The purpose of this course is to explain 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 that follows exposure to a dramatic life-changing event or series of events. We refer to experiences of horror, terror, and real or threatened injury with risk of death as being traumatic. This little word fails to convey the experience, and it is consistently hard for those who have lived through terrible events to express the profound feelings and changes that they have experienced. This is especially true when talking with persons who, due to a lack of a personal experience, may not have insight into feelings that are often beyond the description of words.
1980 brought PTSD into recognition by its inclusion in the third edition of the DSM, the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, which defined 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 amongst 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 go by such terms as soldiers 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 (Anders, 2012).
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 them, may have targeted others, or have affected material objects that of great value to that person, such as the loss of the World Trade Center twin towers on September 11, 2001 that brought shock to a nation. When exposed to such an event, especially when it is beyond that persons ability to realistically influence or control, intense feelings of helplessness, fear, and/or horror may result.
|Some events that have been recognized are experiencing or witnessing a violent death, rape, kidnapping, assault, bombing, serious accident, earthquake, flood, hurricane, tornado, wartime battle, mugging, etc.|
Be aware that helplessness, fear, even horror are normal, strong reactions to profound events. It is when these intense, pervasive feelings linger after the event of origin has concluded that we refer to them as post trauma, or a post traumatic event as a way of acknowledging lingering turmoil that accompanies the presence of stresses yet to be resolved. To resolve these stresses often takes help.
PTSD is rightly referred to as the I cant stop remembering disease. In the United States, 50 percent of all women and 60 percent of all men will experience at least one traumatic event within their lifetime. One out of every ten of these will continue to suffer from unwanted thoughts, anxieties, or fearful memories long after the distressing event is over (National Center for PTSD, April 25, 2012).
Our bodies, during high stress events, 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 for a run to safety.
Once the immediate danger is over, or at least we perceive that the risk has lessened, the 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) is a variation of PTSD. Some practitioners argue that Acute Stress Disorder is 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. The initial traumatic event must have involved actual or threatened death or serious injury, or a threat to the physical integrity of self or another person, and the person 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. They then continue to re-experience the event through thoughts, dreams, or flashbacks, and avoid stimuli that remind them of the stressor. During this time, they 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. Whether or not the high lingering 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 (AHRQ. June 6, 2012).
|(Gore, 2012) (National Center for PTSD, April 25, 2012)|
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. 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 (Ciechanowski, 2012).
In PTSD, the uniting factor is a lingering memory of the feelings, thoughts, or sights that were present during an event. These may be re-experienced along with a replay of physiological reactions felt or experienced during the time of the event (i.e. racing heart, rapid breathing, feelings of falling, or feelings of being trapped, etc.).
| Both of the following initial criterion must be present for a diagnosis of PTSD:
| Re-experiencing symptoms
(Must have at least one)
|Avoidance and numbing symptoms
(Must have one of the first two listed, plus one other from this list)
|Increased arousal symptoms
(Must have at least two)
|The general appearance of those having PTSD may also be affected.
Children are not exempt from lingering effects of trauma. Younger children 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 often present.
Adolescents aged twelve through seventeen years may have responses similar to adults.
Those who experience the effects of PTSD report a continual reliving of the trauma. This 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 used to enjoy, 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 certain 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.
|Claire is a 42-year old single female who three years ago was in a storm power-blackout. She was trapped in a dark elevator alone for several hours, awaiting rescue. Elevators now trigger a memory association, or flashback, of that horrific ordeal. To even approach an elevator leads Claire to re-experience, relive the horror of being entombed, buried alive in stale air and total darkness. Rather than experience the flashbacks Claire began an active avoidance of elevators that included decisions that altered lifestyle, career, and social connections.
