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Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a term for certain psychological consequences of exposure to, or confrontation with, stressful experiences that the person experiences as highly traumatic. These experiences can involve actual or threatened death, serious physical injury, or a threat to physical and/or psychological integrity. It is occasionally called post-traumatic stress reaction to emphasize that it is a routine result of traumatic experience rather than a manifestation of a pre-existing psychological weakness on the part of the patient. more...

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Symptoms can include the following: Nightmares, flashbacks, emotional detachment or numbing of feelings (emotional self-mortification or dissociation), insomnia, avoidance of reminders and extreme distress when exposed to the reminders ("triggers"), irritability, hypervigilance, and and excesive startle response.

Experiences likely to induce the condition include:

  • childhood physical/emotional or sexual abuse
  • adult experiences of rape, war and combat exposure
  • violent attacks
  • natural catastrophes
  • life-threatening childbirth complications

For most people, the emotional effects of traumatic events will tend to subside after several months. If they last longer, then diagnosing a psychiatric disorder is generally advised. Most people who experience traumatic events will not develop PTSD. PTSD is thought to be primarily an anxiety disorder, and should not be confused with normal grief and adjustment after traumatic events. There is also the possibility of simultaneous suffering of other psychiatric disorders (i.e. comorbidity). These disorders often include major depression or general anxiety disorder

PTSD may have a "delayed onset" of years, or even decades, and may even be triggered by a specific body movement if the trauma was stored in the procedural memory, by another stressful event, such as the death of a family member or someone else close, or by the diagnosis of a life-threatening medical condition.

Also, doctors have conducted clinical studies indicating traumatized children with PTSD are more likely to later engage in criminal activities than those who do not have PTSD.


Psychological distress after trauma was reported in 1900 BC by an Egyptian physician who described hysterical reactions to trauma (Veith 1965). Hysteria was also related to "traumatic reminiscences" a century ago (Janet 1901). At that time, Sigmund Freud's pupil, Kardiner, was the first to describe what later became post-traumatic stress disorder symptoms (Lamprecht & Sack 2002).

Hippocrates utilized a homeostasis theory to explain illness, and stress is often defined as the reaction to a situation that threatens the balance or homeostasis of a system (Antonovsky 1981). The situation causing the stress reaction is defined as the "stressor", but the stress reaction, and not the stressor is what jeopardizes the homeostasis (Aardal-Eriksson 2002). Post-traumatic stress can thus be seen as a chemical imbalance of neurotransmitters, according to stress theory.

However, PTSD per se is a relatively recent diagnosis in psychiatric nosology, first appearing in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. It is said development of the PTSD concept partly has socio-economic and political implications (Mezey & Robbins 2001). War veterans were to a great deal incapacitated by psychiatric illness, including post-traumatic stress in the aftermath of the Vietnam War. However, they had difficulties receiving economic compensation since there was no psychiatric diagnosis available by which veterans could claim indemnity. This situation has changed, and PTSD is now one of several psychiatric diagnoses for which a veteran can receive compensation, such as a war veteran indemnity pension, in the US (Mezey & Robbins 2001). While PTSD-like symptoms were recognized in combat veterans following many historical conflicts, the modern understanding of the condition dates to the 1980s.


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Noah Wyle and real-life trauma; popularly known for his role as a doctor on television's top-rated drama, "ER," Noah Wyle has put his bedside manner to
From Psychology Today, 3/1/02 by Carin Gorrell

Noah Wyle is not a doctor. Nor is he a psychologist. And he's not suffering from a mental illness. But he has seen, firsthand, the face of one poignant and prevalent disorder, and it was enough to spur him into action.

"There isn't a face--it's every face," Wyle responds when I ask him to describe the face of post-traumatic stress disorder, or PTSD, a debilitating condition that some people develop after experiencing or witnessing an extremely traumatic event. The 30-year-old actor and star of NBC's "ER" had flown to New York City the day before to speak out about recognizing and treating the disorder. And these days, everyone is listening.

When terrorists attacked the country on September 11, naturally our first concern was rescuing victims, particularly those who might be alive amid the World Trade Center rubble. Soon, however, it became apparent that not only had few survived the collapse but that there was another population of survivors to worry about: those left to grapple with memories of the tragedy. Mental health practitioners rushed to Ground Zero to aid those on the front lines--firefighters, police officers, even journalists covering the story--and soon many were predicting an epidemic of PTSD.

The disorder is by no means a new one. It was first described during the Civil War as "irritable heart" by an army surgeon treating soldiers displaying symptoms including chest pains, disturbed sleep, depression and irritability. Many refer to it as "combat fatigue" or "shell shock," and it's often associated with war veterans.

But PTSD isn't always a result of an act of war or terrorism. In fact, some of the most common traumas that lead to the disorder include being raped, being sexually or physically assaulted and experiencing the sudden, unexpected death of a loved one. About 20 percent of people who experience an extreme trauma will develop the disorder, according to one study published in the Journal of Consulting Clinical Psychology, and women seem twice as susceptible to PTSD, most likely because they are more often victims of rape, sexual assault and child abuse.

