The occurrence of a traumatic event in one’s life causes different reactions that vary depending on the individual. Some of the events can lead to mental disorders while other do not. PTSD needs to be considered in patients who have been exposed to a traumatic event. Statistics indicate that 3% of adults have suffered from PTSD at one time and the lifetime prevalence rates range from 1.9% to 8.8%. Psychological treatment like psychological therapies can be used to alleviate the effects of the condition. Similarly, drug treatment can be effective for the condition. Patients who exhibit complex PSTD need specialist multidisciplinary care. Post-traumatic stress disorder is a mental condition that develops from the exposure of horrifying or life-threatening events. Many individuals demonstrate signs of recovery following a traumatic incident. The condition can occur from one even or it can emanate from prolonged exposure to trauma (Bisson, Cosgrove, Lewis & Roberts, 2015). It is difficult to predict who is likely to develop PTSD yet patients who suffer from the condition have increased risks of having poor physical health, immunology disorders, and psychiatric comorbidity and are an economic burden due to the high cost of treating such conditions and lost productivity. Some of the symptoms of PTSD include intrusive recollections, avoidance of the stimuli that relate to the event, hyperarousal, and alterations in cognition and mood. Medication can be made to an individual who has demonstrated the signs for one month. However, the delayed presentation can also be common and can include issues like where the symptoms are common. The purpose of this paper is to expound post-traumatic stress disorders. The papers looks into peer-reviewed articles on PTSD to establish the existing literature and how they have covered the subject. Interest in the subject was driven by being in the armed forces and the high rates of such conditions affecting the group. Similarly, the
Discussion
Post-traumatic stress disorder is a highly researched topic due to the burden that it places on the individual and the society. The fifth edition of the American Psychiatry Association DSM-5 has updated PTSD diagnostic criteria. The condition now belongs to trauma and stressor-related disorders. Avoidance has also been added as a diagnostic cluster. It also highlights the negative cognition and traumatic events are no longer defined by a reaction of horror, fear or even helplessness. The world health organization has also retained six PTSD related symptoms and eliminated the ones shared by other conditions. Such modifications are significant because previous studies indicate that there are only 55% overlaps between individuals who have PTSD in the DSM IV and DSM 5 criteria. There is a 30% overlap in DSM –IV, DSM 5 and ICD -11. The new criteria for diagnosis identify PTSD negative cognition and worldviews, self-denigration and encourage clinicians to consider the features in the assessment and interventions. Any discrepancies in the diagnostic templates indicate to the clinicians that there are significant differences in the diagnostic criteria and the array of symptoms in an individual ( Shalev, Liberzon & Marmar, 2017 ).
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PTSD emerges from exposure to traumatic events whereas its prevalence has also increased in the last three decades following the expansion of what constitutes a traumatic event. Community studies show that the exposure to lifetime traumatic events ranges from 50% to 90%. According to the NCS, lifetime prevalence rates are 10.1% for females and 4.9% in males. Exposure to trauma among men and women was 19.4% and 7.6% respectively. A European survey indicated that 63.3% of the sample reported a lifetime experience of a traumatic event where the prevalence rates for PTSD were 0.5% and 2.32%. A Detroit area survey done in 1996 indicated that there is a probability of 9.2% risk of PTSD following a traumatic event. A quarter of the population exposed to a traumatic event develops PTSD although the figure can be higher for life-threatening events than those with lower psychological impact (Schlaepfer & Nemeroff, 2012).
There are significant differences in the prevalence of traumatic events and PTSD across countries. The occurrence of PTSD following a traumatic incident seems to be consistent across cultures despite the variations in PTSD in the U.S and European countries. A study of the Epidemiology in Europe identified 28 traumatizing events where six were identified as closely related to the subsequent development of PTSD. Such events include rape, beating by a romantic partner or spouse, or a caregiver, stalking, a sick child and other events that the participants were not ready to disclose. Earlier studies identified assaultive violence as carrying the highest risks. Another high contributor is a sudden unexpected death of a loved one. Previous traumatic events are also a significant contributor of PTSD (Schlaepfer & Nemeroff, 2012).
Signs and Symptoms
Some of the symptoms that can easily be identified in an individual include persistent intrusive recollection, negative alterations in cognition and mood, avoidance of stimuli associated with the trauma and hyperarousal. According to the DSM -5 criteria, some of the symptoms needed for the diagnosis of PTSD include intrusion symptoms ranging from recurrent, involuntary as well as intrusive distressing memories, dreams, dissociated reactions, intense psychological distress to identified cues and noticeable reaction to the cues ( Levin, Kleinman & Adler, 2014 ).