Rather than seek professional help Claire feels she is dealing with a weakness or flaw in her personality, and is determined to see this through on her own.
|Currently Claire always takes the stairs. When pressed she jokingly tells friends it is for the exercise. Whenever a medical appointment or business meeting is held high in a large building she cancels, often without giving a reason. Last year her employer moved to a new building and rather than work in a high-rise office Claire changed jobs to move into a small suburban house and a job bagging groceries.|
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 (BestPractice, 2012).
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, or 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 much is shared, no two people will have the same reactions to traumatic events, nor will they benefit from exactly the same care. Due to individual characteristics, gains made and ground lost, the treatment plan will see many revisions, changes, and updates.
Ideally, care starts at the time of the traumatic incident. 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 affected is safely removed from the crisis situation. Effort is then 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. 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. In all cases, follow up contact should be arranged within one month.
|(NICE Guideline 26, 2005.)|
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 care giver 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 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 affect 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 establishing a priority of teaching skills to minimize symptoms while maximizing function in the person seeking help will pay dividends in the long run.
Positive Coping Skills for PTSD:
1. Learn about trauma and its effects By learning how PTSD affects them, survivors of trauma can recognize they are not alone. Hundreds of thousands of others have experienced what they suffer. They are not weak, nor are they crazy, and most especially they are not alone.
2.Talk to others When survivors are able to talk about their problems with others, the feelings and the emotions can be expressed outward, instead of being kept bottled in a pressure cooker. Urge the use of reasonable caution for your client. Some, who step forward to help, though they may claim special skills, are inept (i.e. trauma tourists who flock to any major disaster scene). Others are predators seeking advantage from those who are vulnerable. Help your client make good choices.
3. Establish routine visits with a health professional Questions will arise during treatment that will need to be answered. Am I the only one that feels this way? Am I abnormal? Am I a bad person? Make it a routine to set the next appointment at the time of the current visit to a trained health professional. Better still, set a fixed schedule for visiting such as the second Tuesday of each month at one p.m.
4. Practice relaxation - Never think that the ability to relax comes naturally. Relaxation is a learned skill and methods can include breathing exercises, swimming, stretching, meditation, prayer, listening to quiet music, spending time in nature, and so on. It is normal to initially be uncomfortable with relaxation. The process of relaxing quiets a person and, therefore, may allow uncomfortable physical sensations, thoughts, and sometimes emotions (things you typically distract yourself from) to intrude. Part of learning the skill of relaxation is learning how to move quickly past the disturbing thoughts and feelings that you push into the background during everyday activities and find a space completely away from distraction.
5. Increase positive distractions Art, work, recreation can all distract, or refocus away from negative intrusions into a persons thoughts, feelings, and emotions. Art in particular has had a big impact on many PTSD survivors. Something expressed in the act of creating improves mood, harmony, and allows more rapid healing.
6. Exercise We all know about endorphins these days. These feel good chemicals distract, encourage, and bring the feeling of peace. Dont let your client miss out on those benefits.
7. Call when you need help Everyone has good days and bad. For those with PTSD there will be days when the usual coping skills will not work. Know that these will happen. Plan ahead. Set up with a counselor or support person the ability to call at those times when nothing seems to work.
8. Stay far away from alcohol and street drugs For many people, alcohol and drugs seem like a reasonable aid for distraction. The thoughts, emotions, and adverse feelings that compose the primary symptoms of PTSD lurk just beyond the realm of control. Drinking and the use of recreational drugs open the door for flashbacks, nightmares, and re-experiencing the past trauma.
9. Join a support group It is often difficult for a survivor of PTSD to join a group. Knowing, and seeing, that they are not alone is worth the work. Several nationwide survivors organizations are available, as well as locally sponsored groups. By increasing contact with others, the tendency to isolate can be overcome.
10. Volunteer to help others Nothing heals the spirit like helping someone else. Encourage the contribution of time and ability so that your client can feel the benefit of making a positive impact on another persons life. Encourage them to help with youth programs, medical services, literacy programs, community sporting activities, etc.
11. Make the effort to renew personal relations with family and friends Reconnecting with family and friends from before the traumatic event eases the tendency to distrust strangers and new acquaintances felt by PTSD sufferers.
