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Posttraumatic stress disorder

post-traumatic stress disorder, post-traumatic stress disorder in children
Posttraumatic stress disorder PTSDnote 1 is a mental disorder that can develop after a person is exposed to a traumatic event, such as sexual assault, warfare, traffic collisions, or other threats on a person's life1 Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in how a person thinks and feels, and an increase in the fight-or-flight response These symptoms last for more than a month after the event Young children are less likely to show distress but instead may express their memories through play1 A person with PTSD is at a higher risk for suicide and intentional self-harm2

Most people who have experienced a traumatic event will not develop PTSD2 People who experience interpersonal trauma for example rape or child abuse are more likely to develop PTSD, as compared to people who experience non-assault based trauma such as accidents and natural disasters5 About half of people develop PTSD following rape2 Children are less likely than adults to develop PTSD after trauma, especially if they are under ten years of age6 Diagnosis is based on the presence of specific symptoms following a traumatic event2

Prevention may be possible when therapy is targeted at those with early symptoms but is not effective when carried out among all people following trauma2 The main treatments for people with PTSD are counselling and medication3 A number of different types of therapy may be useful7 This may occur one-on-one or in a group3 Antidepressants of the selective serotonin reuptake inhibitor type are the first-line medications for PTSD and result in benefit in about half of people4 These benefits are less than those seen with therapy2 It is unclear if using medications and therapy together has greater benefit28 Other medications do not have enough evidence to support their use and in the case of benzodiazepines may worsen outcomes910

In the United States about 35% of adults have PTSD in a given year, and 9% of people develop it at some point in their life1 In much of the rest of the world, rates during a given year are between 05% and 1%1 Higher rates may occur in regions of armed conflict2 It is more common in women than men3 Symptoms of trauma-related mental disorders have been documented since at least the time of the ancient Greeks11 During the World Wars study increased and it was known under various terms including "shell shock" and "combat neurosis"12 The term "posttraumatic stress disorder" came into use in the 1970s in large part due to the diagnoses of US military veterans of the Vietnam War13 It was officially recognized by the American Psychiatric Association in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders DSM-III14

Play media Video explanation

Contents

  • 1 Classification
  • 2 Risk factors
    • 21 Trauma
      • 211 Foster care
      • 212 Domestic violence
      • 213 Military experience
      • 214 Refugees
    • 22 Genetics
    • 23 Drug and substance abuse
  • 3 Pathophysiology
    • 31 Neuroendocrinology
    • 32 Neuroanatomy
  • 4 Diagnosis
    • 41 Screening and assessment
    • 42 Diagnostic and statistical manual
    • 43 International classification of diseases
    • 44 Differential diagnosis
  • 5 Prevention
    • 51 Psychological debriefing
    • 52 Risk-targeted interventions
  • 6 Management
    • 61 Psychotherapy
      • 611 Cognitive behavioral therapy
      • 612 Eye movement desensitization and reprocessing
      • 613 Interpersonal psychotherapy
    • 62 Medication
      • 621 Antidepressants
      • 622 Benzodiazepines
      • 623 Glucocorticoids
      • 624 Cannabinoids
    • 63 Other
      • 631 Exercise, sport and physical activity
      • 632 Play therapy for children
      • 633 Military programs
  • 7 Epidemiology
    • 71 United States
  • 8 Veterans
    • 81 United States
    • 82 United Kingdom
    • 83 Canada
  • 9 History
  • 10 Terminology
  • 11 Research
    • 111 Psychotherapy adjuncts
  • 12 Notes
  • 13 References
  • 14 External links

Classification

PTSD was classified as an anxiety disorder in the DSM-IV, but has since been reclassified as a "trauma- and stressor-related disorder" in the DSM-5 The characteristic symptoms are not present before exposure to the traumatic event In the typical case, the individual with PTSD persistently avoids trauma-related thoughts and emotions, and discussion of the traumatic event, and may even have amnesia of the event However, the event is commonly relived by the individual through intrusive, recurrent recollections, flashbacks, and nightmares15 While it is common to have symptoms after any traumatic event, these must persist to a sufficient degree ie, causing dysfunction in life or clinical levels of distress for longer than one month after the trauma to be classified as PTSD clinically significant dysfunction or distress for less than one month after the trauma may be acute stress disorder1161718

Risk factors

No quieren They do not want to by Francisco Goya 1746–1828 depicts an elderly woman wielding a knife in defense of a girl being assaulted by a soldier19

Persons considered at risk include, for example, combat military personnel, victims of natural disasters, concentration camp survivors, and victims of violent crime Individuals frequently experience "survivor's guilt" for remaining alive while others died Causes of the symptoms of PTSD are the experiencing or witnessing of a stressor event involving death, serious injury or such threat to the self or others in a situation in which the individual felt intense fear, horror, or powerlessness20 Persons employed in occupations that expose them to violence such as soldiers or disasters such as emergency service workers are also at risk20 Other occupations that are at higher risk, including police officers, firefighters, ambulance personnel, health care professionals, train drivers, divers, journalists, and sailors, in addition to people who work at banks, post offices or in stores21 The size of the hippocampus is inversely related to post-traumatic stress disorder and treatment success; the smaller the hippocampus, the higher risk of PTSD22

Trauma

See also: Psychological resilience

PTSD is believed to be caused by the experience of a wide range of traumatic events and, in particular if the trauma is extreme, can occur in persons with no predisposing conditions2324 Most people will experience at least one traumatizing event in their lifetime25 Men are more likely to experience a traumatic event, but women are more likely to experience the kind of high-impact traumatic event that can lead to PTSD, such as interpersonal violence and sexual assault6

Posttraumatic stress reactions have not been studied as well in children and adolescents as adults6 The rate of PTSD may be lower in children than adults, but in the absence of therapy, symptoms may continue for decades6 One estimate suggests that the proportion of children and adolescents having PTSD in a non-wartorn population in a developed country may be 1% compared to 15% to 3% of adults, and much lower below the age of 10 years6 On average, 16% of children exposed to a traumatic event develop PTSD, varying according to type of exposure and gender26

Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood272829 Experiencing bullying as a child or an adult has been correlated with the development of PTSD30 Peritraumatic dissociation in children is a predictive indicator of the development of PTSD later in life31 This effect of childhood trauma, which is not well-understood, may be a marker for both traumatic experiences and attachment problems3233 Proximity to, duration of, and severity of the trauma make an impact, and interpersonal traumas cause more problems than impersonal ones34

Quasi-experimental studies have demonstrated a relationship between intrusive thoughts and intentional control responses such that suppression increases the frequency of unwanted intrusive thoughts These results suggest that suppression of intrusive thoughts may be important in the development and maintenance of PTSD35

Foster care

Adults who were in foster care as children have a higher rate of PTSDmedical citation needed

Domestic violence

An individual that has been exposed to domestic violence is predisposed to the development of PTSD However, being exposed to a traumatic experience does not automatically indicate that an individual will develop PTSD16 There is a strong association between the development of PTSD in mothers that experienced domestic violence during the perinatal period of their pregnancy36

Military experience

A US Long-Range Patrol team leader in Vietnam, 1968

77% of veterans in the United States who were wounded, in a survey self-reported PTSD as a health problem37 Early intervention appears to be a critical preventive measure38 Soldiers prepared for the potential of a traumatic experience are more prepared to deal with the stress of a traumatic experience and therefore less likely to develop PTSD16

Among American troops in Vietnam a greater portion of women experienced high levels of war-zone stress compared to theater men—399 percent versus 235 percent The key to this fact is that the vast majority 6,250 or 833% of the women who served in the war zone were nurses who dealt almost daily with death Black veterans had nearly 25 fold the risk of developing war zone-related PTSD as compared to white/other veterans Hispanics had more than three times the risk But the most revealing fact, theater veterans injured or wounded in combat had nearly four times the risk of developing PTSD compared to those not injured/wounded according to two key studies—the August 2014 National Vietnam Veterans Longitudinal Study NVVLS Paired with the late 1980s National Vietnam Veterans Readjustment Study NVVRS39

The long-term medical consequence of PTSD among male veterans who served in the Vietnam War was that they were almost twice as likely to die in the quarter of a century between the two key studies than those who did not have PTSD PTSD can have numerous clinical and occupational effects It was also found those with PTSD were more likely to die of chronic conditions such as cancer, nervous system disorders, and musculoskeletal problems The cause of this relationship is not certain other than lingering stress from combat such as nightmares, intrusive memories, and hyper-vigilance are aggravating factors contributing to psychological and physiological illnesses39

The perceived similarities between Hispanic and Vietnamese soldiers, and the discrimination Hispanic soldiers faced from their own military, made it difficult for Hispanic soldiers to dehumanize their enemy Hispanic veterans who reported experiencing racial discrimination during their service displayed more symptoms of PTSD than Hispanic veterans who did not40

PTSD is under-diagnosed in female veterans41 Sexual assault in the military is a leading cause for female soldiers developing PTSD; a female soldier who is sexually assaulted while serving in the military is nine times more likely to develop PTSD than a female soldier who is not assaulted A soldier's assailant may be her colleague or superior officer, making it difficult for her to both report the crime and to avoid interacting with her assailant again42 Until the Tailhook scandal drew attention to the problem, the role that sexual assault in the military plays in female veterans developing PTSD went largely unstudied43

Protective effects include social support, which also helps with recovery if PTSD develops4445 For more aggravating factors to recovery once home, see social alienation among returning war veterans

Refugees

See also: Migrant health

Because of their exposure to war, hardships, and traumatic events, refugees are also at an increased risk for PTSD46 The rates for PTSD within refugee populations range from 4% to 86%47 While the stresses of war impact everyone involved, displaced persons have been shown to be more affected than nondisplaced persons48

Genetics

Main article: Genetics of posttraumatic stress disorder

There is evidence that susceptibility to PTSD is hereditary Approximately 30% of the variance in PTSD is caused from genetics alone For twin pairs exposed to combat in Vietnam, having a monozygotic identical twin with PTSD was associated with an increased risk of the co-twin's having PTSD compared to twins that were dizygotic non-identical twins49 There is evidence that those with a genetically smaller hippocampus are more likely to develop PTSD following a traumatic event Research has also found that PTSD shares many genetic influences common to other psychiatric disorders Panic and generalized anxiety disorders and PTSD share 60% of the same genetic variance Alcohol, nicotine, and drug dependence share greater than 40% genetic similarities31

Several biological indicators have been identified that are related to later PTSD development Heightened startle responses and a smaller hippocampal volume have been identified as biomarkers for the risk of developing PTSD22 Additionally, one study found that soldiers whose leukocytes had greater numbers of glucocorticoid receptors were more prone to developing PTSD after experiencing trauma50

Drug and substance abuse

Play media A video discussing links between PTSD and binge drinking in survivors of the September 11 attacks

Drug abuse and alcohol abuse commonly co-occur with PTSD51 Recovery from posttraumatic stress disorder or other anxiety disorders may be hindered, or the condition worsened, by medication or substance use; resolving these problems can bring about improvement in an individual's mental health status and anxiety levels5253

Pathophysiology

Neuroendocrinology

PTSD symptoms may result when a traumatic event causes an over-reactive adrenaline response, which creates deep neurological patterns in the brain These patterns can persist long after the event that triggered the fear, making an individual hyper-responsive to future fearful situations1654 During traumatic experiences the high levels of stress hormones secreted suppress hypothalamic activity that may be a major factor toward the development of PTSD55

PTSD causes biochemical changes in the brain and body, that differ from other psychiatric disorders such as major depression Individuals diagnosed with PTSD respond more strongly to a dexamethasone suppression test than individuals diagnosed with clinical depression5657

