PTSD: Post Traumatic Stress Disorder (FL INITIAL Autonomous Practice - Differential Diagnosis)

Post-Traumatic Stress Disorder (PTSD) is a life-altering condition that 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 "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 feelings and thoughts is especially true when talking with persons who, due to a lack of 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 in 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 then, separating posttraumatic 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 (Nordqvist, 2016).

An Acute Stress Reaction occurs when a person has experienced, witnessed, or been confronted with an event that threatens physical or psychological injury, death, or great harm. This harm could have been directed towards the individual, targeted others, or affected material objects of great value to that person, such as the loss of the World Trade Center twin towers on September 11, 2001, an occurrence that traumatized an entire nation. When exposed to such an event, especially when it is beyond that person's ability to influence or control realistically, intense feelings of helplessness, fear, or horror may result.

Be aware that helplessness, fear, and even horror are normal strong reactions to profound events. When intense, pervasive feelings linger after the event of origin has concluded, we refer to them as "post-trauma," or use the term of "post traumatic event" to acknowledge lingering turmoil that accompanies the presence of stresses yet to be resolved. The process of resolving these stresses often takes help.

PTSD is called the "I cannot stop remembering!" disease. 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 (Sareen, 2015). 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 they 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.

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. 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 unknown. Victims of PTSD are consistent, however, in showing a measurable surge of stress hormones when they are reminded of their trauma (Jain, 2016).

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 people with PTSD have 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 (RSNA, 2016). It is as though the environmental shock of the traumatic event physically produces a structural change in how 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 original event (i.e., racing heart, rapid breathing, feelings of falling, or sensations of being trapped, etc.).

Children are not exempt from the lingering effects of trauma. Younger children, in particular, may react differently 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 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 parent's reactions to the traumatic event.

Children aged six through eleven years may show extreme withdrawal, disruptive behavior, 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 the age, those who experience the effects of PTSD report continually reliving the trauma. This reliving can occur in the form of nightmares or disturbing recollections, sensations, or emotions during the day. Sleep problems, depression, and feelings of numbness or detachment are common. Sufferers may lose interest in things they once enjoyed, including experiencing affection. Irritability increased aggressiveness, and even violence can be new behaviors 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. 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 (Sareen, 2015).

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 lessening symptom duration with treatment.

An initial referral to specialty help may come from a physician or other healthcare provider, or individuals desiring assistance may schedule to meet with a provider on their own. Those qualified to evaluate the presence of PTSD are psychiatrists, psychologists, advanced nurse practitioners, and clinical social workers who possess specific training in assessing psychological problems.

Once recognized, treatment for PTSD begins with developing 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 same care. Due to individual characteristics, gains were 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 allow the survivor of a life-threatening, life-changing event to feel safe, connected, and heard. PFA starts by ensuring that the individual surviving the trauma is safely removed from the crisis and knows they are safe. The effort is made to make the person feel a distinct transition into safety by providing something to drink and eat and physical comforts such as a warm, dry blanket. The connection is made between the trauma survivor and the person giving care by asking gentle, caring questions such as "What is your name?" "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, the care provider stays available should that decision change.

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 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 individuals 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 focuses on the long-term, which will pay dividends in recovery success. 

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 or crazy, and most especially, they are not alone.
2. Talk to others – When survivors can talk about their problems with others, their feelings and 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 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 with a trained health professional at the time of the current visit. Better still, set a fixed visit schedule 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, etc. It is normal to be uncomfortable with relaxation initially. The process of relaxing quiets a person and 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 to move quickly past the disturbing thoughts and feelings you push into the background during everyday activities and find a space completely away from negative distractions.
5. Increase positive distractions – Art, work, and recreation can all distract or refocus away from negative intrusions into a person's thoughts, feelings, and emotions. Art, in particular, has greatly impacted many PTSD survivors. Something expressed in the act of creating improves mood and harmony and allows more rapid healing.
6. Exercise – We all know about endorphins these days. These "feel good" chemicals distract, encourage, and bring a feeling of peace. Do not let your client miss out on those benefits.
7. Call when you need help – Everyone has good and bad days. For those with PTSD, there will be days when the usual coping skills will not work. Know that these will happen. Plan ahead. Make arrangements 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 conscious control. Drinking and 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" and locally sponsored groups are available. 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 positively impacting another person's life. Please encourage them to help with youth programs, medical services, literacy programs, community sporting activities, etc.
11. Make an 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 people living with PTSD.
12. Move – If the location where the person lives or work creates associations with traumatic memories, then suggest they leave that area and those prompts behind. Later, when they feel up to it, there will be a benefit in returning long enough to gain mastery over the surroundings that provoke bad memories. That is then. Right now, we are coping.

Treatment for PTSD combines the best 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 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 and isolating the intrusive thoughts associated with the production of anxiety and any resulting behaviors. Stimuli that trigger thoughts that 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 each day.

Exposure Therapy (ET) is closely related to Cognitive Behavior Therapy, though there is some debate over it being an offshoot, a subsequent specialty, or merely having some things in common with CBT. ET is a confrontational educational approach where the person with PTSD is carefully educated concerning the common reactions to trauma and how to manage them (i.e. breathing training, counting, focusing past the fear, etc.). Repeatedly exposed to the past trauma in carefully controlled doses. Exposure Therapy's goal is 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 thought by refocusing the individual's attention into a back and forth series of physical movements across that person's midline. Theories of 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 who have 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 clients who are too early in their recovery for exposure to a group setting and those who may never be ready for this step.

Psychodynamic psychotherapy explores the emotional conflicts caused by a traumatic event, particularly as they relate to childhood and early life experiences (Rothbaum, 2016). Through retelling 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, and 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 are right.

Medication may be useful in symptom suppression, yet it 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 on 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, the duration of pharmacotherapy should continue at least six months to a year to reduce relapse or reoccurrence of symptoms (Stein, 2016).

Sertraline and paroxetine, which have been FDA approved for use in PTSD, and 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 may be considered with serotonin-norepinephrine reuptake inhibitors (SNRIs) or other antidepressants.

Atypical antipsychotics such as risperidone or olanzapine have shown some benefit in reducing PTSD symptoms in trials compared to placebo (Stein, 2016). 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 is anecdotal and small group studies have 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.

Pharmaceutical agents getting a guarded thumbs down in studies for help in PTSD include Mood Stabilizers, Tiagabine, Topiramate, and Divalproex (Stein, 2016). These medications have shown little to no positive use in small, 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 terror or horror incidents, our mind also seeks to cope. 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, balancing the 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. When a situation, individual, or object triggers a flashback, that individual re-experiences aspects of an event in an involuntary and usually very distressing manner. 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 by the event. 

Treatment that combines medication to help lessen symptoms and psychiatric therapy to help the mind accept and adjust to life after the distress-causing event is very helpful for most people. Using 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.

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