Avoidance symptoms include efforts to avoid distressing thoughts and feelings associated with a traumatic event, avoidance of external reminders. Negative alterations in cognition and mood symptoms include difficulties in remembering important aspects which are typically caused by amnesia, having persistent or exaggerated negative expectations of the world, other people and oneself. Another symptom is distorted cognition of the causes or consequences of blaming others or self. The patient can exhibit persistent negative emotional state and diminished interests to participate in important activities. Others includes feelings of detachment or being estranged from others and a continued inability to experience positive emotions ( Levin, Kleinman & Adler, 2014 ).
Symptoms related to alteration in arousal and reactivity include having an irritable behavior as well as angry outburst where there is little or no provocation. Patients can also demonstrate reckless or a destructive behavior. Others include being hyper-vigilant, having exaggerated startled response, sleep disturbance and having problems with concentration ( Levin, Kleinman & Adler, 2014 ).
Epidemiology
Epidemiology involves the study of how PTSD is distributed and its determinants in the population. Several studies have been conducted to determine the prevalence of the disorder in different populations. The prevalence is the number of people in a population who have the disorder in a given time. Estimating the proportion is influenced by several factors including the occurrence of the disorder, the duration, and demographic factors. It is useful to quantify such estimates with the period they were measured. Similarly, it is important to recognize that prevalence is dynamic thus it can change over time, people or even places. The prevalence of PTSD is often discussed in terms of lifetime whereas there are instances when statistics are used to determine its occurrence over time, for example, one year (Dorrington et al., 2014).
The U.S. National Comorbidity survey replica that was carried out from February 2001 to April 2003 sampled 9,282 participants aged 18 years and above. DSM –IV criteria were used to estimate the prevalence of PTSD in American adults to be 6.8%. The current past year was 3.5% whereas the lifetime prevalence of the disorder in men was 3.6% and 9.7% in women. The prevalence rate in twelve months was 1.8% in men and 5.2% in women. These findings are similar to an earlier survey conducted in 1990 and involved interviews of a national sample of 8,098 participants aged 15-54. The estimated prevalence rate for the general population was 7.8% where women had 10.4% while 5% of men experienced PTSD in some point of their lifetime (Dorrington et al., 2014; Gradus, 2017).
There is no population-based epidemiological study on the prevalence of PTSD in children. There are however studies that have examined the prevalence of the PTSD in high-risk children who have been exposed to traumatic incidences of natural disasters or abuse. The prevalence rates from such studies significantly differ. Studies, however, indicate that children who have been exposed to traumatic events are likely to have a higher prevalence of the disorder compared to adults in the general population. In a study by Kilpatrick and colleague, in 2003, the six-month study on the prevalence rate indicated that boys had 3.7% while girls had 6.3% (Gradus, 2017).
The prevalence rates according to a study by the world bank in 2008 involving twenty-seven countries varies between states with China recording the lowest at 0.3% while New Zealand having 6.1%. There are however challenges in trying to compare the statistics from the various countries given that there are methodological differences in the administration of the surveys and the sampling strategies (Gradus, 2017).
The prevalence of the veterans indicated that the prevalence rates were 30.9% for men and 26.9% for women who served in the armed forces in the Vietnam war. 15.2% of men and 8.1% of the females from the Vietnam theater veterans were diagnosed with PTSD when the study was conducted in November 1986 to February 1988. According to a study on the Gulf war veterans by Kang and others, the prevalence rate of PTSD was 12.1%. The authors estimated that the prevalence in all Gulf War Veteran population was 10%. According to a population-based study involving 1938 participants by the RAND Corporation, Center for Military Health Policy Research the prevalence rate of PTSD was 13.8 (Dorrington et al., 2014; Gradus, 2017).
PTSD Subtypes
Dissociation is a direct defense against major traumatic events. There is a dissociative subtype of PTSD which is characterized by symptoms of derealization and depersonalization. The confrontation with the previous experiences where escape was impossible challenges the patient to establish an escape from the external environment and internal distress when escape is impossible. In such a situation, consciousness can be altered to take into consideration the overwhelming experiences that force a person to continue operating under fierce conditions ( Levin, Kleinman & Adler, 2014 ).
Natural History of the Disorder
Exposure to trauma differentiates PTSD from other disorders. Similarly, the condition exhibits re-experiencing symptoms, like nightmares and flashbacks. Other symptoms are similar to those of other mental disorders like generalized anxiety, a panic disorder as well as depression and depression. Thus it is necessary to identify if an individual is experiencing symptoms that relate to the traumatic incident. Similarly, individuals who do not meet the criteria for PTSD may exhibit significant impairments that call for intervention. Patients can also demonstrate subthreshold PTSD possesses intermediate impairment levels between the ones who have full PTSD with no symptoms hence requiring dimensional initiatives to psychopathology (Sareen, 2014).