Most people with PTSD show a low secretion of cortisol and high secretion of catecholamines in urine,58 with a norepinephrine/cortisol ratio consequently higher than comparable non-diagnosed individuals59 This is in contrast to the normative fight-or-flight response, in which both catecholamine and cortisol levels are elevated after exposure to a stressor60

Brain catecholamine levels are high,61 and corticotropin-releasing factor CRF concentrations are high6263 Together, these findings suggest abnormality in the hypothalamic-pituitary-adrenal HPA axis

The maintenance of fear has been shown to include the HPA axis, the locus coeruleus-noradrenergic systems, and the connections between the limbic system and frontal cortex The HPA axis that coordinates the hormonal response to stress,64 which activates the LC-noradrenergic system, is implicated in the over-consolidation of memories that occurs in the aftermath of trauma65 This over-consolidation increases the likelihood of one's developing PTSD The amygdala is responsible for threat detection and the conditioned and unconditioned fear responses that are carried out as a response to a threat31

The HPA axis is responsible for coordinating the hormonal response to stress31 Given the strong cortisol suppression to dexamethasone in PTSD, HPA axis abnormalities are likely predicated on strong negative feedback inhibition of cortisol, itself likely due to an increased sensitivity of glucocorticoid receptors66 PTSD has been hypothesized to be a maladaptive learning pathway to fear response through a hypersensitive, hyperreactive, and hyperresponsive HPA axis67

Low cortisol levels may predispose individuals to PTSD: Following war trauma, Swedish soldiers serving in Bosnia and Herzegovina with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels68 Because cortisol is normally important in restoring homeostasis after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD

It is thought that the locus coeruleus-noradrenergic system mediates the over-consolidation of fear memory High levels of cortisol reduce noradrenergic activity, and because people with PTSD tend to have reduced levels of cortisol, it has been proposed that individuals with PTSD cannot regulate the increased noradrenergic response to traumatic stress69 Intrusive memories and conditioned fear responses are thought to be a result of the response to associated triggers Neuropeptide Y has been reported to reduce the release of norepinephrine and has been demonstrated to have anxiolytic properties in animal models Studies have shown people with PTSD demonstrate reduced levels of NPY, possibly indicating their increased anxiety levels31

Other studies indicate that people that suffer from PTSD have chronically low levels of serotonin, which contributes to the commonly associated behavioral symptoms such as anxiety, ruminations, irritability, aggression, suicidality, and impulsivity70 Serotonin also contributes to the stabilization of glucocorticoid production

Dopamine levels in a person with PTSD can help contribute to the symptoms associated Low levels of dopamine can contribute to anhedonia, apathy, impaired attention, and motor deficits Increased levels of dopamine can cause psychosis, agitation, and restlessness70

Hyperresponsiveness in the norepinephrine system can be caused by continued exposure to high stress Overactivation of norepinephrine receptors in the prefrontal cortex can be connected to the flashbacks and nightmares frequently experienced by those with PTSD A decrease in other norepinephrine functions awareness of the current environment prevents the memory mechanisms in the brain from processing that the experience, and emotions the person is experiencing during a flashback are not associated with the current environment70

There is considerable controversy within the medical community regarding the neurobiology of PTSD A 2012 review showed no clear relationship between cortisol levels and PTSD The majority of reports indicate people with PTSD have elevated levels of corticotropin-releasing hormone, lower basal cortisol levels, and enhanced negative feedback suppression of the HPA axis by dexamethasone3171

Neuroanatomy

Regions of the brain associated with stress and posttraumatic stress disorder72

The three brain areas with changed function are the prefrontal cortex, amygdala, and hippocampus Much of this research stems from PTSD victims from the Vietnam War

For example, a prospective study using the Vietnam Head Injury Study showed that damage to the prefrontal cortex may be protective against later development of PTSD73 PTSD patients have decreased brain activity in the dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex, areas linked to the experience and regulation of emotion74

The amygdala is strongly involved in forming emotional memories, especially fear-related memories Neuroimaging studies in humans have revealed aspects of PTSD morphology and function75 During high stress, the hippocampus, which is associated with placing memories in the correct context of space and time and memory recall, is suppressed According to one theory this suppression may be the cause of the flashbacks that can affect people with PTSD When someone with PTSD undergoes stimuli similar to the traumatic event, the body perceives the event as occurring again because the memory was never properly recorded in the person's memory3176unreliable medical source

The amygdalocentric model of PTSD proposes that the amygdala is very much aroused and insufficiently controlled by the medial prefrontal cortex and the hippocampus, in particular during extinction77 This is consistent with an interpretation of PTSD as a syndrome of deficient extinction ability7778

A 2011 study found that fear extinction-induced IGF2/IGFBP7 signalling promotes the survival of hippocampal neurons in 2-3 week old newborn mice This suggests that enhancing IGF2 signalling and adult neurogenesis might be suitable to treat diseases linked to excessive fear memory such as PTSD79 Further animal and clinical research into the amygdala and fear conditioning may suggest additional treatments for the condition

The basolateral nucleus BLA of the amygdala is responsible for the comparison and development of associations between unconditioned and conditioned responses to stimuli, which results in the fear conditioning present in PTSD The BLA activates the central nucleus CeA of the amygdala, which elaborates the fear response, including behavioral response to threat and elevated startle response Descending inhibitory inputs from the medial prefrontal cortex mPFC regulate the transmission from the BLA to the CeA, which is hypothesized to play a role in the extinction of conditioned fear responses31

In a 2007 study Vietnam War combat veterans with PTSD showed a 20% reduction in the volume of their hippocampus compared with veterans having suffered no such symptoms80 This finding was not replicated in chronic PTSD patients traumatized at an air show plane crash in 1988 Ramstein, Germany81 A 2016 study strengthened theory that a smaller hippocampus increases the risk for post-traumatic stress disorder, and a larger hippocampus increases the likelihood efficacious treatment82

