Post-Traumatic Stress Disorder Disease

DESCRIPTION

A condition seen in people who experienced an event that would be extremely distressing to most human beings, e.g., serious threat to one's life, physical or psychological integrity; serious threat or harm to one's children, spouse, siblings, parents or other close relatives or friends; sudden destruction of one's home or community; seeing another person who has recently been (or is being) injured or killed as a result of a man-made violent act or natural disaster.

The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
Symptoms of this condition did not exist prior to the trauma, and symptoms persist for at least one month following the trauma
There is a subtype of post-traumatic stress disorder (PTSD) with a delayed onset of the symptoms which starts at least six months after the trauma
The acute form of PTSD is defined as the duration being less than 3 months
Chronic form is defined when the duration of symptoms is more than 3 months
System(s) affected: Nervous
Genetics: N/A
Incidence/Prevalence in USA: Up to 30% of victims of disasters develop PTSD. Lifelong prevalence in general population ranges from 1-14%.
Predominant age: The elderly and the very young are more vulnerable
Predominant sex: Adult women are more inclined to ask for help. Young boys may be more vulnerable to trauma than girls. Most men with PTSD have experienced combat or exposure to trauma on the job. Most women with PTSD have a history of rape or being physically assaulted.

SIGNS AND SYMPTOMS

The traumatic event is persistently re-experienced in one or more of the following ways:
- 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.
- Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
- Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
- Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
- Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event, such as increased heart rate, changes in blood pressure, discoloration of the skin, blurred vision, hyperperistalsis in smooth muscle, nausea, vomiting, diarrhea, urinary urgency, etc.
Persistent avoidance of the stimuli associated with the trauma, or numbing of general responsiveness (not present before the trauma) as indicated by three (or more) of the following:
- Efforts to avoid thoughts, feelings or conversations associated with the trauma
- Efforts to avoid activities, places or people that arouse recollections of the trauma
- Inability to recall an important aspect of the trauma (psychogenic amnesia)
- Markedly diminished interest or participation in significant activities (in young children, loss of recently acquired developmental skills such as toilet training or language skills)
- Feelings of detachment or estrangement from others
- Restricted range of affect (e.g., unable to have loving feelings)
- Sense of a foreshortened future (e.g., does not expect to have a career, marriage, or a normal life span)
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
- Difficulty falling or staying asleep (insomnia)
- Irritability or outbursts of anger
- Difficulty in concentrating
- Hypervigilance
- Exaggerated startle response
Others:
- Duration of the disturbance is more than 1 month
- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

CAUSES

Events which are insults to one's personal integrity, self-esteem and security are psychologically traumatic and may lead to PTSD

RISK FACTORS

Individuals with a history of childhood neglect or dysfunctional families, children of alcoholic parents, or childhood abuse, are predisposed and more susceptible to developing PTSD in response to trauma

LABORATORY

N/A

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Character pathology as shown on the Minnesota multiple personality inventory (MMPI)

SPECIAL TESTS

Neuropsychological testing is helpful in cases of dementia and more subtle cognitive dysfunction
EEG to rule out any brain damage (results may be altered by any drug affecting EEG patterns such as - sleeping pills, antidepressants, neuroleptics and other psychotropic medications)
Psychological testing and a thorough mental status examination are valuable in a complete, thorough assessment of the patient
Sleep lab studies of 8 hour EEG help in diagnosis of sleep disorders
Through an examination and interview, assisted by amobarbital (Amytal) (given intravenously) or similar substances, one may uncover traumatic material in patients with amnesia. Similarly, an examination assisted by hypnosis may help in the diagnosis.
Tests may be affected by withdrawal or intoxication from drugs and alcohol; any organic brain syndromes such as multiple infarct dementia, other forms of dementia, and forms of epilepsy

IMAGING

CT scan of the head and MRI of the brain are valuable to rule out any brain damage

DIAGNOSTIC PROCEDURES

Psychiatric examination
Psychological testing
Note: The American Psychiatry Association has implemented in 1994, a new diagnostic and classification manual for psychiatric disorders. This includes a new diagnostic category entitled Acute Stress Disorder. The signs and symptoms are essentially the same as those described for PTSD, except for the fact that in acute stress disorder, the disturbance lasts for a minimum of 2 days and the maximum of 4 weeks and occurs within 4 weeks of the traumatic event. If the symptoms last more than 4 weeks, or begin more than 30 days after the original trauma, the condition is diagnosed as PTSD.

APPROPRIATE HEALTH CARE

Most treatment is done on an outpatient basis
In case of crisis such as a patient being suicidal or dysfunctional with activities of daily living, inpatient intensive treatment on a psychiatry unit is indicated

GENERAL MEASURES

As indicated by the patient's general condition, treatment includes individual psychotherapy, group therapy, hypnotherapy, narcoanalysis and narcosynthesis, and behavior therapy
Crisis intervention shortly after the traumatic event is very valuable for the immediate distress and may prevent the development of a chronic or delayed form of post-traumatic stress disorder
Relaxation exercises to help reduce anxiety and improve sleep have been found helpful

SURGICAL MEASURES

N/A

ACTIVITY

As indicated by patient's physical condition
Restoration of regular sleep at night is essential in cases of insomnia

DIET

A healthy diet of complex carbohydrates, proteins, and multivitamins and minerals. Avoid fatty foods.

PATIENT EDUCATION

Lenore Terr: Too
Scared to Cry. Harper & Row, NY, 1990

PREVENTION/AVOIDANCE

Crisis intervention immediately after the traumatic event involving intensive support and treatment may prevent the development of chronic PTSD later

POSSIBLE COMPLICATIONS

Alcohol and substance abuse, depression, suicide, self-inflicted violence and reenactment of trauma

EXPECTED COURSE AND PROGNOSIS

The lack of crisis intervention immediately following the trauma may lead to the persistence of symptoms. If symptoms last less than 3 months, the patient is still in the acute form of PTSD. If symptoms persist over 3 months, patients may develop chronic PTSD which may lead to loss of job, marital conflicts, total disability and repeated and/or lengthy hospitalizations with severe morbidity.
If the onset of symptoms is at least 6 months or more after the original traumatic event, the patient suffers from a delayed onset type
The more chronic and delayed the onset, the worse the prognosis. Early treatment in acute phase associated with better prognosis.

ASSOCIATED CONDITIONS

Personality disorders such as borderline personality disorder, depression, panic disorder, anxiety disorder, and dissociative disorders

AGE-RELATED FACTORS

Pediatric: Young children are susceptible to abuse and neglect; can develop chronic PTSD with failure to progress and grow in healthy way
Geriatric: Have fewer social support resources; adjustment to trauma less flexible; more sensitive to medication and need dose adjustment.
Others: N/A

PREGNANCY

Avoid psychotropics in the first trimester. Focus on non-pharmacologic treatment techniques such as psychotherapy, hypnotherapy, relaxation therapy, etc.

OTHER NOTES

N/A

ABBREVIATIONS

PTSD = post-traumatic stress disorder

Clinical Investigations

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