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General Ptsd Overview

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anthony

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Expert Consensus Treatment Guidelines For Post-traumatic Stress Disorder

A Guide For Patients and Families


If you or someone you care about has been diagnosed with post-traumatic stress disorder (PTSD), you may feel that your problem is rare and that you have to face it alone. This is not the case. There are many people in a similar situation, and lots of help is available. As many as 70% of adults in the United States have experienced at least one major trauma in their lives, and many of them have suffered from the emotional reactions that are called PTSD. It is estimated that 5% of the population currently have PTSD, and that 8% have had PTSD at some point in their lives. Women are twice as likely to have PTSD as men. Fortunately, very effective treatments for PTSD are now available to help you or your loved one overcome this problem and get back to a normal life. This guide is designed to answer the most commonly asked questions about PTSD based on answers to a recent survey of 100 experts.

WHAT IS POST-TRAUMATIC STRESS DISORDER?

The diagnosis of PTSD requires exposure to an extreme stressor and a characteristic set of symptoms that have lasted for at least 1 month.

What is an extreme stressor? Examples include:
  • Serious accident or natural disaster
  • Rape or criminal assault
  • Combat exposure
  • Child sexual or physical abuse or severe neglect
  • Hostage/imprisonment/torture/displacement as refugee
  • Witnessing a traumatic event
  • Sudden unexpected death of a loved one
Other kinds of severe (but not extreme) stress can be very upsetting but generally do not cause PTSD (such as losing a job, divorce, failing in school, the expected death of an elderly parent).

A person with PTSD has three main types of symptoms:

Re-experiencing of the traumatic event

  • Intrusive distressing recollections of the event
  • Flashbacks (feeling as if the event were recurring)
  • Nightmares (the event or other frightening images recur frequently in dreams
  • Exaggerated emotional and physical reactions to triggers that remind the person of the event.

Avoidance and emotional numbing

  • Extensive avoidance of activities, places, thoughts, feelings, or conversations related to the trauma
  • Loss of interest
  • Feeling detached from others
  • Restricted emotions.

Increased arousal
As indicated by:
  • Difficulty sleeping
  • Irritability or outbursts of anger
  • Difficulty concentrating
  • Hypervigilance
  • An exaggerated startle response.

What other problems are associated with PTSD?

The three types of symptoms of PTSD described above are the most typical reactions to traumas. However, there are other problems that are also common. Many of these will improve when the PTSD symptoms are successfully treated, but some may require additional treatment on their own.

Panic attacks

Individuals who have experienced a trauma may have panic attacks when exposed to something that reminds them of the trauma (e.g., encountering a man who looks like the rapist, riding in a car again after having had a bad accident, hearing a storm blow up after being in a destructive hurricane). A panic attack involves intense feelings of fear or discomfort that are accompanied by physical or psychological symptoms. Physical symptoms include pounding or racing heart, sweating, trembling or shaking, a feeling of shortness of breath or choking, chest pain, nausea, dizziness, chills, hot flashes, numbness, or tingling. The person may also experience psychological symptoms such as feeling unreal or detached or fearing that he is going crazy, dying, or is having a heart attack.

Severe avoidant behavior

Avoidance of reminders of the trauma is one of the characteristic symptoms of PTSD. However, sometimes the avoidance begins to extend far beyond reminders of the original trauma to all sorts of situations in everyday life. This can become so severe that the person becomes virtually housebound or is able to go out only if accompanied by someone else.

Depression

Many people become depressed after experiencing a trauma and no longer take interest or pleasure in things they used to enjoy before. They may also develop unjustified feelings of guilt and self-blame and feel that the experience was their fault, even when this is clearly not true. For example, a rape victim may blame herself for having walked in the parking lot alone early in the evening; a victim of industrial disaster may blame himself for not having noticed an imperceptible noise in the engine that preceded the explosion.

Suicidal thoughts and feelings

Sometimes the depression can become so severe that people feel that life is no longer worth living. Studies show that as many as 50% of rape victims report suicidal thoughts. If you or your loved one is having suicidal thoughts following a traumatic event, it is very important to consult a professional right away and get the help you need to overcome this.