Diagnosis

PTSD can be particularly difficult to diagnose, because numerous factors can lead to over-reporting eg, disability and under-reporting eg, avoidance symptoms, dysfunction and distress

Screening and assessment

A number of screening instruments are used for screening adults for PTSD, as well as youth, such as the UCLA PTSD Index for DSM-IV83 The Primary Care PTSD Screen,8485 PTSD Checklist,868788 GAD-7,89 Child PTSD Symptom Scale,90 and M3 Checklist91 are other screening tools2592

The US Department of Veterans Affairs' Evidence-based Synthesis Program published an exhaustive systematic review of studies about PTSD screening instruments, fully reviewing 15 of the highest quality studies There were a total of 12 PTSD screening tools reviewed, 7 that screen for only PTSD and 5 that "screen for the psychiatric disorders commonly encountered and treated by primary care providers" The authors divided these into brief, intermediate, and multiple condition screens25 The brief screens SIPS, ADD, and PDI-4A were least useful due to poor discrimination Of the intermediate screens Breslau, M3,91 PC-PTSD,85 and SPAN, their performances were "comparable" The most used screen, the PCL or PTSD Checklist,88 was the longest one 17 items and had the most variability in cut points across various clinical populations While the 5 multidimensional screens—those that screened for multiple psychiatric conditions—performed less well than the PTSD-only screens, "this might be preferable, as 'false positives' on multidimensional screens may reflect psychiatric symptomatology requiring further evaluation" Of these multidimensional screens, "the M-3 performed better than the GAD-7 at identifying probable cases of PTSD" The M3 uses a "two-staged screening approach" that also assesses for depression, bipolar, and anxiety disorders The study concludes with recommendations for future research25

The American Academy of Child and Adolescent Psychiatry has a practice guideline for the assessment and treatment of PTSD in children and adolescents93 The American Psychiatric Association has a more general practice guideline for the assessment and management of acute stress disorder and PTSD94

A revised form of the Impact of Events scale IES-R gives a total score ranging from 0 to 8895 A score of 24 or more confers a clinical concern for PTSD, and a score of 33 is suggested to represent the best cutoff for a probable diagnosis of PTSD96

Diagnostic and statistical manual

Since the introduction of DSM-IV, the number of possible events that might be used to diagnose PTSD has increased; one study suggests that the increase is around 50%97 Various scales to measure the severity and frequency of PTSD symptoms exist9899 Standardized screening tools such as Trauma Screening Questionnaire100 and PTSD Symptom Scale101 can be used to detect possible symptoms of posttraumatic stress disorder and suggest the need for a formal diagnostic assessment

In the May 2013 DSM-5, PTSD was classified as a trauma- and stress-related disorder1

International classification of diseases

The diagnostic criteria for PTSD, stipulated in the International Statistical Classification of Diseases and Related Health Problems 10 ICD-10, may be summarized as:102

  • Exposure to a stressful event or situation either short or long lasting of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone
  • Persistent remembering, or "reliving" the stressor by intrusive flashbacks, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor
  • Actual or preferred avoidance of circumstances resembling or associated with the stressor not present before exposure to the stressor
  • Either 1 or 2:
  1. Inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor
  2. Persistent symptoms of increased psychological sensitivity and arousal not present before exposure to the stressor shown by any two of the following:
  • difficulty in falling or staying asleep
  • irritability or outbursts of anger
  • difficulty in concentrating
  • hyper-vigilance
  • exaggerated startle response

The International Statistical Classification of Diseases and Related Health Problems 10 diagnostic guidelines state:102 In general, this disorder should not be diagnosed unless there is evidence that it arose within 6 months of a traumatic event of exceptional severity A "probable" diagnosis might still be possible if the delay between the event and the onset was longer than 6 months, provided that the clinical manifestations are typical and no alternative identification of the disorder eg, as an anxiety or obsessive-compulsive disorder or depressive episode is plausible In addition to evidence of trauma, there must be a repetitive, intrusive recollection or re-enactment of the event in memories, daytime imagery, or dreams Conspicuous emotional detachment, numbing of feeling, and avoidance of stimuli that might arouse recollection of the trauma are often present but are not essential for the diagnosis The autonomic disturbances, mood disorder, and behavioural abnormalities all contribute to the diagnosis but are not of prime importance The late chronic sequelae of devastating stress, ie those manifest decades after the stressful experience, should be classified under F620

Differential diagnosis

A diagnosis of PTSD requires that the person has been exposed to an extreme stressor such as one that is life-threatening Any stressor can result in a diagnosis of adjustment disorder and it is an appropriate diagnosis for a stressor and a symptom pattern that does not meet the criteria for PTSD, for example a partner being fired, or a spouse leaving If any of the symptom pattern is present before the stressor, another diagnosis is required, such as brief psychotic disorder or major depressive disorder Other differential diagnoses are schizophrenia or other disorders with psychotic features such as Psychotic disorders due to a general medical condition Drug-induced psychotic disorders can be considered if substance abuse is involved15

The symptom pattern for acute stress disorder must occur and be resolved within four weeks of the trauma If it lasts longer, and the symptom pattern fits that characteristic of PTSD, the diagnosis may be changed15

Obsessive compulsive disorder may be diagnosed for intrusive thoughts that are recurring but not related to a specific traumatic event15

Prevention

See also: Traumatic memories

Modest benefits have been seen from early access to cognitive behavioral therapy103 Critical incident stress management has been suggested as a means of preventing PTSD, but subsequent studies suggest the likelihood of its producing negative outcomes104105 A review "did not find any evidence to support the use of an intervention offered to everyone", and that "multiple session interventions may result in worse outcome than no intervention for some individuals"106 The World Health Organization recommends against the use of benzodiazepines and antidepressants in those having experienced trauma107 Some evidence supports the use of hydrocortisone for prevention in adults, however there is limited or no evidence supporting propranolol, escitalopram, temazepam, or gabapentin108

