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Post Traumatic Stress Disorder (PTSD)Posttraumatic stress disorder (PTSD) is chronic and fairly common following an overpowering trauma (, , ). It is classified as an anxiety disorder by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The major indicators encompass:
The current DSM-IV-TR criteria for diagnosing PTSD can be found here . Many people afflicted with PTSD have other DSM-IV disorders and many try suicide for escape. Most of the description of PTSD has remained unchanged since its original designation as a separate anxiety disorder in the DSM-III in 1980 (2, 3, 4). However, the exposure criteria for diagnosis of PTSD have broadened (4). And the subjective response to that trauma has taken into account individual perceptions of that trauma (5). For that reason, it is a good idea to be aware of the criteria used in the published studies as they have changed from 1980 to 1994 when the DSM-IV was published. Where the dates do not clarify the criteria used in the references that we cite, we will state which version was used. Perhaps the most complete database and gateway to current and vetted information on PTSD can be found at the National Institute of Mental Health. For the historical evolution of the description of PTSD, there are two comprehensive books, one by Healy (6) and the other by Trimble (7). Sociodemographic PerspectiveAs part of the National Institutes of Health National Comorbidity Survey, the prevalence, severity, and comorbidity of 12-month DSM-IV mental disorders were assessed between 2001 and 2003 (). The World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview was used to interview 9,282 English-speaking respondents in the USA who were 18 or more years of age. Estimated 12-month prevalence of mental disorders was 26.2% for any disorder, 18.1% for anxiety, 9.5% for mood, 8.9% for impulse control, and 3.8% for substance abuse. Of these, 40.4% were deemed to be mild, 37.3% were moderate, and 22.3% were said to be serious. Multiple disorders were seen in 45% (23% with 3 or more diagnoses). The data indicated that although mental disorders are relatively widespread, a small percentage of the afflicted have serious cases and these folk often have more than one disorder. The reported prevalence of PTSD and associations with traumas varies with the population studied and the methods used to collect and interpret the data. The following studies illustrate the point. A survey published in 1995 of 5,877 people ages 15 to 54 years as part of the National Comorbidity Survey found the estimated lifetime prevalence of PTSD to be 7.8% (). Women and previously married people of either sex had the highest PTSD prevalence. The highest risk among women was for those who had been raped or sexually molested. Physical assaults led to 29% of women experiencing PTSD some time in their lives. Among men, the highest risk was having participated in combat and witnessing [violent death]. Combat led to a lifetime prevalence of 39% in these men. They also found that only two-thirds of those experiencing PTSD recover even after many years. Relatively few studies have looked at the epidemiology of PTSD in the general population. One such study is a nation wide general-population survey of psychiatric disorders among 2,493 people, published in 1987 (). They found PTSD prevalence to be 1% in the total population, approximately 3.5% in Vietnam veterans who had not been wounded and in civilians who had been exposed to physical attack, and 20% in wounded Vietnam veterans. Interestingly, presence of behavioral problems before the age of 15 predicted adult exposures to physical attack, and in veterans, it predicted exposure to combat and concomitant PTSD. Hyperalertness and disturbances of sleep were commonly found in the civilians as well as veterans. But, full symptoms of PTSD as described in the DSM-III were common only in wounded veterans According to a study published in 1991, 2,895 people living in North Carolina were found to have a lifetime and six-month prevalence of PTSD of 1.3% and 0.44% (). Those who had PTSD had experienced significantly more child abuse, parental separation or divorce before the age of 10, parental poverty, troubled family psychiatric history, and employment instability. Folks with PTSD seemed to have more frequent comorbid psychiatric conditions, and decreased social support. They also had increased frequency of peptic ulcers, hypertension, and bronchial asthma, and a greater rate of attempted suicide. It was more common for those with chronic vs. acute PTSD to have social phobias, exhibit greater amount of avoidance, and reduced social support. Another study published in 1991 studied 1,007 young adults from an HMO in Detroit, Michigan (). For exposure to traumatic events, the lifetime prevalence was 39.1%. Of those exposed, the rate of PTSD was 23.6%. For the whole sample, there was a lifetime PTSD prevalence of 9.2%. Risk factors for exposure to traumatic events included being male, early