The purpose of this course is to discuss the reality of post-traumatic stress disorder (PTSD) and to explain ways to help those suffering to recover and live a healthy life, post-trauma.
At the conclusion of this course the learner will be able to:
Post-Traumatic Stress Disorder (PTSD) is a life-altering condition which may occur following exposure to a dramatic life-changing event or series of such events. We refer to experiences of horror, terror, and threatened, (real or perceived), injury with the risk of death as being “traumatic.” This little word fails to convey the scope of the experience, and it is consistently hard for those who have lived through those terrible events to express the profound feelings and changes they have suffered. This inability to articulate one's feeling and thoughts is especially true when talking with persons who, due to a lack of a personal experience, may not have full insight into feelings that are often beyond the description of words.
1980 brought PTSD into recognition by its inclusion into the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association, which defines the grouping of symptoms within the syndrome. Until that time, separating post-traumatic stress from the throws of severe grief or depression had been clouded by disagreeing perceptions and competing definitions among professionals in the mental health fields.
The presence of lingering traumatic effects among survivors of horrific events is historically well documented among the writings of scholars, philosophers, and healers since ancient times. Herodotus, the Greek historian for example, among his essays detailed the experience of one soldier in the battle of Marathon, 490 BC, describing how the man went blind after witnessing the brutal death of a soldier standing next to him, though the blinded man himself survived the struggle without physical injury. Recognition of cognitive, emotional, or physical effects that linger long after witnessing or being involved in traumatic events goes by such terms as soldier’s heart, shell shock, combat fatigue, compensation sickness, stress response syndrome, or the term common to those of us from the previous generation, Post-Vietnam Syndrome.1
An Acute Stress Reaction occurs when a person has experienced, witnessed, or been confronted with an event which threatens physical or psychological injury, death, or great harm. This harm could have been directed towards the individual, may have targeted others, or have affected material objects that possess great value to that person, such as the loss of the World Trade Center twin towers on September 11, 2001, an occurrence which traumatized an entire nation. When exposed to such an event, especially when it is beyond that person’s ability to realistically influence or control, intense feelings of helplessness, fear, and/or horror may result.
A large study incorporating 24 countries rated the probability and frequency of traumatic events associated with the development of PTSD;
Be aware that helplessness, fear, even horror are normal strong reactions to profound events. It is when intense, pervasive feelings linger after the event of origin has concluded that we refer to them as “post-trauma,” or use the term of “post traumatic event” as a way of acknowledging lingering turmoil that accompanies the presence of stresses yet to be resolved. The process of resolving these stresses often takes help.
PTSD is rightly referred to as the “I can’t stop remembering!” disease. In overall population studies in the United States and Canada, the lifetime occurrence of PTSD ranged from 6.8 to 12.3 percent of the adult population with women generally having around four times higher rates of lingering traumatization to horrific events.2 Please be aware that no demographic group is completely spared from the risk of PTSD in response to exposure to extreme events. Lingering fear and horror can affect any of us given the right circumstance.
During high-stress events, our bodies release adrenaline, a chemical responsible for increasing blood pressure, heart rate, pulse, and the transfer of glucose to muscles. It does this automatically and immediately in the face of fear, without conscious volition. This “hard-wired” response to terror primes our physiology to fight for our lives, or to make a run to safety.
Once the immediate danger is over, or at least once the perceive risk has lessened, our body initiates a cascade of chemical reactions designed to “defuse” the reaction fear initiated. This closing down, or damping, of the stress response is linked to an essential hormone known as cortisol.
Acute Stress Disorder (Acute Stress Reaction, ASD) is a variation of PTSD. Some practitioners argue that Acute Stress Disorder is, in fact, an initial stage or precursor of the longer duration PTSD which frequently follows. Acute Stress Disorder lasts for a minimum of two days and a maximum of four weeks and occurs within four weeks of the initial stressing event. A diagnosis of ASD is made when the initial traumatic event involved actual or threatened death or serious injury, or a threat to the physical integrity of one’s self or another person, and the person with acute symptoms must have felt fear, helplessness, or horror.During the event, or immediately after, those experiencing this early onset disorder will experience some of the following: numbing, detachment, derealization, depersonalization or dissociative amnesia. The individual then continues to re-experience the event through thoughts, dreams, or flashbacks and avoids stimuli that remind them of the stressor. During this time, they are likely to report symptoms of anxiety and significant impairment in at least one essential area of functioning.