Women also make up the majority of PTSD sufferers with whom Wyle has come into contact. In 1999, Wyle spent three weeks in a Macedonian refugee camp during the war in Kosovo with Doctors of the World, a nonprofit organization that provides medical care to the needy and had approached him about doing charity work.

"I was supposed to be there in an observing capacity so that I could speak intelligently about their work," Wyle admits. "But a bus would pull up with 600 people in it and women were handing their kids to me, people were running for ambulances and medical supplies, and I'm there just to watch? I don't think so." Of tile camp's 10,000 refugees, most were women and many of them had witnessed the murder of their husbands or confided they had been sexually assaulted.

"There was a certain hollowness in their eyes, a certain manic behavior," Wyle says. "I would see women scrubbing the wash, the same patch of a piece of clothing, for two or three hours. They were trying to get back into some routine of normal life, but in the refugee camp nothing was familiar." This kind of behavior is typical of a PTSD sufferer and falls into one of three sets of diagnostic symptoms associated with the disorder: avoiding reminders of the traumatic event.

"PTSD is stimulus-driven," explains Matthew Friedman, M.D., Ph.D., the executive director of the Department of Veterans' Affairs National Center for PTSD and a psychiatry and pharmacology professor at Dartmouth Medical School. "Stimuli that resemble the trauma are going to bring that trauma back to the victims. So part of PTSD involves numbing, emotional shutdown and avoidance." The second set of symptoms focuses on sufferers' tendency to continually relive the event, both while sleeping in the form of nightmares and while awake, when flashbacks occur. These images cause extreme emotional or physical reactions, including shaking, chills, heart palpitations and panic. The final set concentrates on hyperarousal, as victims are prone to irritability, sudden anger, startling easily or being unable to concentrate.

How an individual responds to a traumatic event depends, in part, on what he or she brings to the table, Friedman points out. For instance, people who have experienced a prior trauma, have a family history of psychiatric problems or grew up in a disruptive household or with abusive parents are at greater risk for developing symptoms. Amount of social support and degree of resiliency--which has both a genetic and experiential component--also play important roles.

"Most of us were impacted by September 11," says Ray Monsour Scurfield, D.S.W., L.C.S.W., an assistant professor of social work at the University of Southern Mississippi. "But after a few months, it started taking somewhat of a backseat for some people and less of a backseat for others. The key is questioning whether a person feels their memories are beyond their control. If they're wallowing in isolation and denial and painful memories--if they're a prisoner to them--it's time to seek help."

This psychological imprisonment is something Wyle likens to piecing together jigsaw puzzles. "If you do the same puzzle every day, you get the same picture every day because you've got the same pieces," he says. "But if you wake up one morning and something traumatic happens, when you put your pieces together, nothing fits right. And when you do get them to fit it makes a different picture, one somewhat grotesque. Ultimately, you just want your picture to look like it always did, but it's never going to look that way again."

After witnessing the refugees' anguish, Wyle knew he wanted to do more to help victims of trauma and violence. So when he returned to the U.S. he began working with Human Rights Watch, a human rights advocacy group. Then Dr. Carter, the character he plays on "ER," was stabbed on the show, and Wyle found himself portraying many of the symptoms he'd witnessed in Macedonia. That's when Moving Past Trauma (MPT), a community outreach program that works to increase awareness about and treatment of PTSD, asked him to be one of their spokesmen. He agreed and soon began working with Kellie Greene, another program spokeswoman.

What's noteworthy about Greene is that she's also a PTSD survivor, though by looking at her today one would never guess that there was a time when she was afraid to step foot outside of her apartment. The energetic, outgoing, 36-year-old is constantly smiling and seems ready and able to take on the world. But on January 18, 1994, Greene was attacked and brutally raped by a stranger who had followed her home. She was traumatized and subsequently unable to concentrate or make simple decisions. She also began isolating herself from her family and friends and was plagued by nightmares and flashbacks of her rape.

"Flashbacks are powerful and very frightening," Greene tells me the same morning I meet Wyle. The two were scheduled to speak throughout the day at several venues including "The Today Show" and the YWCA, which helped launch MPT's program. "You go back to the moment the trauma was happening and re-experience it; your body has all of the senses of it reoccurring." Her symptoms were unrelenting for about six months, until one night she found herself sobbing uncontrollably in the shower and contemplating suicide. Greene called her mother for help, who made an appointment for her with a psychiatrist the next morning.

"I told him everything I was going through, and then he opened a book and read all of my symptoms back to me," Greene says. "He said, `It's post-traumatic stress disorder,' and just having him validate it calmed me down." She was prescribed Zoloft, an antidepressant and selective serotonin re-uptake inhibitor (SSRI), to help assuage her symptoms. Zoloft and Paxil, also an antidepressant and SSRI, are currently the only two drugs approved by the FDA for treating PTSD. Greene's psychiatrist then worked with her for six months using cognitive restructuring--a form of cognitive behavioral therapy--along with teaching her breathing exercises that helped alleviate her panic attacks.