Methods used to Diagnose, Evaluate and Manage the Disorder
There are controversies surrounding the development of PTSD. The delayed onset of the symptoms is one of them. Usually, an individual will exhibit the largest number of symptoms just after the trauma where they would diminish over time. According to a review of the issue, 25% of participants with PTSD experienced delayed onset of the symptoms. Such individuals have subthreshold symptoms following a traumatic event and then experience a sudden increase in the symptoms that are above a threshold over time. In DSM – 5 Delayed PTSD symptoms arise when the full treatment of PTSD has not been done six months following the occurrence of an incident. Patients present to the physician with various physical symptoms like depression and substance abuse. The mental health professional should screen for evidence of past traumatic events. Patients in primary healthcare present with the following symptoms, headache, and pain and sleep disturbances. In the mental health clinics, they present with substance use, depression and self-harm (Dorrington et al., 2014; Sareen, 2014).
Some individuals show signs of improvements from PTSD with time without undergoing any medication. Such people are ready to continue with their normal life once they fully recover from the incident. The symptoms, in this case, can gradually decline to the extent that they are no longer severe enough to affect the relationship or work of patient. Some people recover in six months even with no medication while other can have their symptoms last much longer. However, others continue to exhibit the symptoms especially if the incidences keep on recurring thus affecting an individual for a long period. Extended exposure to PTSD can have devastating effects on the patient and the community at large as the condition keeps on deteriorating with time affecting the ability of the patient to perform as expected. The condition, in this case, becomes chronic calling urgent medical attention.
The diagnosis of PTSD involves a psychologist or psychiatrist. The patient must demonstrate the symptoms for at least a month. They must show one re-experiencing symptom and one avoidance symptoms. They should also have at least two arousal as well as reactivity symptoms and at least two cognition and mood symptoms. Once the physician has identified that the patient is suffering from PTSD, they establish the best approach for treating the condition. They can choose psychotherapy or medication or even a combination of the two depending on the initial examination. The historical past of the patient will be useful in determining the kind of treatment that will be most effective. The physician will then decide on the number of sessions that the patient will attend following the diagnosis exercise. The physician will then observe the patient throughout the entire process to determine their progress and to establish whether to continue with the treatment. A decline in the symptoms that were initially identified Indicates that the patient is responding well to the treatment.
Risk Factors
Majority of the techniques used to treat PTSD are less risky. All psychotherapies do not involve any form of a risk given that they are only intended to address the traumatic event. Care should be taken to avoid physical injuries or harm in case a patient turns out to be violent in any sessions. Some of the risk factors include intense or long-lasting trauma, other incidences early in life, occupational risks, substance abuse, other mental problems like depression and anxiety. Lack of social support can also be a risk factor. Biological risk factors include abnormalities, heart rate, elevated norepinephrine, low levels of cortisol. Some of the demographic risk factors include gender where a study shows that the prevalence of PTSD in women is twice the rate applicable to men. Other factors include the level of education, income, ethnicity, and marital status. The characteristic of the severity of the stressor and the history of the exposure are environmental risk factors. Exposure, especially at a young age, worsens the situation. Cases of instability in the family also increase the chances of developing PTSD (Sareen, 2014).
Other Causative Factors
Most individuals in the community have faced traumatic events that would meet the criterion for PTSD stressors. The following events are common in men; witnessing the death of another person or a bad injury, a life-threatening accident or being threatened with a weapon. In women, the following are the traumatic events; the experience of a natural disaster, witnessing the killing of another person, injury or life-threatening. Individuals with symptoms of PTSD are often exposed to several traumatic events. That led to the development of PTSD. Understanding the history of the patient and their meaning of traumatic events can be helpful in coming up with a treatment plan.
Nervous System Structures
Following the occurrence of a traumatic event, the body and brain changes as every cell record the memory of the embedded trauma. Such recorded information can be reactivated repeatedly. There are instances that the alterations created by the imprints become transitory and are forgotten in weeks. However, in some situations, the changes evolve to apparent symptoms that impair the functioning of an individual interfering with their jobs and way of life. Survivors of a traumatic event find it hard to understand some of the changes that happen in addition to integrating their meaning and the manner in which they affect their lives and what can be done to alleviate the problem. Different parts of the brain are responsible for performing unique duties including survival instinct which is done by the brain stem, processing of information done by the midbrain and cognitive processing by the cortex. In a traumatic event, the stem brain or reptilian takes charge and shifts the body to the reactive mode. It shuts down all non-essential processes from the body and the mind orchestrating survival mode. The sympathetic nervous system, in this case, readies the body to flee, fight or freeze. Individuals who experience PTSD are unable to shift to the restorative mode and remain in a reactive state.