Treatment for PTSD combines the best of therapeutic approaches with medication based care. As each person and each traumatic event is 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 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 individuals attention into a back and forth series of physical movements across that persons 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 are able to 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. 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 is able to 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 fiance was trapped by their vehicles steering wheel after suffering neck trauma from airbag deployment, and was later charged with distracted driving which contributed to the crash. The fiance 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 orthopod was able to offer to her that skills among other specialists within his practice group, the groups sleep specialist in particular, could benefit Emily. Discussing Emily's case as a practice, with the orthopod and sleep specialist as point of care prescribers the following treatment regimen was developed.
|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 cars 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;
Medication alone has a poor success rate. Medication in combination with therapeutic interventions has the best overall success. If you have a client on medication alone, please urge them to seek counseling or formal therapy.
Only two medications are currently approved by the FDA for treatment of PTSD. These are the selective serotonin reuptake inhibitors (SSRIs) sertaline 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 (Alexander, 2012).
Consensus favors early pharmacotherapy for PTSD, at the time of diagnosis of 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 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 in order to reduce relapse or reoccurrence of symptoms (Stein, April 16, 2012).
Sertaline 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 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. When considering atypical antipsychotics as the primary or adjunct medication therapy, the general rule for antipsychotic administration of start low, go slow applies (Stein, April 16, 2012).
Ancillary pharmacology agents such as alpha-adrenergic receptor blockers, benzodiazepines, and mood stabilizers all show benefit, especially for instances where little or no benefit is gained with the use of SSRIs. Under current study by 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 to which existing traumatic memories come to play in response to situational or emotional triggers (Poundja, 2012).
|Some Benefit||MAO Inhibitors
|Uncertain Benefit||Atypical Antipsychotics
|(Alexander, 2012) (Stein, April 16, 2012)|
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 uses both medication to help lessen symptoms and psychiatric therapy to help the mind accept and adjust to life after the event that is causing distress 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 a 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.
AHRQ. (June 6, 2012). Interventions for the Prevention of Posttraumatic Stress Disorder in Adults after Exposure to Psychological Trauma. AHRQ Agency for Healthcare Research and Quality. Retrieved from (Visit Source) on January 19, 2013.
Alexander, W. (January 2012). Psychopharmacotherapy for Post-Traumatic Stress Disorder in Combat Veterans. Pharmacy and Therapeutics. Retrieved from (Visit Source) on January 19, 2013.
Anders, CJ, (April 4, 2012). From Irritable Heart to Shellshock: How Post Traumatic Stress Became a Disease. Io9. Retrieved from (Visit Source) on November 27, 2012.
BestPractice. (October 31, 2012). Post-traumatic Stress Disorder: Prognosis. British Medical Journal Evidence Center. Retrieved from (Visit Source) on January 19, 2013.
Ciechanowski, P., et al. (July 12, 2012). Posttraumatic Stress Disorder: Epidemiology, Pathophysiology, Clinical Manifestations, and Diagnosis. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.
Gore, TA, (April 25, 2012). Posttraumatic Stress Disorder. Medscape E-medicine. Retrieved from (Visit Source) on December 28, 2012.
National Center for PTSD. (April 25, 2012). How Common is PTSD?. U.S. Department of Veteran Affairs. Retrieved from (Visit Source) on January 15, 2013.
National Collaborating Centre for Mental Health. (March 2005). Clinical Guideline 26. Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. National Institute for Clinical Excellence (NICE). Retrieved from (Visit Source) on December 6, 2012.
Poundja, J., et al. (February 14, 2012). Trauma Reactivation Under the Influence of Propranolol: An Examination of Clinical Predictors. European Journal of Psychotraumatology. Retrieved from (Visit Source).
Stein, MB., et al. (April 16, 2012). Pharmacotherapy for Posttraumatic Stress Disorder. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.
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