Post-Traumatic Stress Disorder, or PTSD, is
a psychiatric disorder that can occur following the experience or witnessing of
life-threatening events such as military combat, natural disasters, terrorist
incidents, serious accidents, or violent personal assaults like rape. People
who suffer from PTSD often relive the experience through nightmares and
flashbacks, have difficulty sleeping, and feel detached or estranged, and these
symptoms can be severe enough and last long enough to significantly impair the
person’s daily life.
PTSD is marked by clear biological changes
as well as psychological symptoms. PTSD is complicated by the fact that it
frequently occurs in conjunction with related disorders such as depression,
substance abuse, problems of memory and cognition, and other problems of
physical and mental health. The disorder is also associated with impairment of
the person’s ability to function in social or family life, including
occupational instability, marital problems and divorces, family discord, and
difficulties in parenting.
PTSD is not a new disorder. There are
written accounts of similar symptoms that go back to ancient times, and there
is clear documentation in the historical medical literature starting with the
Civil War, where a PTSD-like disorder was known as "Da Costa’s
Syndrome." There are particularly good descriptions of post-traumatic
stress symptoms in the medical literature on combat veterans of World War II
and on Holocaust survivors.
Careful research and documentation of PTSD
began in earnest after the Vietnam War. The National Vietnam Veterans Study
estimated in 1988 that the prevalence of PTSD in that group was 15.2% at that
time, and that 30% had experienced the disorder at some point since returning
from Vietnam.
PTSD has subsequently been observed in all
veteran populations that have been studied, including World War II, Korean
conflict, and Persian Gulf, and in United Nations peacekeeping forces deployed
to other war zones around the world. PTSD also appears in military veterans in
other countries with remarkably similar findings – that is, Australian Vietnam
veterans experience much the same symptoms as American Vietnam veterans.
PTSD is not only a problem for veterans,
however. Although there are unique cultural- and gender-based aspects to the
disorder, it occurs in both men and women, adults and children, Western and
non-Western cultural groups, and all socioeconomic strata. A national study of
American civilians conducted in 1995 estimated that the lifetime prevalence of
PTSD was 5% in men and 10% in women.
Most people who are exposed to a traumatic,
stressful event experience some of the symptoms of PTSD in the days and weeks
following exposure. Available data suggest that about 8% of men and 20% of
women go on to develop PTSD, and roughly 30% of these individuals develop a
chronic form that persists throughout their lifetimes.
The course of chronic PTSD usually involves
periods of symptom increase followed by remission or decrease, although for
some individuals symptoms may be unremitting and severe. Some older veterans
who report a lifetime of only mild symptoms have experienced significant
increases following retirement, severe medical illness in themselves or their
spouses, or reminders of their military service such as reunions or media
broadcasts of the anniversaries of war events.
In recent years a great deal of research has
been aimed at development and testing of reliable assessment tools. It is
generally thought that the best way to diagnose PTSD – or any psychiatric
disorder, for that matter – is to combine findings from structured interviews
and questionnaires with physiological assessments. A multi-method approach is
especially helpful to address concerns that some patients might be either
denying or exaggerating their symptoms.
An estimated 7.8 percent of Americans will
experience PTSD at some point in their lives, with women (10.4%) twice as
likely as men (5%) to have PTSD. About 3.6 percent of U.S. adults ages 18 to 54
(5.2 million people) have PTSD during the course of a given year. This
represents a small proportion of those who have experienced a traumatic event
at some point in their lives, for 60.7% of men and 51.2% of women reported at
least one traumatic event. The traumatic events most often associated with PTSD
are: for men: rape, combat exposure, childhood neglect, and childhood physical
abuse. For women: rape, sexual molestation, physical attack, being threatened
with a weapon, and childhood physical abuse.
About 30 percent of the men and women who
have spent time in war zones experience PTSD. An additional 20 to 25 percent
have had partial PTSD at some point in their lives. Thus more than half of all
male Vietnam veterans and almost half of all female Vietnam veterans have
experienced "clinically serious stress reaction symptoms." PTSD has
also been detected among veterans of the Gulf War, with some estimates running
as high as 8 percent.