Substance abuse

People with PTSD may turn to alcohol or drugs to try to deaden their pain. They may also misuse prescription or over the-counter drugs. Although this may seem to be an understandable reaction, inappropriate substance use greatly aggravates the person’s symptoms and makes successful treatment much more difficult. Alcohol and drugs can provide only temporary relief and, in the long run, make a bad situation much worse. Facing the problem without alcohol or drugs will help you get over it sooner and with fewer problems.

Feelings of alienation and isolation

People with PTSD need increased social support, but they often feel very alone and isolated by their experience and find it very difficult to reach out to others for help. They find it especially hard to believe that other people will be able to understand what they have gone through. PTSD symptoms may also make it difficult to function socially. For example, someone who has been assaulted by a stranger may develop a fear of all strangers. Marital and family misunderstandings are also common after a severe trauma.

Feelings of mistrust and betrayal

After going through a terrible experience, you may lose faith in other people and feel that you have been betrayed or cheated by the world, by fate, or by God. However, getting better requires reaching out and taking the chance that other people will understand. A good alliance with your therapist and/or spiritual counsellor can go a long way towards helping you reconnect.

Anger and irritability

Anger and irritability are common reactions among trauma survivors. Of course, any time we have been treated wrongly, and especially when we have been assaulted, anger is a natural and justified reaction. However, extreme anger can interfere with recovery and make it hard for a person to get along with others at home, at work, and in treatment.

Severe impairment in daily functioning

Some people with PTSD have very severe problems functioning both socially and at work or school for a long period of time after the trauma. For example, an assault victim may refuse to leave the house alone after dark, thus severely curtailing social and leisure activities. A person may lose his ability to concentrate and be unable to fulfill his obligations at work. A rape victim may become too fearful to stay alone and have to move back into her parents’ home after 10 years of independent living. Prompt treatment is crucial because it helps prevent these problems from ever developing.

Strange beliefs and perceptions

Occasionally, someone who has undergone a severe trauma may temporarily develop strange ideas or perceptions (e.g., believing that that they can communicate with or actually see a dead parent). Although these symptoms are scary and resemble delusions and hallucinations, they are usually temporary and often go away on their own.

What is the usual course after exposure to an extreme stressor?

How long psychological disturbances last after a trauma can vary greatly. Some people have few or no long-lasting effects, whereas others may continue to have problems for months or even years after the trauma and will not get better unless treated by a professional. The range of possible responses to a trauma are described below in order of severity.

Only a mild and brief response to a stressor

Although some people may have no problems at all after a terrible experience, it is more common to have at least some symptoms after a trauma. Often these go away quickly without any treatment.

Acute stress disorder

Acute stress disorder is diagnosed when symptoms last for less than 1 month, but are more severe than what most people have. This is too brief to be considered PTSD but increases the risk of later developing PTSD.

Acute PTSD

When the symptoms last for longer than 1 month and are seriously interfering with the person’s ability to function, the diagnosis is changed to PTSD. If symptoms have lasted only 1–3 months, this is called acute PTSD. Anyone who continues to have severe symptoms for longer than a month after a trauma should consult a health professional.

Chronic PTSD

If symptoms continue for longer than 3 months, this is called chronic PTSD. Once PTSD becomes established, it is less likely to improve without treatment and you should definitely get help right away.

Delayed PTSD

Although the symptoms of PTSD usually begin immediately after (or within a few weeks of) the trauma, they sometimes appear only several months or even years later. This is more likely to happen on the anniversary of the traumatic event or if another trauma is experienced, especially if it reminds the person of the original event.

This Guide was prepared by Edna B. Foa, Ph.D., Jonathan R. T. Davidson, M.D., Allen Frances, M.D., and Ruth Ross, M.A. The guide includes recommendations contained in the Expert Consensus Treatment Guidelines for Posttraumatic Stress Disorder. The Editors gratefully acknowledge the Anxiety Disorders Association of America (ADAA) for their generous help and permission to adapt their written materials. Abbott Laboratories, Bristol-Myers Squibb, Eli Lilly, Janssen Pharmaceutica, Pfizer Inc, and Solvay Pharmaceuticals provided unrestricted educational grants in support of this project. Reprinted from J Clin Psychiatry 1999;60 (suppl 16).
 
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