Post traumatic stress disorder

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Overview
Posttraumatic Stress Disorder (PTSD) is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. It is a severe and ongoing emotional reaction to an extreme psychological trauma. This stressor may involve someone's actual death or a threat to the patient's or someone else's life, serious physical injury, or threat to physical and/or psychological integrity, to a degree that usual psychological defenses are incapable of coping. It is important to make a distinction between PTSD and Traumatic stress, which is a similar condition, but of less intensity and duration. The condition has also been known historically or colloquially as shell shock, traumatic war neurosis, or post-traumatic stress syndrome (PTSS).

Traumatic experiences

 * Childhood physical, emotional, or sexual abuse, including prolonged or extreme neglect; also, witnessing such abuse inflicted on another child or an adult
 * Experiences and interactions that are experienced as psychological "attacks"; for example a continual perception of psychological force, invalidation or annihilation.
 * Experiencing (including witnessing) an event perceived as life-threatening, such as:
 * 1) a serious accident
 * 2) medical complications or serious illness such as cancer
 * 3) violent physical assault or witnessing such an event, including torture
 * 4) adult experiences of sexual assault
 * 5) warfare, policing and other occupations exposed to violence or disaster
 * 6) violent, life threatening, natural (or man made) disasters
 * 7) incarceration

Diagnostic criteria
The diagnostic criteria for PTSD, per the Diagnostic and Statistical Manual of Mental Disorders IV (Text Revision) (DSM-IV-TR), may be summarized as:
 * A. Exposure to a traumatic event
 * B. Persistent reexperience
 * C. Persistent avoidance of stimuli associated with the trauma
 * D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep or hypervigilance)
 * E. Duration of symptoms more than 1 month
 * F. Significant impairment in social, occupational, or other important areas of functioning

Notably, criterion A (the "stressor") consists of two parts, both of which must apply for a diagnosis of PTSD. The first (A1) requires that "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." The second (A2) requires that "the person’s response involved intense fear, helplessness, or horror." The DSM-IV-TR criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience." Since the introduction of DSM-IV, the number of possible PTSD traumas has increased and one study suggests that the increase is around 50%.

Treatment
Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling for PTSD includes education about the condition and provision of safety and support. Cognitive therapy shows good results, and group therapy may be helpful in reducing isolation and social stigma. The psychotherapy programs with the strongest demonstrated efficacy are all cognitive behavioral programs and include variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and combinations of these procedures. Exposure involves assisting trauma survivors to therapeutically confront distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders.

Prolonged Exposure
Exposure therapy is a very effective treatment designed to help a traumatized person learn to confront safe but feared memories and situations through gradual prolonged exposure (PE). Over time, prolonged exposure therapy reduces the debilitating anxiety and avoidance centered on the feared memories and situations, allowing the person to lead a more normal life. With prolonged exposure, the patient is instructed to revisit the traumatic event by imagining that it is currently happening. The person provides detailed descriptions of all thoughts, physical sensations, and emotional reactions to the memory. This is repeated several times over the course of therapy, and it is taped to be listened to later as homework.

PTSD patients are also exposed to real life situations and objects that trigger anxiety and avoidance. Each person, place, situation and activity that triggers anxiety and avoidance is identified and evaluated for safety and relevance to the patient's normal functioning. These things are then repeatedly confronted until the anxiety and avoidance centered on them goes away. Therapy starts small and works its way to more feared and challenging situations.

CISM
Early intervention after a traumatic incident, known as Critical Incident Stress Management (CISM) is often used to reduce traumatic effects of an incident, and potentially prevent a full-blown occurrence of PTSD. However recent studies regarding CISM seem to indicate iatrogenic effects. Six studies have formally looked at the effect of CISM, four finding that although patients and providers thought it was helpful, there was no benefit for preventing PTSD. Two other studies have indicated that CISM actually made things worse. Some benefit was found from being connected early to Cognitive Behavioral Therapy, or for some medications such as propranolol. Effects of all these prevention strategies was modest.

EMDR
One psychotherapeutic method, specifically targeted at the disorder PTSD, is Eye Movement Desensitization and Reprocessing (EMDR). According to some studies, this may be the most effective psychotherapeutic treatment for PTSD,, but this research is largely supported by those with the copyright for EMDR. Most reviews find that EMDR, Cognitive Behavioral Therapy, Exposure Therapy, and Psychodynamic Therapy are all equally effective. Other forms of talk therapy may prove useful, but only insofar as the individual sufferer is enabled to come to terms with the trauma suffered and successfully integrate the experiences in a way that does not further damage the psyche. Some have shown that a technique of "rewriting" the content of nightmares through imagery rehearsal so that they have a resolution can not only reduce the nightmares but also other symptoms.