"The classic principle that applies to almost every PTSD therapy is therapeutic re-experiencing of an aspect of the original trauma," explains Scurfield. "The person has to learn to master the memory and be able to revisit the trauma in a way that's not overwhelming." Fortunately, the rate of recovery from PTSD is high--particularly if recognized early on--and there are numerous types of therapy for treating it. But because this field of research is relatively new, there is little empirical evidence confirming what works best and for whom.

"The evidence suggests that cognitive behavioral treatments are most effective for PTSD," Friedman says. "But a large number of people in treatment receive two types of treatment, maybe even more." The most typical combination is some form of psychotherapy plus pharmacotherapy, one that seems to have done the trick for Greene.

"I feel really good today," Greene now says. Fully recovered, she devotes her time to promoting awareness of PTSD. She began speaking publicly about her own experiences seven years ago when she joined the speakers' bureau of the Rape, Abuse & Incest National Network. She also formed her own organization, Speaking Out About Rape, where she works daily with other rape survivors.

"It was difficult at first to talk in front of a large group because the wounds were so fresh," Greene confesses. "But by sharing my experience, it was no longer a random act of violence; it had a purpose." That purpose has taken on added meaning since the events of September 11, which Greene watched unfold on television.

"I could really identify with what firefighters were feeling," she says. "I knew the dark place that these people were going to go in the months that followed. It's hell." Wyle, too, had a strong personal response to the attack. He observed the aftermath while in Los Angeles after his mother called and told him to turn on his television.

"I was shocked when I saw one shot of a thousand people walking across the Brooklyn Bridge; it looked just like a thousand refugees going across the border from Kosovo to Macedonia," Wyle says. "I was pretty dedicated [to MPT] before the attack, but if anything, I feel validated in that what we were talking about before was timely and important."

Fortunately, research suggests that most people will not develop PTSD in response to September 11. Studies show that the severity and duration of an individual's exposure to a traumatic event strongly influence the likelihood of developing PTSD. Consequently, people closest to it--those in the World Trade Center when the planes hit, for instance, or those who witnessed people jumping from windows--are more susceptible than are the majority of Americans who watched the tragedy on television.

For those who develop PTSD, symptoms most likely appear within a few days of the traumatic event. Friedman emphasizes, however, that symptoms can take months and sometimes years to surface. Even so, experts now assert that the original prediction of a PTSD epidemic after September 11 was premature and that most of us should expect normal and full recovery to take place. They also stress that experiencing symptoms of stress, anxiety and depression is a fairly predictable, well-understood response to a catastrophic event. But that doesn't imply we should ignore symptoms if they arise and linger.

"New York City has been inspirational in so many ways to people in the rest of the country," Wyle says. "But if I was going to speak to anybody here about PTSD, I'd say, `Really check in with yourself.' If you're having trouble sleeping, if images are invading your life, if you find yourself becoming desensitized, then definitely seek out medical help. The city seems to be coping very well, but that doesn't mean we should forget that there are a lot of people suffering that need not be."


To find out about treatment or locate a therapist, call or visit the Web site of any of the organizations listed below.


By George Everly, Jr.

Therapists are finding that early intervention as well as other forms of therapy can be useful tools for PTSD recovery.

Early intervention often includes structured group discussions within three to 10 days of the trauma. Participants are divided into small groups where they voluntarily talk about the traumatic event, express what their thoughts were at the time it occurred, describe the worst aspects of the event and discuss their reactions to the trauma. Professionals warn, however, that care must be taken with early intervention. Studies show that one-on-one single-session treatment shortly after trauma can diminish rather than enhance its effectiveness.

Cognitive behavioral approaches such as stress inoculation training (SIT) and prolonged exposure (PE) also are effective in relieving PTSD symptoms. Skills such as relaxation, thought stopping and guided self-dialogue form the core of SIT, whereas PE involves multiple sessions where the patient relives the traumatic experience in a safe environment until it loses its potency.

A less traditional approach called eye movement desensitization and reprocessing (EMDR), which initially required patients to fix their eyes upon the therapist's rapidly moving finger, instead now employs oscillating taps or tones while the patient concentrates upon the traumatic event in the hope of becoming desensitized to it. Controlled research on EMDR is largely supportive and many practicing clinicians report positive results with their patients.

Finally, on the pharmaceutical front, Zoloft and Paxil are the only drugs that are approved for the treatment of PTSD.

George S. Everly, Jr., Ph.D., is an adjunct professor of psychology at Loyola College in Maryland.

COPYRIGHT 2002 Sussex Publishers, Inc.
COPYRIGHT 2002 Gale Group

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