important aspects of the trauma and loss of interest in participating in activities. Feel detached from others, have a restricted range of emotions and are often unable to have loving relationships. Feel little hope for their future. Experience symptoms of increased emotional stimulation such as difficulty sleeping, irritability or angry outbursts, difficulty concentrating, increased vigilance and exaggerated or startled responses. According to the standard diagnostic manual known as the Diagnostic and Statistical Manual of Mental Disorders (DSM), the above-mentioned symptoms have to continue for at least a month and cause significant distress or impairment in social, occupational or other important areas of functioning in order for a diagnosis of PTSD to be made. In general, people with PTSD respond to situations more intensely than those who do not have the disorder. Whereas others may respond with denial, a person with PTSD will respond by withdrawing and may turn to alcohol, drugs or suicide. Unable to work through their feelings, they often become incapable of initiating and maintaining relationships and work as they could before the trauma. These feelings of distress may also lead to other anxiety disorders such as obsessive-

2 compulsive disorder, panic disorder, generalised anxiety disorder, acute stress disorder and depression. Cause The cause of PTSD is complex and can it be said that the exact cause of PTSD remains unknown. However, it is agreed that a defining factor is that a person with PTSD must have experienced a profoundly distressing event, such as a natural disaster, assault, terrorism or serious accident. The disorder tends to be more severe when the stressor involves deliberate human malice as opposed to a "twist of fate" or bad luck. But because not all people who experience a serious stressor develop PTSD, other variables such as preceding trauma and social support may play a role in the development of the disorder. Symptoms The symptoms of PTSD fall into three categories: Intrusion Avoidance Hyperarousal Intrusion Memories of the trauma can recur unexpectedly, and episodes called "flashbacks" intrude into their current lives. This happens in sudden, vivid memories accompanied by painful emotions that hold the victim s attention completely. The flashback may be so strong that individuals almost feel as if they are experiencing the trauma again or seeing it unfold before their eyes. They may also have nightmares of the traumatic incident. Avoidance Avoidance symptoms often affect relationships with others: the person with PTSD often avoids close emotional ties with family, colleagues and friends. At first, the person feels emotionally numb and can complete only routine, mechanical activities. Later, when re-experiencing the event, the individual may alternate between the flood of emotions caused by re-experiencing the trauma and the inability to feel or express emotions at all. The person with PTSD avoids situations or activities that are reminders of the original traumatic event because such exposure may cause symptoms to worsen. Depression is a common product of the inability to resolve painful feelings. Some people also feel guilty because they survived a disaster while others - particularly if these were friends or family - did not. Hyperarousal PTSD can cause its sufferers to act as if they are constantly threatened by the trauma that caused their illness. They can become suddenly irritable or explosive, even when they are not provoked. They may have trouble concentrating or remembering current information, and, because of their terrifying nightmares, they may develop insomnia. The constant feeling that danger is near causes exaggerated startle reactions. Many people with PTSD also attempt to rid themselves of their painful re-experiences, loneliness and panic attacks by abusing alcohol or other drugs as an attempt to "self-medicate". A person with PTSD may show poor control over his or her impulses and may be at risk for suicide.

3 Prevalence In South Africa, there has been an increase in Post-Traumatic Stress Disorder due to crimes such as hijacking and violence encountered during housebreaking, and urban terrorism such as bomb blasts. Course There are usually three phases of response to traumatic stress: Phase One Impact Phase (first few days after the trauma) Responses include: Shock Feeling emotionally numb Dissociation and disorganised thinking Increased arousal and hyper-vigilance Feeling regressed and helpless Phase Two Recoil Phase (may last two to four weeks) Mood swings (anger, sadness, anxiety) Flashbacks and intrusive thoughts such as am I going crazy? The individual begins to adapt Phase Three Reorganisation Phase Symptoms subside Social and occupational functioning improve The above is the normal course after having experienced a trauma. Should the symptoms of phase one and two persist beyond four to six weeks, then the individual is more than likely experiencing PTSD. PTSD usually appears within three months of the trauma, but sometimes may appear later. Risk factors It is impossible to predict who will get PTSD; however, several factors are known to contribute to, or to increase someone s risk for the development of the condition. These include, but are not limited to: Personal identification of the event, through both witnessing a traumatic event or personally experiencing it. Witnessing a traumatic occurrence in which you know the victim Lack of knowledge of the event ahead of time The severity and intensity of the event Cumulative exposure to traumatic events Chronic exposure to traumatic incidents Pre-existing PTSD or other psychiatric disorder

4 Feelings of helplessness Research suggests that children are more susceptible to PTSD than adults when exposed to a similar stressor. People who have had prior psychiatric disorders are more vulnerable to PTSD. This is thought to be true because their previous illness reflects greater sensitivity to stress. When to see a doctor It is strongly recommended that if you have experienced a traumatic event, that you seek appropriate help. Please also see the comments on treatment below. Although it was previously believed that a type of trauma counselling (called debriefing) within 24 to 72 hours after the event can help to prevent the development of PTSD, evidence now suggest that this treatment may be harmful in some cases. Should traumatic stress symptoms persist beyond four to six weeks, therapy is indicated and medication may be necessary. Diagnosis The essential feature of PTSD is the development of characteristic symptoms following exposure to an extreme traumatic stress. The following criteria are indicated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as the diagnostic criteria for PTSD: A. The person has been exposed to a traumatic event in which both of the following were present: (1)The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. (2)The person s response involved intense fear, helplessness or horror. In children, this may be expressed instead by disorganised or agitated behaviour. B. The traumatic event is persistently re-experienced in one or more of the following ways: (1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. (2) Recurrent distressing dreams of the event. In children, there may be frightening dreams without recognisable content. (3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated). In young children, trauma-specific re-enactment may occur. (4) Intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.