Research has determined that if your body is low or lacking in the hormone cortisol, you will not be able to effectively or efficiently shut down the stress reaction prompted by the impulse for flight or fight. Without adequate cortisol, you continue to feel the stress effects caused by adrenaline for a much longer time. Some studies have shown that victims of trauma who possess a higher “normal” level of catecholamines (stimulating hormones of which adrenaline is a member) tend to develop PTSD in greater numbers than those without the elevated levels. Whether or not the lingering high levels of stress hormones cause traumatic memories to be “imprinted” or remembered in much greater clarity and detail than would otherwise be the case, is not yet known. Victims of PTSD are consistent, however, in showing a measurable surge of stress hormones when they are reminded of their trauma.4
Whether physical changes to the brain occur from heightened levels of stress hormones, as some believe, or those hormones are merely contributing factors, it is clear that the brains of PTSD sufferers have actually been changed during the traumatic event. Researchers, using both magnetic resonance imaging (MRI) and positron emission tomography (PET) scans, have shown that the brain changes the way it stores memories in those who have PTSD.6 It is as though the environmental shock of the traumatic event physically produces a structural change in the manner that a person stores memories. How this happens, or even why, is not yet certain.
In PTSD, the uniting factor is a lingering memory of feelings, thoughts, or images that remain present for some time following an extreme event. These stored sensations may be re-experienced along with a replay of any physiological reactions felt or experienced during the time of the original event (i.e. racing heart, rapid breathing, feelings of falling, or sensations of being trapped, etc.).
Diagnosis of PTSD may only occur when all of the following criteria are present or addressed. Once met, one of two specifications may (or may not) be added to the core diagnosis of PTSD:
Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):
Criterion B (one required): The traumatic event is persistently re-experienced, in the following way(s):
Criterion C (one required): Avoidance of trauma-related stimuli after the trauma, in the following way(s):
Criterion D (two required): Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):
Criterion E (two required): Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):
|Criterion F (required): Symptoms last for more than one month.|
|Criterion G (required): Symptoms create distress or functional impairment (e.g., social, occupational).|
|Criterion H (required): Symptoms are not due to medication, substance use, or other illness.|
Dissociative Specification. In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:
|Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although the onset of symptoms may occur immediately.|
Children are not exempt from lingering effects of trauma. Younger children, in particular, may have different reactions to trauma than adults. For children aged five years or younger, typical reactions can include a fear of being separated from a parent or caretaker, crying, whimpering, screaming, immobility and/or aimless motion, trembling, frightened facial expressions, and excessive clinging. Parents may also notice regressive behaviors. Children of this age tend to be strongly affected by their parents' reactions to the traumatic event.
Children aged six through eleven years may show extreme withdrawal, disruptive behavior, and/or an inability to pay attention. Regressive behaviors, nightmares, sleep problems, irrational fears, irritability, refusal to attend school, outbursts of anger, and fighting are also common. The child may have somatic complaints with no medical basis. Schoolwork often suffers. Also, depression, anxiety, feelings of guilt, and emotional numbing are frequently present.
Adolescents aged twelve through seventeen years may have responses similar to adults.
No matter what the age, those who experience the effects of PTSD report a continual reliving of the trauma. This reliving can occur in the form of nightmares and/or disturbing recollections, sensations, or emotions that occur during the day. Sleep problems, depression, feelings of numbness or detachment are common. Sufferers may lose interest in things that they once enjoyed, including experiencing affection. Irritability, an increase in aggressiveness, and even violence can be new behaviors that they did not exhibit before.
Many with PTSD report experiencing distress when seeing events, objects, or persons which remind them of the traumatic event. It is common to avoid key places, situations, or people who provoke recall of events they would like to forget. Dates, such as the anniversary of the triggering event, can be especially difficult.
