Post Traumatic Stress Disorder (PTSD) - What is it? | Stress Articles

By: David Reeves

The purpose of this article is to discuss the meaning/definition of PTSD, not the rights or wrongs of the different treatment models, and as such these notes are meant only as a guide in helping to recognise and understand the nature of stress caused by trauma.

Adults suffering from childhood related traumas such as physical, psychological and/or sexual abuse, can suffer quite a number of the symptoms discussed in this article. Theirs is a form of longer term PTSD and is not to be confused with the person who has suffered trauma as an adult. In such cases the term Prolonged Duress Stress Disorder (PDSD) may be more appropriate.

Doctors have for a long time noted that traumatic events can lead to psychological disturbance.

The two categories of events that can cause PTSD are man made and natural disasters. We have: assault, rape, burglary, torture, war, hostage situations, acts of terrorism; then there are earthquakes, storms, fires, floods, animal attacks, car, sea, rail and air disasters, the list goes on and on. These are the sort of events that are so removed from our everyday experience that even the healthiest of people are ill equipped to cope with them. Usually the symptoms of PTSD appear within 3 months of the trauma, but it can take up to 6 months to appear. Some times people can keep a lid on their symptoms until something triggers a reaction to an event that happened years before. On the face of it, it appears that it has taken years for the PTSD to manifested its self; in fact it has been found that the person in question has always had the defining symptoms, but has managed to hide them from the outside world.

Who will develop problems after trauma?

Research into the effects of trauma have shown that, in general, the more devastating and terrifying the trauma is, the more likely it is that a person exposed to it will develop psychiatric symptoms. Aspects of the disaster or trauma which increase the likelihood of psychiatric distress include a lack of warning about the event, injury during the trauma, death of a loved one, exposure to the grotesque (e.g., maimed bodies), darkness, experiencing the trauma alone, torture, and the possibility of recurrence. However, it should be emphasized that it is not necessary to experience torture or to see bodies and blood in order to develop psychiatric problems after trauma. Researchers are less sure, at this time, what factors protect some people from psychiatric illness following exposure to trauma. - (American Psychiatric Association)

A Brief History

For as long as wars or disasters have been occurring, people who have been involved in them have been at risk of PTSD. Many different labels have been attached to the stress symptoms/reactions depending on the traumatic events preceding the onset of a set of symptoms. These are a few of the names that have at one time or other been given to stress disorders associated with traumatic incidents.

1. Shell-shock
2. Combat/War Neurosis
3. Traumatic Neurosis
4. Rape trauma syndrome
5. Nuclearisim
6. Operational Fatigue
7. Fright Neurosis
8. Survivor Syndrome
9. Compensation Neurosis

Following the Great Fire of London in 1666, Samuel Pepys reportedly suffered from nightmares and intrusive imagery.

During the American Civil War, a syndrome called "Soldiers Heart" was diagnosed, which was very similar to today's Post Traumatic Stress Disorder.

As we have gotten more understanding of how people react to traumatic events, the definition and treatment of PTSD has changed. There is an urban myth that in the First World War soldiers who showed signs of the disorder were shot. Whilst a soldier was not shot for showing signs of the disorder, it was often mistaken for a weakness in the person's psychological make up. In 1919 (Southard) this diagnosis changed to shell shock, in 1941 (Kardiner) it became 'traumatic neurosis', and in 1974 (Burgess and Holstrom) 'rape trauma syndrome'.

There was intense debate during the first half of the 20th century on the actual cause of these syndromes.

Freud, Janet, Breurer and Charcot suggested that psychological trauma caused hysterical/physical symptoms, but their views were not widely accepted. The general consensus at the time was that an event no matter how traumatic in itself was not a sufficient cause of post trauma symptoms.

Researchers looked mainly for organic causes. Many doubted that the symptoms were real, suggesting that they were the result of malingering for the purpose of gaining compensation after such things as road traffic accidents. This became known as 'Compensation Neurosis'. Unfortunately, this is a fact that has to be taken in to consideration when presented with a set of symptoms by someone who is going through the legal system after a traumatic incident. Such cases can distract from the genuine sufferer, tarring everyone with the same brush.

