Post-traumatic stress disorder

In the aftermath of a life-threatening trauma, 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. 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 Post Traumatic Stress Disorder (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.

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. 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. Health care workers confronted with the aftermath of violence or natural disaster can also develop PTSD.

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. 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.

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

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 PTSD, memories and environmental cues provoke out-of-proportion fear responses to ordinary situations, 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."

Getting help

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. Although medication and psychotherapy have not been directly compared, the combination seems to work better than medication alone.

Can PTSD be prevented?

Preventive medication is under consideration. Working on the understanding that adrenaline acts 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.

April 2005 Update