conduct problems, low education level, extraversion, family psychiatric problems, and family substance abuse. Risk factors for PTSD included neuroticism, pretrauma anxiety or depression, family history of anxiety, and separation from parents at an early age. There was a stronger risk of PTSD with the history of anxiety and affective disorders than with substance abuse or dependence. In 1992, a study was published that analyzed the frequency and consequences of 10 different potentially traumatic events on 1,000 adults from four southeastern USA cities (). The subjects consisted of equal numbers of men and women, blacks and whites, and younger, middle-aged, and older adults. Demographic differences included greater lifetime exposure to traumas in whites and men vs. blacks and women. Exposure in the last year was highest in young adults as was the highest PTSD rates. Black men seemed to be the most susceptible to the perceived stress of the various traumas. Of the 10 potentially traumatic events, 69% of the sample experienced at least one in their lifetime, and 21% experienced at least one in the past year. Sexual assault was associated with the highest risk for PTSD. Tragic death occurred most often. Motor vehicle accident had the worst combination of impact and frequency. Previous trauma has been shown to increase the risk for PTSD (). Consistent effects have been shown for familial psychopathology, child abuse, and preexisting psychopathology. However, trauma severity, lack of social support, and additional life stress seems to be more important than pretrauma (). A meta-analysis of 14 risk factors has demonstrated three categories of risk factors for PTSD in adults (). Each individual effect size was modest. One category that predicts PTSD in some populations consists of gender, race, and age at trauma. A second category that was more consistent in predicting PTSD, although not in all populations and dependent on the research methods, includes general childhood adversity, previous trauma, and education. And the third category that was more uniformly predictive included family psychiatric history, child abuse, and individual psychiatric history. Results from the longitudinal collaborative personality disorders study showed several interesting associations with PTSD (). Borderline personality disorders (BPD) reported the highest rates of exposure to trauma especially sexually associated, the highest rates of PTSD, and the earliest age of trauma exposure. Those folks with the more severe personality disorder such as BPD and schizotypal had more exposure to trauma and greater rates of being physically attacked either as an adult or as a child. A 35% lifetime prevalence of PTSD was reported among those with personality disorders who had experienced a trauma. Post PTSD there appears to be increased risk of other psychiatric disorders at least in women (). Using the DSM-III-R criteria, lifetime psychiatric disorders were assessed in a stratified random sample of 801 mothers of children who had participated in a study of cognitive and psychiatric outcomes related to birth weights. The women in this study had a 40% lifetime prevalence of traumatic events and 13.8% prevalence of PTSD. PTSD was associated with increased risk for alcoholism (hazards ratio = 3.0) and first-onset major depression (hazards ratio = 2.1: about the same risk as after other anxiety disorders). Women who had pre-PTSD anxiety disorders had a significantly increased risk for major depression. And pre-PTSD major depression increased the risks for exposure to PTSD inducing trauma and PTSD. In 1992, the results were published on the association of civilian stress of crime and non-crime trauma and prevalence of PTSD in a random national sample of 4,008 adult women (). Lifetime prevalence of PTSD for the total sample was 12.3% and 4.6% within the last 3 months. Lifetime prevalence of exposure to any type of trauma was 69%. Exposure to crimes that involved aggravated or sexual assault or homicide of a close friend or relative was associated with a PTSD prevalence of 36%. Crime victims vs. non-crime victims had a significantly higher prevalence of PTSD (25.8% compared to 9.4%). The 1996 Detroit Area Survey of Trauma assessed by telephone, 2,181 people, ages 18 to 45 years, for the prevalence of specific types of trauma and their risk of leading to PTSD (). Using the criteria of the DSM-IV, they found the post-trauma conditional risk of PTSD to be 9.2% in women and 6.2% in men. The overall lifetime exposure to trauma was 89.6%. Sudden unexpected death of a loved one (a close relative or friend) was the most common precipitating trauma that led to PTSD (31% of all cases). Death of a loved one occurred in 60% of those surveyed and had a 14.3% risk for PTSD. Controlling for the type of trauma, women had a higher risk of PTSD. The highest risk for PTSD was related to assaultive violence such as combat and rape (20.9%). Although the highest risk for PTSD is associated with combat, rape or physical assault, in spite of