5 (5) Physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following: (1) Efforts to avoid thoughts, feelings or conversations associated with the trauma. (2) Efforts to avoid activities, places or people that arouse recollections of the trauma. (3) Inability to recall an important aspect of the trauma. (4) Markedly diminished interest or participation in significant activities. (5) Feeling of detachment or estrangement from others. (6) Inability to feel certain emotions (e.g. unable to have loving feelings). (7) Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children or a normal life span). D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following: (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle responses. E. Duration of the disturbance (symptoms in Criteria B, C, D) is more than one month. F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. Acute PTSD: if duration of symptoms is less than three months. Chronic PTSD: if duration of symptoms is three months or more. PTSD with delayed onset: if onset of symptoms is at least six months after the trauma. Treatment Not everyone who experiences trauma requires treatment. Some recover with the help of family, friends or clergy. But many do need professional treatment to recover from the psychological damage that can result from experiencing, witnessing or participating in an overwhelmingly traumatic event.

6 If you have suffered a trauma and recognise that you have symptoms of PTSD, then the following practical guideline may be helpful: Remove yourself from exposure to further trauma if possible i.e. stabilise your situation. Find a therapist who has experience in treating PTSD, and, preferably, who is knowledgeable about the kind of trauma you have experienced. Be truthful with your therapist about your experience and symptoms. If you feel that the therapist is not right for you, you have the right to one that is. You also have the right to a second opinion. Consult a psychiatrist to determine if you would benefit from medication. Have a medical doctor examine you for any additional medical problems. Avoid unhealthy behaviour and coping addictions, drug and non-drug alike. Find a support group for people with PTSD. Remove yourself from people and situations that are not supportive. Learn about PTSD from reading about it, and talking to health professionals and other people who have had the condition. Removing yourself from exposure to further trauma may not be as simple as it sounds - for example if you are a policeman / woman or a paramedic. Regular trauma debriefing by a professional qualified to do so should prevent the development of PTSD. Every time a trauma has been witnessed, debriefing should be helpful and useful. Medication Evidence that PTSD is characterized by specific psychobiological dysfunctions has contributed to a growing interest in use of medication in its treatment. The most common type of medication prescribed for PTSD is antidepressants. Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRI s) may be particularly helpful in treating the core symptoms of PTSD - especially intrusive symptoms, and are also associated with improvements in overall functioning. Medication treatments can also be effective in treating the associated depression and disability. Sertraline (Zoloft) and paroxetine (Aropax) are licensed for the treatment of PTSD in some countries. Because they are probably not helpful and because of the risk of addiction, benzodiazepines (also known as traquilizers ), should be avoided or used very judiciously. A psychiatrist should carefully monitor medication. Medication can take a few weeks to take effect and must not be stopped suddenly. Medication is often used in conjunction with psychotherapy. The relief from symptoms that medication provides allows most patients to participate more effectively in psychotherapy when their condition may otherwise prohibit it. Psychotherapy Although single-session psychological debriefing is offered as immediate psychological assistance to survivors of all kinds of traumatic events, its efficacy in the prevention of symptoms of PTSD, anxiety or depression has not been systematically studied and empirically supported. Some studies even indicate adverse effects, which have been explained in several ways. For example, it has been argued that the stimulation of emotional ventilation (talking about what happened and about your emotions) after a traumatic event may be too overwhelming for some survivors, whereas a period of rest and reduced talking about the event may in fact be an adaptive or coping response. Furthermore, the psycho-education (provision of information re PTSD and other possible symptoms, prognosis and treatment) provided during the debriefing may increase the awareness of stress symptoms that would otherwise not have been noted.

7 In addition to debriefing, psychiatrists, psychologists and other mental health professionals use a variety of effective therapeutic methods to help people with PTSD work through their trauma and pain. Cognitive Behaviour Therapy (CBT) focuses on correcting the painful and intrusive thoughts and behaviour and thought by teaching relaxation techniques and examining (and challenging) the mental processes that are causing and/or maintaining the problem. In general, psychotherapy (e.g. CBT) focuses on helping the individual examine personal values and how behaviour and experience during the traumatic event affected them. Family therapy may also be recommended to assist the family of an individual who is experiencing post-traumatic stress symptoms. Discussion groups or peer-counselling groups encourage survivors of similar traumatic events to share their experiences and reactions to them. Group members may help one another realise that many people would have done the same thing and felt the same emotions. In summary, on the basis of current empirical (scientific) evidence, more benefits are expected from early treatment of only those patients with acute stress disorder or acute PTSD with a number of CBT sessions or sessions of cognitive therapy in order to prevent a chronic course of PTSD. Can PTSD be prevented? (Also see the comments on psychotherapy above and its role in preventing a chronic course of PTSD.) There is some preliminary evidence to suggest that intervening with a medication within hours of a traumatic event may prevent the onset of PTSD, but further work in this area is needed. Children and Trauma Even though young children may not fully understand the context of what is happening to them and around them, they are nonetheless sensitive to changes in their world. They respond to change in significant people such as parents, to changes in their environment, to changes in routine, and to changes in emotional climate. Trauma, if untreated, can have lasting effects on the child s personality development. While the child may not have the cognitive capacity to understand or remember an incident, the trauma may still have an impact on him or her. Children, despite their resilience, may not necessarily get over a trauma without some form of psychotherapy. There is a discrepancy between the adult s perception of the child s vulnerability and the child s report of their own reactions. Adults should be able to recognise and acknowledge the child s symptoms of anguish and pain. A lack of observable behaviour or symptoms does not mean that the child has come to terms with the trauma. When a child has experienced a traumatic event, it is important to allow him or her to talk about what happened, to "speak about the unspeakable". Parents often need support too and it is therefore recommended that both child and parents seek professional help.

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