Psychological debriefing

Trauma-exposed individuals often receive treatment called psychological debriefing in an effort to prevent PTSD103 However, several meta-analyses find that psychological debriefing is unhelpful and is potentially harmful103109110 This is true for both single-session debriefing and multiple session interventions106 The American Psychological Association judges the status of psychological debriefing as No Research Support/Treatment is Potentially Harmful111

Psychological debriefing was in the past, however, the most often used preventive measure, partly because of the relative ease with which this treatment can be given to individuals directly following an event It consists of interviews that are meant to allow individuals to directly confront the event and share their feelings with the counselor and to help structure their memories of the event This treatment has since been found to be potentially harmful103

Risk-targeted interventions

For one such method, see trauma risk management

Risk-targeted interventions are those that attempt to mitigate specific formative information or events It can target modeling normal behaviors, instruction on a task, or giving information on the event112113

Management

Further information: Treatments for combat-related PTSD An assistance dog trained to help veterans with PTSD

Systematic reviews have found that combination therapy psychological and pharmacotherapy is no more effective than psychological therapy alone114

Psychotherapy

Many forms of psychotherapy have been found to be efficacious for trauma-related problems such as PTSD Basic counseling practices common to many treatments for PTSD include education about the condition, and provision of safety and support16101

The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral programs, variants of exposure therapycitation needed, stress inoculation training SIT, variants of cognitive therapy CT, eye movement desensitization and reprocessing EMDR,115 mindfulness-based meditation116 and many combinations of these procedures117 EMDR and trauma-focused cognitive behavioral therapy TFCBT were recommended as first-line treatments for trauma victims in a 2007 review; however, "the evidence base for EMDR was not as strong as that for TFCBT Furthermore, there was limited evidence that TFCBT and EMDR were superior to supportive/non-directive treatments, hence it is highly unlikely that their effectiveness is due to non-specific factors such as attention"118 A meta-analytic comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in terms of effectiveness in treating PTSD; however, "the contribution of the eye movement component in EMDR to treatment outcome" is unclear119

Furthermore, the availability of school-based therapy is particularly important for children with PTSD Children with PTSD are far more likely to pursue treatment at school because of its proximity and ease than at a free clinic120

Cognitive behavioral therapy

Cognitive behavioral therapy CBT seeks to change the way a trauma victim feels and acts by changing the patterns of thinking or behavior, or both, responsible for negative emotions CBT has been proven to be an effective treatment for PTSD and is currently considered the standard of care for PTSD by the United States Department of Defense121122 In CBT, individuals learn to identify thoughts that make them feel afraid or upset and replace them with less distressing thoughts The goal is to understand how certain thoughts about events cause PTSD-related stress

Recent research on contextually based third-generation behavior therapies suggests that they may produce results comparable to some of the better validated therapies123 Many of these therapy methods have a significant element of exposure124 and have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms125

Exposure therapy is a type of cognitive behavioral therapy126 that involves assisting trauma survivors to re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders; this therapy modality is well supported by clinical evidencecitation needed The success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD127 Some organizationswhich have endorsed the need for exposure128129 The US Department of Veterans Affairs has been actively training mental health treatment staff in prolonged exposure therapy130 and Cognitive Processing Therapy131 in an effort to better treat US veterans with PTSD

Eye movement desensitization and reprocessing

Main article: Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing EMDR is a form of psychotherapy developed and studied by Francine Shapiro132 She had noticed that, when she was thinking about disturbing memories herself, her eyes were moving rapidly When she brought her eye movements under control while thinking, the thoughts were less distressing132

In 2002, Shapiro and Maxfield published a theory of why this might work, called adaptive information processing133 This theory proposes that eye movement can be used to facilitate emotional processing of memories, changing the person's memory to attend to more adaptive information134 The therapist initiates voluntary rapid eye movements while the person focuses on memories, feelings or thoughts about a particular trauma6135 The therapists uses hand movements to get the person to move their eyes backward and forward, but hand-tapping or tones can also be used6 EMDR closely resembles cognitive behavior therapy as it combines exposure re-visiting the traumatic event, working on cognitive processes and relaxation/self-monitoring6 However, exposure by way of being asked to think about the experience rather than talk about it has been highlighted as one of the more important distinguishing elements of EMDR136

There have been multiple small controlled trials of four to eight weeks of EMDR in adults137 as well as children and adolescents135 EMDR reduced PTSD symptoms enough in the short term that one in two adults no longer met the criteria for PTSD, but the number of people involved in these trials was small137 There was not enough evidence to know whether or not EMDR could eliminate PTSD137 There was some evidence that EMDR might prevent depression137 There were no studies comparing EMDR to other psychological treatments or to medication137 Adverse effects were largely unstudied137 The benefits were greater for women with a history of sexual assault compared with people who had experienced other types of traumatizing events such as accidents, physical assaults and war There is a small amount of evidence that EMDR may improve re-experiencing symptoms in children and adolescents, but EMDR has not been shown to improve other PTSD symptoms, anxiety, or depression135

The eye movement component of the therapy may not be critical for benefit6134 As there has been no major, high quality randomized trial of EMDR with eye movements versus EMDR without eye movements, the controversy over effectiveness is likely to continue136 Authors of a meta-analysis published in 2013 stated, "We found that people treated with eye movement therapy had greater improvement in their symptoms of post-traumatic stress disorder than people given therapy without eye movements…Secondly we found that that in laboratory studies the evidence concludes that thinking of upsetting memories and simultaneously doing a task that facilitates eye movements reduces the vividness and distress associated with the upsetting memories"115