a lower risk, the unexpected death of a loved one accounted for a larger percentage of PTSD over all. The mean number of distinct traumatic events experienced by men was significantly higher than by women (5.3 vs. 4.3 respectively). Lifetime prevalence of assault was greater in the inner city, in nonwhites vs. whites (2x), in those with low education, and in those with low income (less than 25k vs. greater than 75k). It was also higher in divorced vs. married. Controlling for race, education, and income eliminated the differences in marital status and residence. Other types of trauma showed no or little association with race and socioeconomic conditions. Most types of traumas peaked between 16 and 20 years of age, and assaults declined dramatically after the age of 20. Sudden unexpected death of a loved one remained high and peaked at 41 to 45 years of age. About 26% of PTSD cases went into remission within 6 months and 40% within 1 year. More than 33% persisted for more than 5 years. PTSD in women persisted about 4 times longer than in men (mean 48.1 vs. 12.1 months). And it also persisted about 4 times longer where trauma was direct vs. experienced indirectly such as trauma to or death of a loved one (mean 48.1 vs. 12.1 months). Combat Trauma and PTSDAs if the consequences of locally malfunctioning social interactions and accidents were not enough cause for serious anxiety, manifestations of global malfunctions such as terrorism, wars in Iraq, Afghanistan, Africa, and the Middle East have spread to a larger population. As a result, our medical system needs to be more robust in discovering those who are most adversely affected. And then in order to minimize disability we need to implement as soon as possible those interventions that are based upon the best scientific evidence (). Surprisingly little is known about the differences in risk, disease evolution, and prognosis of PTSD as a result of combat trauma relative to other traumas (). Using a modified version of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and the Composite International Diagnostic Interview, 5,877 people aged 15-54 from the National Comorbidity Survey were assessed (). Of the 1,703 men who reported a traumatic event, those who listed combat as the most traumatic event compared with those who listed some other trauma as the worst, were more likely to have lifetime PTSD, delayed PTSD onset, and unresolved PTSD symptoms. They were also more likely to be physically abusive to their spouses, divorced, fired from their job, and unemployed. Published in 1993, DSM-III-R axis II personality disorders were assessed in 34 Vietnam War combat veterans who sought treatment for PTSD (). Eighteen of these veterans were inpatients. Both inpatients and outpatients had high rates of personality disorders, but inpatients vs. outpatients had a higher rate of almost all personality disorders. The most common personality disorders overall were borderline, obsessive-compulsive, avoidant, and paranoid. Inpatients had significantly greater likelihood of having paranoid, schizotypal, avoidant, and self-defeating personality disorders. It seems likely that it is important to assess axis II diagnoses when treating PTSD. A significant number of veterans suffer from sleep disorders associated with and without PTSD, alcoholism, obesity, and high blood pressure (, ). One review has stated that depending upon the study, 14 to 50% of war survivors who have been exposed to extreme trauma develop PTSD (). Iraq, Gulf War and PTSDA study conducted at Walter Reed Army Institute of Research and published in 2007 examined associations between PTSD, somatic symptoms, health care visits and absence from work among 2,863 soldiers one year after serving in Iraq (). Of these soldiers, 16.6% met the criteria for PTSD. After controlling for being wounded or injured, those folks with PTSD had significantly poorer health with more physical symptoms and greater severity of those symptoms. They also had greater number of sick calls and more missed days of work. It may be quite difficult to get an accurate assessment of the prevalence of physical and psychological illnesses prior to and after deployment of the armed forces (). In one survey of 4500 men and women of the British armed forces, only about 67% of those invited to receive health-screening questionnaires comply. And of those who did comply, those who met the criteria for PTSD, or who had alcohol related behavior were more reluctant than controls to attend a medical center for evaluation, before or after deployment Although scandal has recently (2007) revealed problems in veterans receiving care, barriers to care are not new. For example, a study published in the New England Journal of Medicine back in 2004, found that among the veterans of combat duty in Iraq and Afghanistan, there was a significant risk of mental health problems and important barriers to receiving mental health services. Those veterans who tested positive more a mental disorder were twice as likely to have concerns