Ordinary, commonplace events can serve as memory association triggers for intrusive images or flashbacks. Typically, a flashback is a disassociation from reality with a reenactment or intensely real memory of the traumatic event. An individual reliving a flashback can experience sounds, smells, images, and even feelings from the original event, and often believes that the event is occurring all over again. Flashbacks may last seconds or hours. Rarely, a flashback may last for days.
PTSD, with treatment, has an average duration of around 36 months. For those individuals who forgo treatment or for whom treatment is not available, the rate of recovery runs a rough average duration of 64 months. Whether treated or not, approximately one-third of those persons reporting PTSD symptoms will be unable to recover to pre-event levels of function.2
Seeking help is where the journey toward health begins. Although PTSD will, for some, heal in time without professional help, studies have consistently shown a higher rate of recovery and a lessening of symptom duration with treatment.
An initial referral to specialty help may come from a physician or other healthcare provider, or an individual desiring assistance may schedule to meet with a provider on their own. Those qualified to make an evaluation for the presence of PTSD are psychiatrists, psychologists, advanced nurse practitioners, and clinical social workers who possess specific training in the assessment of psychological problems.
Once recognized, treatment for PTSD begins with the development of a treatment plan specific to that individual. Although sufferers share much, no two people will have the same reactions to traumatic events, nor will they benefit from the exact the same care. Due to individual characteristics, gains made and ground lost, all treatment plans are destined to see many revisions, changes, and updates.
Ideally, care starts at the time of the traumatic event. What is being termed Psychological First Aid (PFA) is showing promise as an immediate post-crisis intervention. The object of PFA is to immediately give the survivor of a life threatening, life changing event the opportunity to feel safe, feel connected, and feel heard. PFA starts by first making sure that the individual surviving the trauma is safely removed from the crisis situation, and knows they are safe. The effort is made to make the person feel a distinct transition into safety by providing something to drink, to eat, and physical comforts such as a dry, warm blanket. The connection is made between the survivor of the trauma and the person giving care by asking gentle, caring questions such as “What is your name?” and “Are you in pain?” and “Would you like to talk to me about it?” The focus is to reconnect socially and personally without putting pressure on the person. If they express a desire not to talk, then the care provider simply stays available should that decision change.
|As a follow-up to PFA, where symptoms are mild and have been present for less than four weeks from the time of trauma, the practice of
Should be considered by healthcare professionals as a care option.1 In all cases, follow up contact should be arranged within one month.8
An important part of PFA is to let survivors know that feelings of stress in the forms of anger, shame, or guilt are natural and normal following any profoundly disturbing event. The caregiver will make an effort to provide places to go and people to call should that person want to talk to health professionals or to other persons who have lived through similar experiences. Making this effort at the time of first contact, sometimes referred to as a post-crisis debriefing, provides a means of offsetting the common tendency toward isolation and bottling up of feelings that often follow traumatic events. PFA ends with the process of initiating connections for follow-up.
Coping with PTSD is the next level of care for those individuals who are affected by feelings, memories, and emotions that challenge their quality of life. Teaching coping skills is often a part of treatment; however, the rationale for discussing coping before and separate from treatment is the grim fact that there will be no quick fix, no magic bullet for PTSD. Treatment will take the form of a gradual, daily process and establish a priority of teaching skills to minimize symptoms while maximizing function in the person seeking help. It is a focus on the long-term which will pay dividends in recovery success.
Positive Coping Skills for PTSD:
Treatment for PTSD combines the best of therapeutic approaches with medication based care. As each person and each traumatic event are different, no one approach is applicable for every person requiring treatment. For most, medication and therapeutic interventions together are more successful than either alone.
Cognitive Behavioral Therapy (CBT) is often the therapeutic intervention of choice for those with PTSD. CBT focuses on separating out and isolating the intrusive thoughts associated with the production of anxiety and any resulting behaviors. Stimuli that trigger thoughts that in turn promote adverse recollection and reaction are systematically exposed and, where possible, associated with positive responses rather than negative, traumatic ones. CBT helps the individual no longer need to avoid situations or places that remind them of the traumatic event. In most cases, CBT initially begins with one-to-one sessions and the use of a journal, audiotapes, or videotape by the client to record their thoughts and insights as they occur throughout each day.