1. Those who experience greater
stressor magnitude and intensity, unpredictability, uncontrollability , sexual
(as opposed to nonsexual) victimization, real or perceived responsibility, and
betrayal.
2. Those with prior vulnerability
factors such as genetics, early age of onset and longer-lasting childhood
trauma, lack of functional social support, and concurrent stressful life
events.
3. Those who report greater perceived
threat or danger, suffering or being upset, terror, and horror or fear.
4. Those with a social environment
which produces shame, guilt, stigmatization, or self-hatred.
PTSD is associated with a number of distinctive
neurobiological and physiological changes. PTSD may be associated with stable
neurobiological alterations in both the central and autonomic nervous systems,
such as altered brainwave activity, decreased volume of the hippocampus, and
abnormal activation of the amygdala. Both of these brain structures are
involved in the processing and integration of memory . The amygdala has also
been found to be involved in coordinating the body's fear response.
Psychophysiological alterations associated
with PTSD include hyperarousal of the sympathetic nervous system, increased
sensitivity of the startle reflex, and sleep abnormalities.
People with PTSD tend to have abnormal
levels of key hormones involved in response to stress. Thyroid function seems
to be enhanced in people with PTSD. Some studies have shown that cortisol
levels are lower than normal and epinephrine and norepinephrine are higher than
normal. People with PTSD also continue to produce higher than normal levels of
natural opiates after the trauma has passed. An important finding is that the
neurohormonal changes seen in PTSD are distinct from, and actually opposite to,
those seen in major depression; also, the distinctive profile associated with
PTSD is seen in individuals who have both PTSD and depression.
PTSD is associated with increased likelihood
of co-occurring psychiatric disorders. In a large-scale study, 88 percent of
men and 79 percent of women with PTSD met criteria for another psychiatric
disorder. The co-occurring disorders most prevalent for men with PTSD were
alcohol abuse or dependence (51.9 percent), major depressive episode (47.9
percent), conduct disorder (43.3 percent), and drug abuse and dependence (34.5
percent). The disorders most frequently comorbid with PTSD among women were major
depressive disorder (48.5 percent), simple phobia (29 percent), social phobia
(28.4 percent) and alcohol abuse/dependence (27.9 percent).
PTSD also makes a significant impact
on psychosocial functioning, independent of comorbid conditions. For instance,
Vietnam veterans with PTSD were found to have profound and pervasive problems
in their daily lives. This included problems in family and other interpersonal
relationships, employment, and involvement with the criminal justice system.
Headaches, gastrointestinal
complaints, immune system problems, dizziness, chest pain, or discomfort in
other parts of the body are common in people with PTSD. Often, medical doctors
treat the symptoms without being aware that they stem from PTSD.
Most people who are exposed to a traumatic
stressor experience some of the symptoms of PTSD in the days and weeks
following exposure. Available data suggest that among individuals who go on to
develop PTSD, roughly 30 percent develop a chronic form that persists
throughout an individual’s lifetime. The course of chronic PTSD usually has
periods of symptom exacerbation and remission or decrease, although for some
individuals symptoms may persist at an unremitting, severe level. Some older
veterans who report a lifetime of no or only mild symptoms have experienced
symptom exacerbations following retirement, severe medical illness in
themselves or their spouses, or exposure to reminders of their military service
(such as reunions or media broadcasts of the anniversaries of war events).
PTSD is treated by a variety of forms of
psychotherapy and drug therapy. There is no definitive treatment, and no cure,
but some treatments appear to be quite promising, especially
cognitive-behavioral therapy, group therapy, and exposure therapy, in which the
patient repeatedly relives the frightening experience under controlled
conditions to help him or her work throughout the trauma. Studies have also
shown that medications help ease associated symptoms of depression and anxiety
and help ease sleep. The most widely-used drug treatments for PTSD are the
selective serotonin reuptake inhibitors, such as Prozac and Zoloft. At present,
cognitive-behavioral therapy appears to be somewhat more effective than drug
therapy, but it would be premature to conclude that drug therapy is less
effective overall since drug trials for PTSD are at a very early stage. Drug
therapy definitely appears to be highly effective for some individuals and is
helpful for many more. Also, the recent findings on the biological changes
associated with PTSD have spurred new research into drugs that target these
biological changes, which may lead to much increased efficacy.