about the stigmatization and barriers. An anonymous survey was conducted before and after deployment. Those who went to Iraq were significantly more likely to have been in combat. Major depression, generalized anxiety, or PTSD was significantly higher in those who had been in Iraq (15.6 - 17.1 % vs. 11.2%) or before deployment to Iraq (9.3%). The biggest difference was seen in the rates of PTSD. Of those who were afflicted with any of these mental disorders, only 23 to 40% sought mental health care. Genetics and PTSDSince the middle of the 1990’s, specific neurochemical and neuropeptide systems and their affects upon particular cortical and subcortical areas have been shown to be important in reactions to fear and anxiety provoking situations (). Chronic exposure and some powerful acute exposures seem to result in dysregulation of these systems and contribute to symptoms associated with anxiety disorders such as social anxieties, PTSD, and phobias. An excellent review of the current (2005) state of identification of specific genetic predispositions to these disorders can be found in a publication by the Mood and Anxiety Disorders Research Program of the National Institutes of Mental Health (). Another good review (2003) of the genetics of PTSD can be found in reference . The reviewers point out that even though family and twin studies supports the notion of a genetic contribution, the fact that the genetic vulnerability only manifests itself after exposure to a traumatic event makes it difficult to conduct large-scale genetic linkage studies. They suggest that alternative approaches would include case-control or parental genotypes association studies for transmission disequilibrium. It has also been pointed out that the broadly defined phenotype and the comorbid association with other psychiatric illnesses along with the environmental trigger has made it even more complicated to ferret out the genetics involved (, ). Those reviewers suggest that several factors make it a better bet to investigate separate PTSD traits (e.g. auditory startle, low functioning HPA axis, and increased arousal) rather than PTSD as a whole. These confounders include genetic heterogeneity, pleiotropy (one gene with multiple effects), multiple genes, and incomplete penetrance (just a fraction of the cases carrying a specific gene manifest the specific phenotype). Neuro-endocrine System and PTSDIt appears that in PTSD there is either increased negative feedback regulation or downregulation of corticotropin releasing factor (CRF) receptors as a result of chronically increased CRF activity (). Metyrapone has been used to block the adrenal conversion of 11-deoxycortisol to cortisol by 11-beta-hydroxylase which is the last step in the pathway from cholesterol to cortisol. As a result, in the normally functioning HPA-axis, 11-deoxycortisol accumulates in the serum; and CRF and ACTH increase to try to increase the amount of cortisol. In a review of several studies (), it was seen that metyrapone administration resulted in decreased delta sleep (deep sleep) in males with PTSD, and sleep and increased ACTH was significantly decreased in PTSD. Although low cortisol levels as a result of increased negative feedback inhibition on the pituitary are often said to be characteristic of folks with PTSD, it would seem to be counterintuitive and is not always reproducible (16891568, 16594265). Yet, studies most often find an overall heightened activity of the adrenal gland and the hypothalamus (, ) Reduction in volume of the head of the hippocampus and short-term memory impairment has been noted in various populations suffering from PTSD. These include Vietnam veterans, abused women and now with veterans of the 1990-1991 Gulf War (). MRI was used to assess the volumes of the whole brain, temporal lobes, and hippocampus. In comparing 14 veterans with PTSD related to trauma in the Gulf War, 23 deployed veterans, 22 non-deployed reservists, and 29 healthy civilians, the head of the hippocampus was the only region that was shown to be smaller in the veterans with PTSD than in the healthy civilian population. Interestingly, significantly smaller whole hippocampal volume and poorer results in immediate and delayed verbal and visual retrieval was seen in the veterans and reservists when compared to the civilian population. Although animal models for PTSD are quite limited by their inability to model the nuances of psychiatric disorders, they have seen some utility if caution is exercised in their interpretations (). Restraint models in rats have been used to investigate the onset and duration of effects on some of the areas of the brain involved in emotional memories (). Chronic or repeated stress tends to increase fear and aggression, reduces spatial memory, and changes contextual fear conditioning. As a response to chronic stress, basolateral amygdala neurons grow new synapses and increase dendritic complexity. Input from the amygdala alters hippocampal spatial memory. This appears to involve suppression of neurogenesis