Neurotransmitters and receptor system
PTSD is a common psychological problem that is highly connected to the neurotransmitters of the HPA axis and highly manifested in people who have been exposed to physical or psychological traumatic events. Individuals in this case suffer from unexpected flashbacks, nightmares, social stress anxiety, irritability and depression. Following a stressful event, the body increases the cortisol and catecholamine secretion in preparation for a fight or to flee the stressor. Such occurrences spike the excretion of the two and recurrence of a stressor over a long period leads to the deregulation of the HPA axis leading to imbalances in the adrenal hormones, inhibitory transmitters and excitatory neurotransmitters.
Current Treatment Options
Different techniques are used to treat PTSD. Some of the approaches include psychotherapy or medication. According to the national center for PTSD (2017), trauma-focused psychotherapy is highly recommended for the treatment of the disorder. Such techniques focus on the memory of the incident or its meaning. Various strategies are used to process the traumatic experiences including visualization, talking, thinking and changing unhelpful beliefs. In most cases, the different approaches last for 8 to 16 sessions depending on the recovery of the individual. Those techniques with the strongest evidence include prolonged exposure which tries to teach an individual how to gain control by facing the negative feelings. Cognitive processing therapy helps an individual to reframe the negative thoughts from a trauma. Other trauma focus techniques include Brief eclectic psychotherapy, narrative exposure therapy, written narrative exposure and specific cognitive behavioral therapies.
Medication that is helpful in alleviating the problem is also used for depression and anxiety. They are antidepressants known as SSRIs and SNRIs. The two affects serotonin and norepinephrine a naturally occurring chemical in the brain that helps coordinate the communication of cells in the brain and affect the way an individual feels. The following antidepressant medication is recommended for PTSD; Sertraline (Zoloft), Paroxetine (Paxil), Fluoxetine (Prozac) and Venlafaxine (Effexor). Treatment can be provided in clinics, hospitals, and outpatient and at home depending on the needs of the patient and how the physician would like to address the issue.
Future Areas of Research
More studies need to be conducted to identify other treatment options that can be used to address the issue and eliminate the suffering of the patient. The initial diagnosis can be misunderstood with other mental conditions. Relying on the historical experiences of the patient might not be adequate to address the issue. Similarly, there is a need to develop a structured way of solving the PTSD and minimize trial and error. Research should also be conducted to increase knowledge of etiologic and pathologic processes. Further research should be conducted to establish the prevalence rates while taking into account diversity, economic conditions, and occupation.
PTSD is a common mental disorder that develops following a traumatic event or continued exposure to such events. Different conditions must be met for the condition to be classified as PTSD. The patient must experience stressful events. They must re-experience the symptoms of the traumatic event which can be in the form of nightmare or even flashback. The patient must show an effort to avoid a situation including people and places that remind about the traumatic event. The patient must show hyperarousal symptoms. Patients who have the disorder have increased risks of poor physical health and other conditions. There are increased rates of the condition with each country showing different prevalence rates. Such rates are also affected by gender where studies indicate that women are at a higher risk f developing the disorder compared to men. Some events sho.ws similar symptoms to those that relate to PTSD but they do not seem to be extreme to result in PTSD. Different treatment techniques are used to address the issues including medication and physiotherapy. A careful analysis of the patient needs to be done to as they are unlikely to speak about the details of the traumatic events. Once the physician is comfortable with the details from the patient, they can use a combination of therapy and medication or either of the two to address the issue.
References
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Dorrington, S., Zavos, H., Ball, H., McGuffin, P., Rijsdijk, F., & Siribaddana, S. et al. (2014). Trauma, post-traumatic stress disorder and psychiatric disorders in a middle-income setting: prevalence and comorbidity. British Journal Of Psychiatry , 205 (05), 383-389. http://dx.doi.org/10.1192/bjp.bp.113.141796
Gradus, J. (2017). Epidemiology of PTSD - PTSD: National Center for PTSD . Ptsd.va.gov . Retrieved 20 February 2018, from https://www.ptsd.va.gov/professional/PTSD-overview/epidemiological-facts-ptsd.asp
Levin, A., Kleinman, S., & Adler, J. (2014). DSM-5 and Posttraumatic Stress Disorder. The Journal of The American Academy Of Psychiatry And The Law , 42 , 146 -158.
National Center for PTSD. (2017). Treatment of PTSD - PTSD: National Center for PTSD . Ptsd.va.gov . Retrieved 23 February 2018, from http://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp
Sareen, J. (2014). Posttraumatic Stress Disorder in Adults: Impact, Comorbidity, Risk Factors, and Treatment. The Canadian Journal Of Psychiatry , 59 (9), 460-467. http://dx.doi.org/10.1177/070674371405900902
Schlaepfer, T., & Nemeroff, C. (2012). Neurobiology of psychiatric disorders . Edinburgh: Elsevier.
Shalev, A., Liberzon, I., & Marmar, C. (2017). Post-Traumatic Stress Disorder. New England Journal Of Medicine , 376 (25), 2459-2469. http://dx.doi.org/10.1056/nejmra1612499