Pharmacological Regimes
Propranolol, a beta blocker which appears to inhibit the formation of traumatic memories by blocking adrenaline's effects on the amygdala, has been used in an attempt to reduce the impact of traumatic events.

Combination therapies
PTSD is commonly treated using a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and medications such as antidepressants (i.e. SSRI's such as fluoxetine and sertraline, SNRI's such as venlafaxine, and NaSSA's such as mirtazapine) or atypical antipsychotic drugs (such as quetiapine and olanzapine). Recently the anticonvulsant lamotrigine has been reported to be useful in treating some people with PTSD. The US Food and Drug Administration (FDA) recently approved a clinical protocol that combines the drug MDMA with talk therapy sessions.

Other Psychotherapeutic Methods
Relationship based treatments are also often used. These, and other approaches, use attachment theory and an attachment model of treatment. In these cases, the treatment of complex trauma often requires a multi-modal approach.

Recently, the use of Virtual reality and Integrated reality experiences applied as a new type of exposure therapy methods to come types of PTSD (specifically military related patients) has been gaining recognition. The first published reports of this were with the Virtual Vietnam project at Emory University. Now, some of this work is done at the CAREN VR LAB at the SHEBA rehabilitation hospital in Israel, at the Brooke Army Medical Center, and at the largest such program is at Naval Medical Center San Diego and nearby Camp Pendleton Marine Base. The ideas behind this methods is based on introducing PTSD causes in a gradual manner, inside a safe environment, the hope is that training in VR in this manner will reduce stress and transfer to daily reality.

Dr. Jan Bastiaans of the Netherlands has developed a form of psychedelic psychotherapy involving LSD, with which he has successfully treated concentration camp survivors who suffer from PTSD, but this is not a widely accepted method.

Neurochemistry
PTSD displays biochemical changes in the brain and body, which are different from other psychiatric disorders such as major depression.

In PTSD patients, the dexamethasone cortisol suppression is strong, while it is weak in patients with major depression. In most PTSD patients the urine secretion of cortisol is low, at the same time as the catecholamine secretion is high, and the norepinephrine/cortisol ratio is increased. Brain catecholamine levels are low, and corticotropin-releasing factor (CRF) concentrations are high. There is also an increased sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis, with a strong negative feedback of cortisol, due to a generally increased sensitivity of cortisol receptors.

In addition to biochemical changes, PTSD also involves changes in the brain itself. Combat veterans of the Vietnam war with PTSD showed an 8% reduction in the volume of their hippocampus in comparison with veterans who suffered no such symptoms.

Cortisol
The association of PTSD with cortisol levels is controversial within the medical community.

Some researchers have associated the response to stress in PTSD with long-term high levels of norepinephrine, at the same time as cortisol levels are low, a pattern associated with facilitated learning in animals. Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive learning pathway to fear response. With this deduction follows that the clinical picture of hyperreactivity and hyperresponsiveness in PTSD is consistent with the sensitive HPA-axis.

Low cortisol levels are also discussed as a possible pre-existing condition that neurochemically predisposes a person to PTSD. Swedish United Nation soldiers serving in Bosnia with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels.

There is considerable controversy within the medical community regarding the neurobiology of PTSD. A review of existing studies on this subject showed no clear relation between cortisol levels and PTSD. For example, only a slight majority of studies have found a decrease in cortisol levels; many others have found no effect or even an increase.

Neuroanatomy
In animal research as well as human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. Neuroimaging studies in humans have revealed both morphological and functional aspects of PTSD. The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex and the hippocampus. Further animal and clinical research into the amygdala and fear conditioning may suggest additional treatments for the condition.

Prevalence
PTSD may be experienced following any traumatic experience, or series of experiences which satisfy the criteria and that do not allow the victim to readily recuperate from the detrimental effects of stress. The National Comorbidity Survey Report provided the following information about PTSD in the general adult population: The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.

In recent history, the Indian Ocean Tsunami Disaster, which took place December 26, 2004 and took hundreds of thousands of lives, the September 11, 2001 attacks on the World Trade Center and The Pentagon, and the impact and effects of Hurricane Katrina may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as the Red Cross and the Salvation Army provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder.