in the dentate nucleus and shrinking of dendrites in the hippocampus and the medial prefrontal cortex. Interestingly, unlike repeated exposures to stress, a single episode of stress appears to cause a delayed alteration in basolateral amygdala synapse formation unaccompanied by changes in dendritic complexity. No reports have emerged as of this writing (2006) on effects upon the hippocampus and prefrontal cortex. Immune Response and PTSDThe role of endocrine and immunological responses in changes in somatic functioning in PTSD has been reviewed in 2006 (). Common somatic complaints in folks with PTSD include cardiovascular disease, autoimmunity, and chronic pain. The underlying mechanism for alterations in immune functions is thought to be increased activity in the HPA axis and the sympathetic-adrenal-medullary axis Psychological Treatment of PTSDAccording to the National Comorbidity Survey published in 1995, PTSD is one of the most prevalent axis I disorders for which psychological interventions are used (). Several different psychological treatments are being used for PTSD. The principle types of therapies are trauma-focused cognitive behavioral therapy (TFCBT), stress management (SM), eye movement desensitization and reprocessing (EMDR), group cognitive behavioral therapy (GCBT), supportive therapy, psychodynamic therapy, hypnotherapy, and non-directive counseling. TFCBT includes any technique that makes use of trauma focused cognitive, behavioral, or cognitive-behavioral methods. TFCBT facilitates the participant to identify and challenge distorted thinking patterns in relationship to the trauma, themselves and the external world. Exposure therapy is a popular type of TFCBT. It asks the individual to relive the trauma in their imagination. It can take several forms. One technique is to gradually re-expose the patient to various stimuli that were associated with the original trauma. Another technique is to make a detailed audio tape recounting the trauma and play it repeatedly. Psychodynamic therapy integrates the traumatic event into the individual’s overall life experience. EMDR (, ) is a popular and controversial treatment for PTSD (, , , , ). EMDR was described originally as integrating key elements of intrapsychic, behavioral, cognitive, body-oriented and interactional approaches (). Important elements include comprehensive history, especially of the trauma, and processing followed by incorporating new coping methods and more adaptive behaviors. So, EMDR is essentially a well-grounded cognitive trauma-focused cognitive behavioral therapy. But, there is one exception. And that exception is the basis for most of the controversy. That element is the use of the therapist waving a stick or light in front of the client as the client concentrates on the original trauma and its negative cognitions and tries to follow the light with his or her eyes. Francine Shapiro the discoverer of EMDR has reviewed the evidence for her idea in an article published in 2002 (). Systematic reviews of EMDR conducted between 1999 and 2006 have suggested the following. EMDR and other TFCBT appear equally efficacious, but it is unclear if eye movement makes any contribution (2006, ). A comprehensive review of the charges of pseudoscience and theoretical, historical, and empirical issues surrounding EMDR came to the following conclusions (2002, ):
In 1999 an article reviewed three recurring assumptions in EMDR literature and found little support for any of them (), and doubts that proliferation of EMDR is warranted.
Studies on the efficacy of the various psychological treatments of PTSD have often been anecdotal and have shown divergent results (, , , ). However, three recent meta-analyses have been able to sift through these studies and make recommendations as to the most effective approaches. The first of these reviews was a powerful 2005 Cochrane review of the best 29 of the randomized clinical trials (). They examined all of the above therapies except for EMDR. EMDR is controversial but popular, and was to have been the focus of a separate review, but its protocol was withdrawn. RCT’s of EMDR were then added to the PTSD review, but those results (as of April 2007) have not yet been published. We eagerly await their publication. The Cochrane Collaboration made the following conclusions: Individual and group TFCBT were both found to be effective in treating PTSD. They also found that individual TFCBT may be better than SM in treating PTSD at between 2 and 5 months post treatment A meta-analysis of papers on psychotherapy for PTSD published between 1980 and 2003 came to the following conclusions ().
a. Cognitive behavioral therapies, exposure therapies and EMDR seem to be the most effective The most conservative bottom line consensus seems to be that independent of the light waving, EMDR practitioners may be practicing sound TFBCT. Clinical TrialsClinical Trials for PTSD can be found by clicking here
References (Not indexed in PubMed)
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