Eventually, the symptoms were attributed to psychological dysfunctions. It was hypothesized that those with unstable personalities, such as pre-existing unresolved neurotic conflicts, were more likely to develop chronic post trauma states. With this in mind, from before the Second World War, the United States armed forces carried out extensive psychological testing/screening of recruits, rejecting any who were thought to be psychologically unsound.

This view was held until the War in Vietnam was well under way. A change in the way the medical profession and researchers viewed their long standing ideas on trauma came about with the realisation that many war veterans (who had been psychologically screened) were showing signs of long term psychological trauma. This convinced researchers that, if they are exposed to horrific enough stressors, people with sound personalities can and do develop clinically significant psychological symptoms.

The fact that traumatic events such as rape, natural or man made disasters, and war/combat situations, give rise to a characteristic pattern of psychological symptoms, was finally given due credence.

It was in 1980 that the American Psychiatric Association introduced the term Post Traumatic Stress Disorder (PTSD), as a diagnostic category into the Diagnostic and Statistical Manual of Mental Disorders, third edition DSM-III. They said "PTSD is induced by events generally outside the range of normal human experience; events so stressful that they can produce symptoms in almost anyone exposed to them. Normal Stress Management will have little if any effect with PTSD".

This was updated in 1994 and again in 1999 DSM-1111. (see Criteria below)

In 1992 it was added to the World Health Organization's International Classification of Diseases ICD-10 classification F43.1.

For quite some time, the focus of PTSD was on a single life-threatening event or threat to integrity. It was thought that PTSD could not be a result of "normal" events such as bereavement, business failure, interpersonal conflict, marital disharmony, working for the emergency services, etc. The bulk of the research on PTSD seems to have been undertaken in the USA with people who had suffered a threat to life such as combat veterans (especially from Vietnam), victims of accident, disaster, and acts of violence.

It is now recognized that the disorder can result from many types of shocking experiences. However, the symptoms of traumatic stress can also arise from an accumulation of small incidents rather than one major incident.

Examples include:

1. Repeated involvement in dealing with serious crime, e.g. where violence has been used and especially where children are killed or injured.
2. Repeated exposure to horrific scenes at accidents/disasters or fires, such as those endured by members of the emergency services (e.g. murder, bodies - burnt, mutilated, disfigured, dismembered or disembowelled, etc)
3. Repeatedly having to inform people of bereavement caused by accident or violence, again particularly if children are involved.
4. The sudden destruction of a home or community.
5. Seeing another person who has recently been killed or is being seriously injured.
6. A serious threat or perceived threat to one's own life, possible harm to children or spouse.
7. Having to suffer repeated incidents such as in verbal abuse, physical abuse and sexual abuse, regular intrusion and violation, both physical and psychological, as in domestic violence, stalking, harassment, bullying, etc.

Where the symptoms are the result of a series of events over a long period of time, the term Prolonged Duress Stress Disorder (PDSD) may be more appropriate. Whilst PDSD is not yet an official diagnosis in the World Health Organization's ICD-10, it is often used in preference to other terms such as "rolling PTSD" and "cumulative stress".

In summary, PTSD is a natural emotional reaction to a deeply shocking and disturbing experience. It is a normal reaction to an abnormal situation.

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There are now several recognized bodies who give a definition of PTSD. Information in this article has been obtained from several sources, including The American Psychiatric Association and the World Health Organization's International Classification of Diseases.

Definition

PTSD is classed as an anxiety disorder. A person may develop this disorder after witnessing or experiencing a traumatic event, or events of an extremely overwhelming nature, during which they felt intense horror, helplessness, or fear.

The most prevalent features of PTSD are:

1. Hyper-arousal causing irritability
2. Constantly being on alert for danger
3. Re-experiencing of the trauma in the form of intrusive emotions, nightmares and flashbacks
4. Emotional numbing, where the sufferer does not respond to emotional stimulation.

I have included the criteria from the American Psychiatric Association to give you a more comprehensive overview of current thinking.

Criteria

American Psychiatric Association. (1994) Criteria for Post Traumatic Stress Disorder.

The person has been exposed to a traumatic event in which both of the following sections A and B have been present.

1. 1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
      
      
   2. The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behaviour.
      
      
2. The traumatic event is persistently re-experienced in one (or more) of the following ways:
   
   
   1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
      
      
   2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
      
      
   3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and disassociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific re-enactment through play may occur.
      