Interpersonal psychotherapy

Other approaches, in particular involving social supports,4445 may also be important An open trial of interpersonal psychotherapy138 reported high rates of remission from PTSD symptoms without using exposure139 A current, NIMH-funded trial in New York City is now and into 2013 comparing interpersonal psychotherapy, prolonged exposure therapy, and relaxation therapy140full citation needed141142

Medication

While many medications do not have enough evidence to support their use, three fluoxetine, paroxetine, and venlafaxine have been shown to have a small benefit over placebo10 This study concluded that "the drugs included were well tolerated overall" With many medications, residual PTSD symptoms following treatment is the rule rather than the exception143

Antidepressants

Selective serotonin reuptake inhibitors SSRIs and serotonin-norepinephrine reuptake inhibitors SNRIs may have some benefit for PTSD symptoms10144 Tricyclic antidepressants are equally effective but are less well tolerated145 Evidence provides support for a small or modest improvement with sertraline, fluoxetine, paroxetine, and venlafaxine10146 Thus, these four medications are considered to be first-line medications for PTSD144147

Benzodiazepines

Benzodiazepines are not recommended for the treatment of PTSD due to a lack of evidence of benefit and risk of worsening PTSD symptoms148 Some authors believe that the use of benzodiazepines is contraindicated for acute stress, as this group of drugs promotes dissociation and ulterior revivals149 Nevertheless, some use benzodiazepines with caution for short-term anxiety and insomnia150151152 While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD and may actually increase the risk of developing PTSD 2-5 times9 Additionally, benzodiazepines may reduce the effectiveness of psychotherapeutic interventions, and there is some evidence that benzodiazepines may actually contribute to the development and chronification of PTSD For those who already have PTSD, benzodiazepines may worsen and prolong the course of illness, by worsening psychotherapy outcomes, and causing or exacerbating aggression, depression including suicidality, and substance use9 Drawbacks include the risk of developing a benzodiazepine dependence, tolerance ie, short-term benefits wearing off with time, and withdrawal syndrome; additionally, individuals with PTSD even those without a history of alcohol or drug misuse are at an increased risk of abusing benzodiazepines147153 Due to a number of other treatments with greater efficacy for PTSD and less risks eg, prolonged exposure, cognitive processing therapy, eye movement desensitization and reprocessing, cognitive restructuring therapy, trauma-focused cognitive behavioral therapy, brief eclectic psychotherapy, narrative therapy, stress inoculation training, serotonergic antidepressants, adrenergic inhibitors, antipsychotics, and even anticonvulsants, benzodiazepines should be considered relatively contraindicated until all other treatment options are exhausted7154 For those who argue that benzodiazepines should be used sooner in the most severe cases, the adverse risk of disinhibition associated with suicidality, aggression and crimes and clinical risks of delaying or inhibiting definitive efficacious treatments, make other alternative treatments preferable eg, inpatient, residential, partial hospitalization, intensive outpatient, dialectic behavior therapy; and other fast-acting sedating medications such as trazodone, mirtazapine, amitripytline, doxepin, prazosin, propranolol, guanfacine, clonidine, quetiapine, olanzapine, valproate, gabapentin4154155

Glucocorticoids

Glucocorticoids may be useful for short-term therapy to protect against neurodegeneration caused by the extended stress response that characterizes PTSD, but long-term use may actually promote neurodegeneration156

Cannabinoids

There is tentative evidence that medical cannabis may be effective at reducing PTSD symptoms, but, as of 2015update, there is insufficient evidence to confirm its effectiveness for this condition157158 Despite the uncertain evidence, use of cannabis or derived products is widespread among US veterans with PTSD159

The cannabinoid nabilone is sometimes used off-label for nightmares in PTSD Although some short-term benefit was shown, adverse effects are common and it has not been adequately studied to determine efficacy160 Additionally, there are other treatments with stronger efficacy and less risks eg, psychotherapy, serotonergic antidepressants, adrenergic inhibitors The use of medical marijuana for PTSD is controversial, with only a handful of states permitting its use for that purpose161

Other

Exercise, sport and physical activity

Physical activity can influence people's psychological wellbeing162 and physical health163 The US National Center for PTSD recommends moderate exercise as a way to distract from disturbing emotions, build self-esteem and increase feelings of being in control again They recommend a discussion with a doctor before starting an exercise program164

Play therapy for children

Play is thought to help children link their inner thoughts with their outer world, connecting real experiences with abstract thought165 Repetitive play can also be one of the ways a child relives traumatic events, and that can be a symptom of traumatization in a child or young person166 Although it is commonly used, there have not been enough studies comparing outcomes in groups of children receiving and not receiving play therapy, so the effects of play therapy are not yet understood6165

Military programs

Many veterans of the wars in Iraq and Afghanistan have faced significant physical, emotional, and relational disruptions In response, the United States Marine Corps has instituted programs to assist them in re-adjusting to civilian life, especially in their relationships with spouses and loved ones, to help them communicate better and understand what the other has gone through167 Walter Reed Army Institute of Research WRAIR developed the Battlemind program to assist service members avoid or ameliorate PTSD and related problems Wounded Warrior Project partnered with the US Department of Veterans Affairs to create Warrior Care Network, a national health system of PTSD treatment centers168169

Epidemiology

Disability-adjusted life year rates for posttraumatic stress disorder per 100,000 inhabitants in 2004170   no data   < 435   435-45   45-465   465-48   48-495   495-51   51-525   525-54   54-555   555-57   57–585   > 585

There is debate over the rates of PTSD found in populations, but, despite changes in diagnosis and the criteria used to define PTSD between 1997 and 2007, epidemiological rates have not changed significantly171

The United Nations' World Health Organization publishes estimates of PTSD impact for each of its member states; the latest data available are for 2004 Considering only the 25 most populated countries ranked by overall age-standardized Disability-Adjusted Life Year DALY rate, the top half of the ranked list is dominated by Asian/Pacific countries, the US, and Egypt172 Ranking the countries by the male-only or female-only rates produces much the same result, but with less meaningfulness, as the score range in the single-sex rankings is much-reduced 4 for women, 3 for men, as compared with 14 for the overall score range, suggesting that the differences between female and male rates, within each country, is what drives the distinctions between the countries173174