Exposure Therapy (ET) is closely related to Cognitive Behavior Therapy, though there is some debate over it being an offshoot, subsequent specialty, or merely just having some things in common with CBT. ET is an educational confrontational approach where the person with PTSD is carefully educated concerning the common reactions to trauma, ways of managing them (i.e. breathing training, counting, focusing past the fear, etc.), then being repeatedly exposed to the past trauma in carefully controlled doses. The goal of Exposure Therapy is an ability to be in the presence of reminders of the event without anxiety or fear. ET is sometimes referred to as desensitization therapy.
Eye movement Desensitization and Reprocessing (EMDR) is a relatively new, and at times hotly debated, treatment for traumatic memories that uses learned physical movements (eye movements, hand taps, etc.) to purposely draw attention from a thought by refocusing the individual’s attention into a back and forth series of physical movements across that person’s midline. Theories as to how this diversion/distraction process works are still being refined and no one can truly say they know exactly why this process of attentional alteration helps those suffering from PTSD. However, for many it does help and the goal, after all, is about results.
Group Therapy is often used either exclusively or as a component of the overall treatment. Survivors can achieve some understanding and resolution of their trauma within the safety, cohesion, and empathy of a group of persons who truly understand how it is to feel the shame, guilt, rage, fear, doubt, and self-condemnation of PTSD. Not everyone will benefit from Group Therapy. Be alert for those clients that are too early in their recovery for exposure to a group setting, as well as for those who may never be ready for this step.
Psychodynamic Psychotherapy is about exploring the emotional conflicts caused by a traumatic event, particularly as they relate to childhood and early life experiences.9 Through the retelling of the event from the perspective of one who experienced it, to a (and here is the key) calm, empathic, compassionate, nonjudgmental therapist, the survivor of the event can build self-esteem, confidence, better ways of thinking, coping, and living. Gentle guidance in this journey is offered as needed should the therapist feel the timing and ability to cope is right.
Emily is a 38-year old tax accountant who was a passenger in a two-car collision. She remembers sitting at the side of the road with a broken arm, listening to the cries for help from the second vehicle where an older couple was trapped in a burning vehicle. Bystanders were unable to free them. Emily’s fiancée was trapped by their vehicle’s steering wheel after suffering neck trauma from airbag deployment and was later charged with distracted driving which contributed to the crash. The fiancée walked away from Emily and their life together after charges were dismissed at the request of the family of the deceased.
Emily immediately began suffering regular nightmares and sleep problems. She refused to travel anywhere in a private vehicle and experienced shortness of breath and dizziness when using public transport. She began to purposefully miss appointments made with counselors and psychiatrists as a way of avoiding situations she regarded as judgmental.A good therapeutic relationship formed between Emily, the orthopedic surgeon treating her arm, and his office staff.
Utilizing the therapeutic relationship Emily’s orthopedist was able to offer to her that skills among other specialists within his practice group, the group’s sleep specialist, in particular, could benefit Emily. Discussing Emily’s case in a group practice setting, with the orthopedist and sleep specialist as point of care prescribers, the following treatment regimen was developed for Emily.
At six months sleep was better; however flashbacks and triggered unwanted responses were beginning to intrude, as evidenced by a near arrest for beating on a sports car's windshield with a shopping bag as the driver attempted to make an illegal turn while chatting on a cellular phone. Modifications to the existing treatment regimen consisted of;
|At fourteen months Emily has concluded six months of weekly CBT and reports unwanted memories and night terrors now occur only infrequently, and the coping skills she has mastered are sufficient to deal with them when they do occur. Emily has been off pharmacologic therapy for three months now, without adverse effects. She expresses a desire to continue her support group, of which she is now an assistant group leader for others dealing with trauma-related effects, and she has “friended” the practice group onto her Facebook account.|
Medication may be useful in symptom suppression, yet alone has a poor success rate for overcoming PTSD. Medication in combination with therapeutic interventions has the best overall success rate. If you have a client on medication alone, please urge them to seek counseling or formal therapy.
