Not getting over it: Post-traumatic stress disorder

Content provided by the Faculty of the Harvard Medical School

Not getting over it: Post-traumatic stress disorder

For some people, merely recalling a traumatic event feels just like going through it all over again. Psychotherapy and some other strategies can help.

At some time in life, at least half of us will live through a terrifying event in which we experience, are threatened by, or witness grave physical harm. The stress of a life-threatening trauma takes time to ease, whether it arises from a car accident, assault, rape, terrorist attack, combat, or a natural disaster, such as the Asian tsunami and its aftermath.

Most people recover with the support of family and friends, but some develop post-traumatic stress disorder (PTSD), an anxiety disorder that may last a lifetime if appropriate help is not available.

Who develops PTSD?

Many unwelcome and unanticipated life events, such as a spouse’s betrayal or the loss of a job, can cause distressing emotional reactions, but most such events don’t lead to PTSD. Under the current official definition, PTSD is diagnosed only if you have been exposed to actual or threatened death or serious injury and responded with fear, helplessness, or horror. Experts say the Asian tsunami survivors are at especially high risk because of the extent of the devastation, the loss of livelihood and multiple family members, and the lack of a safe and stable environment in which to recover.

However, the definition of PTSD is broadening, as mental health professionals gain more experience with the disorder. Individual traits and circumstances help determine how an event is perceived and how emotionally overwhelming it is. In making a diagnosis of PTSD, a mental health professional considers both the type of trauma and the individual’s reaction. The point in a person’s life when a trauma occurs may also predict her likelihood of developing the disorder.

First described in male war veterans, PTSD is now known to occur in children and women as well, following a range of experiences. Motor vehicle accidents are a leading cause of PTSD in both men and women. In women, rape frequently results in PTSD, and some women develop PTSD after a traumatic childbirth. Women seem to be at heightened risk for PTSD following a trauma involving physical assault, but no more at risk than men after other kinds of trauma. Child abuse, including sexual abuse, can lead to chronic PTSD even if force was not involved. PTSD may also occur following a heart attack or diagnosis of cancer.

The traumatic event does not have to be experienced directly. Health care workers confronted with the aftermath of violence or natural disaster can also develop PTSD. And some people far from the World Trade Center or Pentagon were diagnosed with PTSD after the attacks of Sept. 11, 2001.

What are the symptoms?

Mental health professionals divide the symptoms of PTSD into three types:

• Intrusion: Re-experiencing the trauma in nightmares, daytime flashbacks, unwanted memories, thoughts, images, or sensations. Cues resembling some aspect of the event can cause intense emotional and physical distress, and the person may feel and act as if the event is recurring.

• Avoidance: Avoiding thoughts, feelings, activities, places, and people associated with the trauma. This may result in social withdrawal and becoming numb to positive as well as negative emotions.

• Arousal: Being constantly on guard, resulting in insomnia, irritability, outbursts of anger, difficulty concentrating, or being easily startled. Some people have panic attacks.

After a trauma, it’s normal to experience many of these symptoms temporarily. If your symptoms worsen or interfere with your ability to function after a month or more, you may be given a diagnosis of acute stress disorder. Symptoms lasting more than three months are considered chronic PTSD. Occasionally, someone develops “delayed PTSD” six months later or more, following a reminder of the event.

The disorder can also occur in combination with other psychological difficulties. People with certain mental illnesses and those who’ve experienced PTSD in the past are at increased risk. If a loved one dies unexpectedly or traumatically, PTSD can mingle with bereavement, making recovery more difficult. People with PTSD may try to ease their symptoms with drugs or alcohol. If the underlying PTSD isn’t addressed, treatment for substance abuse will likely be unsuccessful.

Untreated PTSD takes a toll on the body as well as the mind. In the June 28, 2004, Archives of Internal Medicine, researchers from the Veterans Administration reported that women with PTSD have more medical conditions and worse physical health than non-traumatized women, even those with depression.

How PTSD occurs

Using imaging techniques, researchers have begun to construct a picture of the brain under the influence of PTSD. The body responds to a traumatic event by releasing adrenaline, a stress hormone that prepares the body to flee or fight. In the brain, adrenaline and the brain chemical norepinephrine stimulate the amygdala, a deep brain structure that spurs the formation of vivid, emotional memories of the threat. In evolutionary terms, that’s a good survival strategy — for example, putting a hunter on high alert if he later nears the same cave where an animal attacked him. In PTSD, however, the system goes overboard. Memories and environmental cues provoke out-of-proportion fear responses to ordinary situations, thus interfering with normal functioning.

“The amygdala appears to be overreactive in PTSD. We’re currently examining whether it is already overreactive, making someone more vulnerable to PTSD, or becomes that way in response to trauma,” says Roger K. Pitman, M.D., professor of psychiatry at Harvard Medical School. “We’ve also found that two areas of the brain which help keep the amygdala in check, the hippocampus and the anterior cingulate cortex, appear not to function as well in those with PTSD.”