Age-standardized Disability-adjusted life year DALY rates for PTSD, per 100,000 inhabitants, in 25 most populous countries, ranked by overall rate 2004
Region Country PTSD DALY rate,
overall172
PTSD DALY rate,
females173
PTSD DALY rate,
males174
Asia / Pacific Thailand 59 86 30
Asia / Pacific Indonesia 58 86 30
Asia / Pacific Philippines 58 86 30
Americas USA 58 86 30
Asia / Pacific Bangladesh 57 85 29
Africa Egypt 56 83 30
Asia / Pacific India 56 85 29
Asia / Pacific Iran 56 83 30
Asia / Pacific Pakistan 56 85 29
Asia / Pacific Japan 55 80 31
Asia / Pacific Myanmar 55 81 30
Europe Turkey 55 81 30
Asia / Pacific Vietnam 55 80 30
Europe France 54 80 28
Europe Germany 54 80 28
Europe Italy 54 80 28
Asia / Pacific Russian Federation 54 78 30
Europe United Kingdom 54 80 28
Africa Nigeria 53 76 29
Africa Dem Republ of Congo 52 76 28
Africa Ethiopia 52 76 28
Africa South Africa 52 76 28
Asia / Pacific China 51 76 28
Americas Mexico 46 60 30
Americas Brazil 45 60 30

United States

The National Comorbidity Survey Replication has estimated that the lifetime prevalence of PTSD among adult Americans is 68%, with women 97% more than twice as likely as men70 36% to have PTSD at some point in their lives175 More than 60% of men and more than 60% of women experience at least one traumatic event in their life The most frequently reported traumatic events by men are rape, combat, and childhood neglect or physical abuse Women most frequently report instances of rape, sexual molestation, physical attack, being threatened with a weapon and childhood physical abuse70 88% of men and 79% of women with lifetime PTSD have at least one comorbid psychiatric disorder Major depressive disorder, 48% of men and 49% of women, and lifetime alcohol abuse or dependence, 519% of men and 279% of women, are the most common comorbid disorders176

The United States Department of Veterans Affairs estimates that 830,000 Vietnam War veterans suffered symptoms of PTSD177 The National Vietnam Veterans' Readjustment Study NVVRS found 152% of male and 85% of female Vietnam veterans to suffer from current PTSD at the time of the study Life-Time prevalence of PTSD was 309% for males and 269% for females In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans suffered from PTSD symptoms but not the disorder itself Four out of five reported recent symptoms when interviewed 20–25 years after Vietnam178

A 2011 study from Georgia State University and San Diego State University found that rates of PTSD diagnosis increased significantly when troops were stationed in combat zones, had tours of longer than a year, experienced combat, or were injured Military personnel serving in combat zones were 121 percentage points more likely to receive a PTSD diagnosis than their active-duty counterparts in non-combat zones Those serving more than 12 months in a combat zone were 143 percentage points more likely to be diagnosed with PTSD than those having served less than one year Experiencing an enemy firefight was associated a 183 percentage point increase in the probability of PTSD, while being wounded or injured in combat was associated a 239 percentage point increase in the likelihood of a PTSD diagnosis For the 216 million US troops deployed in combat zones between 2001 and 2010, the total estimated two-year costs of treatment for combat-related PTSD are between $154 billion and $269 billion179

As of 2013, rates of PTSD have been estimated at up to 20% for veterans returning from Iraq and Afghanistan25 As of 2013 13% of veterans returning from Iraq were unemployed180

Veterans

Vietnam Veterans Memorial, Washington, DC

United States

Main article: Benefits for US Veterans with PTSD

The United States provides a range of benefits for veterans that the VA has determined have PTSD, which developed during, or as a result of, their military service These benefits may include tax-free cash payments,181 free or low-cost mental health treatment and other healthcare,182 vocational rehabilitation services,183 employment assistance,184 and independent living support,185186

United Kingdom

In the UK, there are various charities and service organisations dedicated to aiding veterans in readjusting to civilian life The Royal British Legion and the more recently established Help for Heroes are two of Britain's more high-profile veterans' organisations which have actively advocated for veterans over the years There has been some controversy that the NHS has not done enough in tackling mental health issues and is instead "dumping" veterans on charities such as Combat Stress187188

Canada

Veterans Affairs Canada offers a new program that includes rehabilitation, financial benefits, job placement, health benefits program, disability awards, peer support189190191 and family support192

History

The 1952 edition of the DSM-I includes a diagnosis of "gross stress reaction", which has similarities to the modern definition and understanding of PTSD193 Gross stress reaction is defined as a "normal personality utilizing established patterns of reaction to deal with overwhelming fear" as a response to "conditions of great stress"194 The diagnosis includes language which relates the condition to combat as well as to "civilian catastrophe"194

Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders195 The condition was added to the DSM-III, which was being developed in the 1980s, as posttraumatic stress disorder193195 In the DSM-IV, the spelling "posttraumatic stress disorder" is used, while in the ICD-10, the spelling is "post-traumatic stress disorder"196

The addition of the term to the DSM-III was greatly influenced by the experiences and conditions of US military veterans of the Vietnam War197 Due to its association with the war in Vietnam, PTSD has become synonymous with many historical war-time diagnoses such as railway spine, stress syndrome, nostalgia, soldier's heart, shell shock, battle fatigue, combat stress reaction, or traumatic war neurosis198199 Some of these terms date back to the 19th century, which is indicative of the universal nature of the condition In a similar vein, psychiatrist Jonathan Shay has proposed that Lady Percy's soliloquy in the William Shakespeare play Henry IV, Part 1 act 2, scene 3, lines 40–62200, written around 1597, represents an unusually accurate description of the symptom constellation of PTSD201