Currently, the FDA approves only two medications for the treatment of PTSD. These are the selective serotonin reuptake inhibitors (SSRIs) sertraline and paroxetine HCl. Consequently, the pharmacologic treatments offered for PTSD are largely composed of medications whose primary focus is in control of the symptoms of PTSD such as insomnia, anxiety, and depression.
Consensus opinion favors initiation of early pharmacotherapy for PTSD, at the time of diagnosis of the persistence of symptoms, e.g. symptom presence for at least four weeks following the initiating event. While the advantages of early pharmacologic intervention in traumatic stress have yet to be proven empirically, in theory, the addition of medication treatment as soon as possible may prevent symptom chronicity, and when effective, duration of pharmacotherapy should continue at least six months to a year to reduce relapse or reoccurrence of symptoms.10
Sertraline and paroxetine, which have been FDA approved for use in PTSD, along with other SSRIs form the first-line medication treatment for traumatic stress symptoms. Typically, SSRIs are initiated at the low end of their therapeutic range and titrated up until a positive response occurs. Should no benefit be seen at six to eight weeks into treatment a different medication regimen, perhaps with serotonin-norepinephrine reuptake inhibitors (SNRIs) or other antidepressants should be considered.
Atypical antipsychotics such as risperidone or olanzapine have shown some benefit in reducing PTSD symptoms in trials compared to placebo.10 When considering atypical antipsychotics as the primary or adjunct medication therapy, the general rule for antipsychotic administration of “start low, go slow” applies.
Ancillary pharmacology agents such as alpha-adrenergic receptor blockers, benzodiazepines, and mood stabilizers all show benefit, especially for instances where little or no symptom control is gained with the use of SSRIs. Under current study by the National Institute of Mental Health (NIMH) is the beta-blocker propranolol, which in anecdotal and small group studies has shown potential for disrupting the laying down of traumatic images in memory and lessening the degree of which existing traumatic memories come to play in response to situational or emotional triggers.
Pharmaceutical agents getting a guarded thumbs down in studies for help in PTSD include10; Mood Stabilizers, Tiagabine, Topiramate, and Divalproex. These medications have shown little to no positive use in small, though well-constructed studies. As always, individual needs and clinician judgment should guide treatment decisions.
Ketamine is a new contender for symptom control in PTSD. While not currently approved for this use, a clinical trial of intravenous Ketamine in randomly selected PTSD sufferers showed what is described as a “meaningful reduction in PTSD and depressive symptoms”. While more studies are needed, keep an eye open for the introduction of this new agent into the battle against PTSD symptoms.
Feelings of fear, uncertainty, guilt, or dread following a life threatening, life altering traumatic event are completely normal. As our body processes the stress chemicals released by incidents of terror or times of horror, our mind seeks to cope as well. For most, a balance will eventually be restored, though the process is by no means easy and may not be quick. For some, perhaps as many as thirty percent, of those exposed to traumatic events, the balancing of mind, psyche, and emotion will take much longer.
PTSD is our name for the grouping of symptoms composed of intrusive memories, feelings, and reactions that extend into the lives of those who survived a trauma. These symptoms may continue for months, even years, after the event itself took place. When a situation, individual, or object triggers a flashback, that individual re-experiences aspects of an event in a manner that is involuntary and usually very distressing. When this occurs, it is important to know that they are not weird or abnormal. Their thoughts have simply been prompted, or triggered, to recall the particularly vivid memories instilled into them by the event.
Treatment that combines both medication to help lessen symptoms and psychiatric therapy to help the mind accept and adjust to life after the distress causing event are, for most people, very helpful. The use of coping skills provides means and methods to get through each day, one day at a time.
There is life, health, and happiness after an event of profound trauma. It may take work to reach it, yet by increasing our knowledge and ability; we can help survivors of horror achieve health without fear.
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)
Advance Practice Nurse Pharmacology Credit, CPD: Practice Effectively, Psychiatric