Post-traumatic stress disorder (PTSD) is a syndrome or a mental disorder that results from exposure to traumatic events either by experiencing the traumatic event itself or witnessing an event that is life-threatening (American Psychiatric Association, 2013). Examples of traumatic events may include but not limited to sexual assault, car accident, warfare, or sudden loss of a loved one. PTSD diagnosis is made using Diagnostic and statistical manual of mental disorders (5th ed.) where there is a particular level or type of traumatic occurrence, lack of exclusion standards as well as a combination of certain symptoms (Yehuda, 2002). Exposure to the traumatic events by the person who has this mental disorder can take place in four ways where the victim experiences the traumatic event directly, witnesses the traumatic event occurring to other people, learns of the traumatic event that has happened to a person who is close such as a relative or friend, or being exposed to traumatic events that are unpleasant, either repeatedly or extremely-particularly when the person is performing his or her professional duty.
Persistent experience of traumatic events in nightmares, thoughts about the traumatic event that are invasive, flashbacks, or exposure to traumatic reminders causes increased emotional distress and strong physiologic activity. Conversely, trauma-related stimuli can be avoided by attempting to avoid any conversations, feelings or thoughts related to the traumatic occurrence and evasion of the external reminders that are associated with a traumatic event such a people, places or activities (Yehuda, 2002). Negative feelings or thoughts that have become worse after trauma or started immediately after the trauma are usually related to the inability to recall main events related to the ordeal. Such thoughts include exaggerated pessimistic assumptions about oneself, others or the world, a marked reduction of interest in daily activities which are significant and can be observed, and isolating oneself from other people. Others include victim overly blaming others or self for cause or consequences of the traumatic event, negative emotions related to the trauma such as guilt, shame, fear or anger, and inability to experience positive effects.
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Altered reactivity and arousal related to trauma comprise of angry outbursts and irritability, destructive behavior that can be risky, hypervigilance, startle response that is exaggerated, the problem with concentrating, and disturbed sleep. Additionally, the period that the symptoms occur has to exceed one month in order to be referred as altered reactivity (Calhoun & Tedeschi, 2014). Also, these manifestations cause significant sadness or cause impairment in the normal functioning of the body systems especially the nervous system. The signs and symptoms are also not attributed to other medical conditions or the use of any substance. However, there are some specific dissociative symptoms such as persistent depersonalization where a person has mixed feelings of detachment from oneself or derealization. It is important to note that any expression that is delayed can be included in case full diagnosis of PTSD is not met six months after experiencing the traumatic event.
Various factors noted in Mental Status Examination may be of help in confirming the PTSD diagnosis (Joshi et al., 2017). These factors are behavioral, cognitive, and emotional. Behavioral factors can be defined as vigilance that is increased, startle response that is increased, increased distress when discussing the traumatic event and not able to interact with the providers. On the other hand, cognitive factors refer to not remembering parts of the traumatic events, exaggerated negative feelings about self and others and lack of concentration (Yehuda, 2002). Lastly, emotional factors can be described as lack of positive affect and emotions that are persistently negative.
Symptoms of PTSD include reliving the traumatic events by having thoughts that are intrusive, nightmares and dreams that are distressing. Secondly, having flashbacks and avoiding the situations that could remind about the traumatic event and try not to talk about it (Calhoun & Tedeschi, 2014). Negative changes in mood with not remembering key things of the trauma and having beliefs, expectations regarding others, the world or oneself that are negatively exaggerated. Thirdly, inability to sleep and concentrate, being overly irritable, increase in vigilance and engaging in the risky and self-destructive behavior. Of note is that PTSD cannot be diagnosed until one month has elapsed after the occurrence of a traumatic event. Diagnosis made in less than one month is acute stress disorder which has similar symptoms as PTSD.
Screening and management of Post-traumatic stress disorder involve the use of self-report measures. For example, Screen for symptoms of post-traumatic stress disorder (SPTSS), SPTSS involves self-report measures consisting of seventeen items, and it assesses PTSD symptoms contained in the DSM-IV. It is useful for people who have a history of several traumatic events or those whose trauma history is not known (Yehuda, 2002). The scores can be used to determine whether the symptoms presented by the client meet the criteria stipulated in DSM or not. PTSD Checklist for DSM-5 (PCL-5) consists of 20 items used to assess the twenty symptoms of PTSD stated in DSM-5. PCL-5 can be applied to monitoring changes in the symptoms during or after treating PTSD and screening and making a provisional diagnosis of PTSD. Trauma symptom inventory (Post-Traumatic Stress Disorder.-35) can also be used. The trauma symptoms inventory consist of items that are related to PTSD symptom criteria B, C and D as stated by the DSM-IV (Calhoun & Tedeschi, 2014). It is useful in research and clinical settings as a means of measuring various symptoms related to trauma. Other self-report measures used include Impact of Event scale-revised (IES-R), Davidson Trauma Scale (TSD), Trauma Symptoms checklist-40 (TSC-40) and Questionnaires for distressing events (DEQ).
Laboratory studies may be useful in assessing substance use disorder that accompanies PTSD such as cortisol, norepinephrine which is currently being used in research, same as imaging for small hippocampi, amygdala and prefrontal cortex (American Psychiatric Association, 2013). Also, etiological studies of PTSD derived when one experiences a serious traumatic event either associated with sexual assault, physical injury or near-death experience can be helpful in diagnosis. It is important to note that chronic PTSD is showing that one was not able to recover from trauma, may be due to lack of resilience. Studies have been done to determine which people cannot adapt to trauma or their adaptive response are prolonged (Calhoun & Tedeschi, 2014). And the findings have been mixed results with some people being completely unable to adapt to trauma.