Statue, Three Servicemen, Vietnam Veterans Memorial

The correlations between combat and PTSD are undeniable; according to Stéphane Audoin-Rouzeau and Annette Becker, "One-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and, after thirty-five days of uninterrupted combat, 98% of them manifested psychiatric disturbances in varying degrees"202 In fact, much of the available published research regarding PTSD is based on studies done on veterans of the war in Vietnam A study based on personal letters from soldiers of the 18th-century Prussian Army concludes that combatants may have had PTSD203

The researchers from the Grady Trauma Project highlight the tendency people have to focus on the combat side of PTSD: "less public awareness has focused on civilian PTSD, which results from trauma exposure that is not combat related " and "much of the research on civilian PTSD has focused on the sequelae of a single, disastrous event, such as the Oklahoma City bombing, September 11th attacks, and Hurricane Katrina"204 Disparity in the focus of PTSD research affects the already popular perception of the exclusive interconnectedness of combat and PTSD This is misleading when it comes to understanding the implications and extent of PTSD as a neurological disorder Dating back to the definition of Gross stress reaction in the DSM-I, civilian experience of catastrophic or high stress events is included as a cause of PTSD in medical literature The 2014 National Comorbidity Survey reports that "the traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women"205 Because of the initial overt focus on PTSD as a combat related disorder when it was first fleshed out in the years following the war in Vietnam, in 1975 Ann Wolbert Burgess and Lynda Lytle Holmstrom defined Rape trauma syndrome, RTS, in order to draw attention to the striking similarities between the experiences of soldiers returning from war and of rape victims206 This paved the way for a more comprehensive understanding of causes of PTSD

The DSM-IV classified PTSD under anxiety disorders, but the DSM-5 created a new category called "Trauma- and Stressor-Related Disorders," in which PTSD is now classified1

Terminology

The Diagnostic and Statistical Manual of Mental Disorders does not hyphenate 'post' and 'traumatic', thus, the DSM-5 lists the disorder as posttraumatic stress disorder However, many scientific journal articles and other scholarly publications do hyphenate the name of the disorder, viz, post-traumatic stress disorder207 Dictionaries also differ with regard to the preferred spelling of the disorder with the Collins English Dictionary - Complete and Unabridged using the hyphenated spelling, and the American Heritage Dictionary of the English Language, Fifth Edition and the Random House Kernerman Webster's College Dictionary giving the non-hyphenated spelling208

Research

Most knowledge regarding PTSD comes from studies in high-income countries209

To recapitulate some of the neurological and neurobehavioral symptoms experienced by the veteran population of recent conflicts in Iraq and Afghanistan, researchers at the Roskamp Institute and the James A Haley Veteran’s Hospital Tampa have developed an animal model to study the consequences of mild traumatic brain injury mTBI and PTSD210 In the laboratory, the researchers exposed mice to a repeated session of unpredictable stressor ie predator odor while restrained, and physical trauma in the form of inescapable foot-shock, and this was also combined with a mTBI In this study, PTSD animals demonstrated recall of traumatic memories, anxiety, and an impaired social behavior, while animals subject to both mTBI and PTSD had a pattern of disinhibitory-like behavior mTBI abrogated both contextual fear and impairments in social behavior seen in PTSD animals In comparison with other animal studies,210211 examination of neuroendocrine and neuroimmune responses in plasma revealed a trend toward increase in corticosterone in PTSD and combination groups

Psychotherapy adjuncts

MDMA was used for psychedelic therapy for a variety of indications before its criminalization in the US in 1985 In response to its criminalization, the Multidisciplinary Association for Psychedelic Studies was founded as a nonprofit drug-development organization to develop MDMA into a legal prescription drug for use as an adjunct in psychotherapy212 The drug is hypothesized to facilitate psychotherapy by reducing fear, thereby allowing people to reprocess and accept their traumatic memories without becoming emotionally overwhelmed In this treatment, people participate in an extended psychotherapy session during the acute activity of the drug, and then spend the night at the treatment facility In the sessions with the drug, therapists are not directive and support the patients in exploring their inner experiences People participate in standard psychotherapy sessions before the drug-assisted sessions, as well as after the drug-assisted psychotherapy to help them integrate their experiences with the drug213 The phase 2 clinical trails of the MDMA-Assisted Psychotherapy, was publicized at the end of November 2016214 Preliminary results suggest MDMA-assisted psychotherapy might be effective215 MAPS is currently waiting for the FDA approval of the phase 3 as of early 2017216

Research is also investigating using D-cycloserine, hydrocortisone, and propranolol as add on therapy to more conventional exposure therapy217

Notes

  1. ^ Acceptable variants of this term exist; see the Terminology section in this article

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External links

Classification
  • ICD-10: F431
  • ICD-9-CM: 30981
  • MeSH: D013313
  • DiseasesDB: 33846
External resources
  • MedlinePlus: 000925
  • eMedicine: med/1900
  • Patient UK: Posttraumatic stress disorder
  • Psychiatry portal
  • Posttraumatic stress disorder at DMOZ
  • Resources for the public from VA National PTSD Center
  • Resources for professionals from VA National PTSD Center
  • Post Traumatic Stress Disorder Information Resource from The University of Queensland School of Medicine
  • AACAP practice parameters for assessment and treatment for PTSD

post-traumatic stress disorder, post-traumatic stress disorder (ptsd), post-traumatic stress disorder checklist, post-traumatic stress disorder chronic, post-traumatic stress disorder dsm 5 criteria, post-traumatic stress disorder icd 10, post-traumatic stress disorder in children, post-traumatic stress disorder in the national comorbidity survey, post-traumatic stress disorder symptoms, post-traumatic stress disorder treatment


Posttraumatic stress disorder Information about

Posttraumatic stress disorder


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    29.10.2014


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