Other agencies, such as the National Meditation Center for World Peace, have created similar special programs. The NMC trains agencies such as crisis centers NGOs and works with international agencies to prevent trauma to children.

Veterans and politics
Early cases of the disorder were recognized after World War I, including individuals treated by Sigmund Freud. The diagnosis was removed from DSM-II, which resulted in the inability of Vietnam veterans to receive benefits for this condition. In part through the efforts of Chaim F. Shatan, who coined the term post-Vietnam Syndrome, the condition was added to the DSM-III as posttraumatic stress disorder.

In the United States, the provision of compensation to veterans for PTSD is under review by the Department of Veterans Affairs (VA). The review was begun in 2005 after the VA had noted a 30% increase in PTSD claims in recent years. The VA undertook the review because of budget concerns and apparent inconsistencies in the awarding of compensation by different rating offices.

This led to a backlash from veterans'-rights groups, and to some highly-publicized suicides by veterans who feared losing their benefits, which in some cases constituted their only income. In response, on November 10, 2005, the Secretary of Veterans Affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for post-traumatic stress disorder..."

The diagnosis of PTSD has been a subject of some controversy due to uncertainties in objectively diagnosing PTSD in those who may have been exposed to trauma, and due to this diagnosis' association with some incidence of compensation-seeking behavior. A psychiatry professor recounts an interview with a veteran who reported to a VA medical center after he had received a leaflet listing PTSD symptoms and encouraging affected veterans to apply for compensation. During the interview, the veteran complained to the psychiatrist of "survivor quilt." Asked what that was, he replied, "I don't know, Doc, but I've got it bad." It transpired that the leaflet had misprinted "survivor guilt" as "survivor quilt," and the veteran had quoted that symptom in his campaign to win PTSD compensation.

The matter of malingering is addressed by Brunet et al., who conclude that "All mental disorders are prone to malingering when there are secondary gains, and PTSD is no exception. However, in the case of PTSD, the reverse is also true": PTSD is often under-reported due to fear of associated stigma, a fear that is particularly high among emergency service workers and military personnel, and in societies where the traumatic event (e.g., sexual assault) may be associated with stigma.

While PTSD-like symptoms have been recognized in combat veterans of many military conflicts, the modern understanding of PTSD dates from the 1980s. Reported cases of combat-related PTSD from Operation Enduring Freedom and Operation Iraqi Freedom are being compiled in ePluribus Media's PTSD Timeline.

Canadian Veterans
Veterans Affairs Canada (VAC) is a new program including rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support.

Law
If an individual suffering from PTSD commits a crime, there may be uncertainty about whether the individual can be held responsible for that act. In extreme cases, the defense of automatism, where the defendant was unable to control his actions, may be available. PTSD may produce an internal defect of reason within the meaning of the M'Naghten Rules (which defines the mental disorder defence in some criminal jurisdictions). The difference is that whereas defenses that rely on automatism result in an acquittal, since no guilt can be assigned to a party unable to control their actions; insanity or mental disorder leaves the "offender" available for sentencing by the court. In the event that a death has resulted, diminished responsibility may be available as an alternative to insanity. This defense reduces what would otherwise have been murder to manslaughter. In the specific instance of spousal abuse, this is often called battered woman syndrome and, more generally, the abuse defense in the U.S.

Trauma and the arts
In recent decades, with the concept of trauma, and PTSD in particular, becoming just as much a cultural phenomenon as a medical or legal one, artists have begun to engage the issue in their work. An important breakthrough in this was the publication of Maus: A Survivor's Tale (1972) by Art Spiegelman. There is now a genre of art that focuses on, exposes, and comments on survivors and survivor-tales. Some want to see art as part of a process of healing, and in this they work in a manner akin to art therapy or the older twentieth century notion of art psychology. There are others who resist the implicit mandate that art should be put into the service of psychological repair. These artists tend to work in a direction that links trauma to questions of memory, identity and politics.

Many movies deal with PTSD. It is an especially popular subject amongst "war veteran" films, often portraying Vietnam war veterans suffering from extreme PTSD and having difficulties adjusting to civilian life.

In more recent work, an example is that of Krzysztof Wodiczko who teaches at MIT and who is known for interviewing people and then projecting these interviews onto large public buildings. Wodiczko aims to bring trauma not merely into public discourse but to have it contest the presumed stability of cherished urban monuments. His work has brought to life issues such as homelessness, rape, and violence. Other artists who engage the issue of trauma are Everlyn Nicodemus of Tanzania and Milica Tomic of Serbia.