Post-traumatic stress disorder

Samar Hafeez, Clinical psychologist and counsellor, Bangalore, India

Post-traumatic stress disorder (PTSD) is a psychobiological disorder that occurs in people who have experienced, witnessed or confronted a life threatening or a traumatic event, such as a natural disaster, death of loved one, a serious automobile accident, a terrorist attack, military or war situation, hostage or a holocaust situation, forced migration, physical or emotional torture or any other violent assault.

PTSD has been described by many names in the past, one amongst them is a term known as “shell shock” which was originally coined in 1915 to describe soldiers or veterans who had trapped emotional energy within them. They were experiencing involuntary shivering, muscular restlessness, crying spells, fearfulness and constant intrusions in memory after significantly damaging or traumatic events. 

PTSD does not just happen to combat veterans. Anyone can develop PTSD at any age, irrespective of gender, ethnicity, culture or nationality. An estimated one in nine women develop PTSD which is about twice as likely than men to get affected.

It is natural for anyone to feel afraid during or after a traumatic event. Fear triggers a mechanism called the “fight-or-flight” response, during which your sympathetic nervous system gets activated, thereby releasing stress hormones called adrenaline and cortisol which provide the body with an intense burst of energy to deal with the imminent danger. Nearly everyone will experience a range of reactions after a trauma, yet some people recover from initial symptoms naturally while others find it difficult to shrug off the impact of unpleasant scenarios.

Accumulating evidence suggests that intense psychological trauma can cause long-lasting alterations in the neurobiological response and in this case, the “fight-or-flight response” is active almost at all times. People with PTSD feel that danger is lurking everywhere and are on a constant lookout for escape mechanisms, which keeps them in a state of constant fear and anxiety.

Several neuroimaging studies revealed that the amygdala (small almond shaped structure in the brain which is involved in emotional valence of events and plays a critical role in the acquisition of a fear response) is hyperresponsive, leading to an exaggerated fear response. The prefrontal cortex was shown to be hyporesponsive and failed to inhibit the amygdala thereby increasing the reactive behaviour in a person with PTSD. 

Finally, researchers looked into the hippocampus (brain structure responsible for the ability to store and retrieve memories). People with severe and chronic PTSD have a smaller hippocampus and this indicates that experiencing chronic untreated PTSD may ultimately be the reason for the change and damage to the structure of the hippocampus thus making it smaller. 

Symptoms

Symptoms fall into 4 categories, beginning after a traumatic event, and some specific symptoms can vary in severity and occurrence.

1. Intrusive thoughts such as recurrent and intrusive recollections of the event; dissociative reactions like flashbacks which are so vivid, it’s like as if they are reliving the traumatic experience; recurrent distressing dreams (related to traumatic event)
2. Persistent avoidance of stimuli associated with trauma, efforts to avoid people, activities, places or objects that bring back distressing memories
3. Negative thoughts and feelings like feelings of detachment or estrangement from others or from oneself, dissociative experiences (losing touch with reality), frightening thoughts, markedly diminished activities, which the person loved to do previous to the traumatic event, distorted beliefs about oneself and others, ongoing fear, horror, anger, shame, intense guilt, restricted range of affection (e.g. unable to have loving feelings) and sense of a foreshortened future (does not expect to have a career, marriage or children etc.)
4. Increased arousal and reactivity (that were not present before the trauma) – this may include being irritable and impulsive or self-destructive behaviour, hypervigilance, problems with concentration, difficulty falling or staying asleep and an exaggerated startle response

Many experience the above-mentioned symptoms within 3 months of encountering a traumatic event, but if the symptoms begin 6 months or more after the event, then this is known as delayed PTSD. However, for a person to be diagnosed with PTSD, the symptoms should last more than 1 month accompanied by significant distress or impairment in daily functioning.

PTSD often co-occurs with other conditions like substance abuse, depression and somatoform disorders. If the trauma is prolonged in a context where the victim has little or no chance of escape, the person has a chance of developing what is known as C-PTSD (Complex post-traumatic stress disorder).

It is important to note that many factors contribute to a breakdown under excessive stress such as the intensity and length of the traumatic event, the person’s biological makeup, personality adjustment before the stressful situation and ways in which a person handles problems once the stressful situation is over.

Therapies

Several approaches to treating PTSD are available today and the most effective ones are mentioned below:

Cognitive processing therapy (CPT) is a specific type of cognitive behavioural therapy that focuses on how a traumatic event is experienced by an individual. It focuses on the ways people think of themselves and their surroundings after a traumatic event. 

CPT is generally delivered over 12 sessions and helps patients learn how to challenge and modify unhelpful beliefs related to the trauma. CPT helps people to properly appraise these unhelpful “stuck points,” and in doing so, the patient creates a new understanding and conceptualisation of the traumatic event so that it reduces its ongoing negative effects on current life and boost progress towards recuperation. This technique has proved to be effective on combat veterans, sexual assault victims and refugees, and can be provided in individual or group therapy.

Eye movement desensitisation and reprocessing therapy (EMDR) uses bilateral auditory or sensory inputs, for example back and forth eye movements or hand tapping to help one process difficult memories and thoughts and emotions related to trauma. This therapy includes three stages (past memories, present disruptions and future actions). It lessens the symptom frequency and takes into account the complete clinical picture.

Prolonged exposure therapy (PE) focuses on gradual exposures to help people with PTSD and to stop avoiding trauma reminders as avoiding reminders may help in the short term, but in the long run it prevents full recovery. PE uses imaginal or virtual exposures which involve recalling the details of trauma or related conditions and it also includes in-vivo exposures, which involve visiting the place where the traumatic event happened.

Progressive muscle relaxation technique is based on the principle that anxiety or fear producing thoughts and events cause physiological bodily tightness and tension. When a person thinks about a situation related to his anxiety, mental images activate the muscles into tension, as though expecting a blow. If one learns how to recognise which muscle groups are getting tensed, one learns to physically let go of that tension, effectively lowering emotional anxiety at that moment. This technique involves progressively tensing and relaxing different muscle groups of the body, which eventually leads to effective reduction in physiological tension. It also helps in reducing fatigue and better quality of sleep.

Post disaster debriefing sessions are typically conducted in groups after the immediate crisis has been quietened down. These sessions allow the participants in the disasters (such as aid givers) to express their feelings and emotions and to learn what people in disastrous situations have experienced. They help to “unwind” psychologically and minimise people’s emotional reactions to traumatic events.

Somatic experiencing method (SE) is a body-oriented approach to the healing of trauma. This SE approach aims at releasing traumatic shock, which is the key to altering PTSD. It offers a framework to asses where a person is “stuck” – whether in a fight, flight or freeze mode – and through that, provides clinical tools to resolve these fixated physiological states.

PTSD is a debilitating condition that is growing in prevalence and, if untreated or under-treated, it can have significant negative impacts on the sufferers, their families and ultimately society at large.

People can opt for a regular and moderate physical activity regime with therapy sessions to improve health conditions that accompany PTSD (e.g. depression, sleep disturbances and cardiovascular diseases). However, it is encouraged to see a psychologist or a trauma and PTSD therapist for face to face sessions and a speedy recovery.