In some imaging studies, these two areas were found to be smaller than average in people with PTSD. They were also smaller in women who had been sexually or physically abused as children. These women may already have had PTSD as a result of the childhood trauma, and they may be at high risk for developing the condition following traumatic incidents in adulthood. Researchers are investigating the contributions of both brain structure and previous experiences to vulnerability to PTSD.

Getting help

If symptoms last more than a month, if they are severe, or if you’d like professional help, consult a psychiatrist, psychologist, social worker, psychiatric nurse specialist, or other mental health care provider experienced in working with trauma. Remember that treatment isn’t about forgetting a trauma or feeling as if it never happened. The goal is to eliminate or reduce its ability to disrupt your life.

Psychotherapy is the centerpiece of most PTSD treatment. The most specific is a cognitive behavioral approach called exposure therapy, which provides a safe environment for you to confront a situation that you fear. People with PTSD often feel that the only way to reduce their anxiety is to avoid anything that stirs their memories of the trauma. But gradual and repeated exposure can reduce symptoms and help change how you respond to the triggering situations.

The particulars of the trauma and personal history influence not only the likelihood of developing PTSD but also the effectiveness of therapy. Specialists from the University of Pennsylvania found that, even after cognitive behavioral therapy, female assault victims had more severe PTSD symptoms if they were physically injured during the attack or had been subject to trauma during childhood. To plan treatment, a therapist is likely to ask about any history of sexual or physical abuse.

If several weeks of psychotherapy don’t resolve symptoms (or if additional help is needed), medications may be prescribed. Depending on how well an individual tolerates the medication, and how long she’s had PTSD symptoms, an approved drug may be prescribed for 6–24 months. The selective serotonin reuptake inhibitors (SSRIs) sertraline (Zoloft) and paroxetine (Paxil) are FDA-approved for the treatment of PTSD, although not all clinical trials have shown them to work better than placebo.

These and other such antidepressants also reduce anxiety. They’re preferable to anti-anxiety medications like benzodiazepines, which cause sedation, can be addictive, and haven’t been shown to work particularly well in PTSD. Although medication and psychotherapy have not been directly compared, the combination seems to work better than medication alone.

PTSD and the brain Several brain areas appear to be involved in post-traumatic stress disorder.

Can PTSD be prevented?

If everyone received some treatment soon after a trauma, could they be spared PTSD? Both psychological and medical approaches have been considered.

A model called “critical incident stress debriefing” has been introduced into many settings. The idea is that providing a little treatment early on — encouraging people to talk about the traumatic event and educating them about common stress reactions — might help prevent PTSD down the road. Unfortunately, it doesn’t seem to help. An expert review of studies by the international nonprofit Cochrane Collaboration concluded that it may interfere with natural recovery from trauma and should not be compulsory for any trauma victims. Although workplaces and schools offer counseling following many types of loss, current research argues against any program that requires graphic recounting of trauma details or explicitly labels certain reactions as normal or pathological.

Preventive medication is also under consideration. Working on the understanding that adrenaline acts on the amygdala to strengthen memories, Dr. Pitman and other researchers at Massachusetts General Hospital are testing whether an adrenaline-reducing medication, the hypertension drug propranolol, might help block abnormal memory formation and prevent PTSD. In a 2002 pilot study, people who received a 10-day course of propranolol, starting within hours of a trauma, were less likely than those who received a placebo to develop PTSD symptoms. They were also less likely to show physical signs of stress (such as a rapid heart beat) when the traumatic incident was recounted three months later. A large-scale trial is now under way.

What you can do

Social support is one of the most important factors that distinguish those who recover from trauma from those who develop PTSD. But providing support to a friend or relative doesn’t mean you have to become an amateur therapist.

“Just be a good listener,” says Ellen Blumenthal, M.D., a psychiatrist at Massachusetts General Hospital. “Help them process the event in their own way. Don’t insist that they talk about the event or tell them to put it out of their mind.”

Just as you don’t necessarily expect someone to function well in the first few months after a death in the family, recognize that people may not act like themselves after a serious trauma. On the other hand, don’t regard traumatized persons solely as victims. Encourage them and give them opportunities to re-engage in enjoyable activities.

If a person becomes increasingly withdrawn, it’s likely that professional help is needed. Warning signs include increasing efforts to avoid people, places, or activities associated with the trauma; detachment from family and friends; drinking or using drugs to feel better; out-of-control anger; and constantly being on the lookout for danger. If a friend shows any of these behaviors or seems to be getting worse rather than better, encourage her to consult a mental health professional.

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Last updated:	August 21, 2006