      
   4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
      
      
   5. Physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.
      
      
3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
   
   
   1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
      
      
   2. Efforts to avoid activities, places, or people that arouse recollections of the trauma.
      
      
   3. Inability to recall an important aspect of the trauma.
      
      
   4. Markedly diminished interest or participation in significant activities.
      
      
   5. Feeling of detachment or estrangement from others.
      
      
   6. Restricted range of affect. (e.g., unable to have loving feelings)
      
      
   7. Sense of a foreshortened future. (e.g., does not expect to have a career, marriage, children, or a normal life span)
      
      
4. Persistent symptoms of increased arousal (not present before the trauma) as indicated by at least two of the following:
   
   
   1. Difficulty falling or staying asleep.
      
      
   2. Irritability or outbursts of anger.
      
      
   3. Difficulty concentrating.
      
      
   4. Hyper vigilance.
      
      
   5. Exaggerated startle response.
      
      
5. The symptoms on Criteria B, C and D last for more than one month.
   
   
6. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
   
   

Conclusion

The majority of PTSD is caused by a single, life-threatening event or threat to integrity. However, the symptoms of traumatic stress can also arise from an accumulation of small incidents rather than one major incident. In some cases the symptoms of PTSD disappear with time, whereas in others they persist for many years. PTSD often leads to other psychiatric problems, such as depression. Research (USA) shows that it hits more females than males.

Many people do need professional treatment to recover from the psychological damage that can result from being involved in or witnessing an overwhelmingly traumatic incident. Not everyone who experiences trauma will need treatment; some may recover with the help of friends and family.

Before a doctor or professional stress consultant can make a diagnosis, there are strict diagnostic criteria which have to be met. This is achieved by asking a series of questions or listening to talk about an event or events in the person's life which they feel significantly changed their behavior and the way they see the world.

The person may or may not know that they have PTSD, but they will know what happened to them. They may not be able to remember all of the details or they may deny or disavow the experience. Even if they try to deny or disavow it, they will still relive their experiences, over and over again. It can take the form of nightmares, and/or flashbacks, and they are prone to lapse into disassociative states. They will re-experience the trauma when exposed to events that resemble or symbolise some elements of the actual traumatic situation. It never stops. Nightmares, and/or flashbacks are the most reported of all the symptoms.

Through a series of debriefing sessions, the person is encouraged to bring up their feelings and emotions. Strong feelings of guilt (e.g. why did I survive when everyone else died?) are often associated with the PTSD sufferer, who may have to go through the experience and the attached emotions several times until they finally reach a catharsis, thus releasing their negative thoughts/feelings, and allowing the negative emotions to dissipate. This is unlike standard Psychoanalysis where the person normally only has to go through the past emotions the once.

Whilst for many years it was thought that only people with a predisposition to trauma would suffer from PTSD, long term research has shown that PTSD is a natural emotional reaction to a deeply shocking and disturbing experience/s. It is a normal reaction to an abnormal situation, and as such can be felt by anybody who has been involved in the sort of traumatic life-threatening events discussed in this article.

It was found that people with pre-psychological conditions and those with out pre-existing problems were equally as likely to suffer PTSD. It seems that your pre-existing psychological state has little bearing on your reaction to traumatic events. It is your understanding and interpretation of the events unfolding around you that determines your reaction.

I think the ancient Greek philosopher Epictatus (55 AD-135AD) summed it up when he said, 'It is not things in themselves which trouble us, but our opinion of things.' It is not what happens to you which leads you to be happy or unhappy, but how you interpret what happens to you.

If you are suffering from PTSD or indeed any sort of psychological problem, remember, it is not a sign of weakness to ask for or to seek professional help.

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David Reeves, works as a Hypnoanalyst and Stress Management consultant in Swindon and Harley Street London, and the USA. He has trained in Battle Field Stress Disorders, and is a member of the International Stress Management Association (UK), The International Association of Hypnoanalysts (UK), and The International Society for Professional Hypnosis (USA, Incorporated under the laws of State of New York), The National Guild of Hypnotists, (USA) The European Therapy Studies Institute, and The Hypnothink Foundation.
Contact: Mindtech Associates