Some of the risk factors according to ( American Psychiatrist Association Diagnostic and statistical manual of mental disorders (5th Ed.) are discussed below. First is pre-existent aspects that include gender since the incidences are high in women, having been exposed to trauma before, a mental illness that is pre-existing, poverty, minimal education, and adversity during childhood. Secondly, peri-traumatic factors such as nature and how severe the trauma is, interpersonal violence, a dissociation that might have happened during the time of the event, pulse rate that is elevated immediately after the trauma (Joshi et al., 2017). Thirdly, post-traumatic factors ranging from developing acute stress disorder will predispose to PTSD, external stressing factors like poverty, difficult or challenging life events that follow after the trauma, lack of proper support from family, friends or society.
Apart from trauma causing psychological stress, pathophysiology of PTSD many times leads to anatomical and neurophysiological changes in the brain. Trauma can cause a reduction in the size of the hippocampus. Also, the hippocampus could be small in size, causing increased risk to PTSD. The amygdala in patients with PTSD is usually more reactive, and it is the one responsible for fear response modulation and processing of emotions. The medial prefrontal cortex seems to be smaller, and its response is reduced in patients having PTSD, as it is responsible for inhibiting control over the response to stress.
Neurotransmitter and neurohormonal changes have been found in persons who have PTSD. The amount of circulating cortisol appear normal to low despite the stress that is ongoing with the corticotropin-releasing hormone being elevated – norepinephrine release by the anterior cingulate cortex is stimulated (Joshi et al., 2017). In PTSD individuals, there is increased activity of the sympathetic nervous system thus there is an increase in the blood pressure, heart rate and the level of skin conduction. Noradrenergic reaction to pharmacological challenges is increased. Also, the functions of serotonin, neuropeptide Y, endogenous opioids, glutamate, and GABA are altered in individuals with PTSD.
Theories of PTSD
There are various theories that have been postulated to explain causes and progression of PTSD. For example, Fear Conditioning Theories where storage of the traumatic events occur such that the person is not able to recover from the trauma or the PTSD (American Psychiatric Association, 2013). Variables due to genetic make-up and cognitive factors can lead to fear conditioning, which refers to the act of pairing of a stimulus that is initially neutral with a stimulus that is aversive and elicits fear. Two mechanisms were hypnotized in the course that leads to the occurrence of symptoms of PTSD following traumatic experiences. Mowrer came up with a two-factor theory that makes assumptions that the factors have a part in causing anxiety disorders. The same theory was further elaborated by Keane and his colleagues. Lang adopted a theory that emphasizes the cognitive structure of activation that is related to imagery. According to Lang's theory, storage of frightening events take place in a broader cognitive framework, and their representation occurs within memory where they are interconnected between nodes in an associative network (American Psychiatric Association, 2013). The emotional processing theory proposed by Foa between 1989 to 1998, emphasizes that representation of traumatic events in the memory is different from that of ordinary events, but still draws on the principle of fear
The Dual Representational Theory (Brewin et al., 2010) which shows the existence of two separate systems in relation to memory. Memory that can be accessed verbally and can be altered by applying reflection –which is the main feature associated with non-traumatic memories (Joshi et al., 2017). Memory that can be accessed is non-verbal, and there is a strong association with the amygdala. Situational accessible memories are where traumatic memories tend to be stored, they are not easy to process and are easily triggered by associational thus causing emotional distress when they are activated. Individuals may have a difficult time integrating the traumatic events with their life narrative thus causing the horrifying memory to have a severe impact on how they view themselves or the world
The Cognitive Theory of PTSD (Ehlers & Clark, 2000) has elaborated cognitive factors like individuals amount of control over a situation and expectancies. They proposed that undergoing stress that is extreme, which is dependent on one's threat appraisal, is a vital factor in causing an occurrence of reactions that are acutely stressful and displays biological, behavioral and emotional effects. Trauma narrative "Hotspots" by Ehlers and Clark who came up with cognitive therapy for PTSD, which is a useful treatment today (Joshi et al., 2017). According to the therapy, negative cognitions, as well as appraisals, are replaced after inventions with appraisals that are more positive.
Conclusion
Post-Traumatic Stress Disorder is a very complicated disorder that disables individuals since it causes them to relive their past traumatic events, which are horrible and should not be taken lightly as this is a disorder which is very common though the signs and symptoms vary from person to person. PTSD can affect both children and the elderly – it is not limited to a particular age group. Proper diagnosis should be made and proper treatment administered to the individuals with PTSD in order to prevent self-harm or harm to others.
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th Ed.). Washington, DC: American Psychiatric Association.
Calhoun, L. G., & Tedeschi, R. G. (Eds.). (2014). Handbook of posttraumatic growth: Research and practice . Abingdon, UK: Routledge Publishers.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behavior research and therapy , 38 (4), 319-345.
Joshi, M., Bartter, T., Joshi, A., Glare, P. A., Nicholas, M. K., & Blyth, F. M. (2017). Post-Traumatic Stress Disorder. Abingdon, UK: Routledge Publishers.
Yehuda, R. (2002). Post-traumatic stress disorder. New England Journal of Medicine , 346(2), 108-114.
