Post-traumatic stress disorder
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Post-traumatic stress disorder | |
---|---|
immunological disorders [2] | |
Duration | > 1 month[a] |
Causes | Exposure to a traumatic event[1] |
Diagnostic method | Based on symptoms[2] |
Treatment | Counseling, medication,[4] MDMA-assisted psychotherapy,[5] selective serotonin reuptake inhibitors[6] |
Frequency | 8.7% (lifetime risk); 3.5% (12-month risk) (US)[7] |
Post-traumatic stress disorder (PTSD)
Most people who experience traumatic events do not develop PTSD.
Prevention may be possible when
In the United States, about 3.5% of adults have PTSD in a given year, and 9% of people develop it at some point in their life.
Symptoms of trauma-related mental disorders have been documented since at least the time of the
Symptoms
Symptoms of PTSD generally begin within the first three months after the inciting traumatic event, but may not begin until years later.
Associated medical conditions
Trauma survivors often develop depression, anxiety disorders, and mood disorders in addition to PTSD.
PTSD has a strong association with tinnitus,[38] and can even possibly be the tinnitus' cause.[39]
In children and adolescents, there is a strong association between emotional regulation difficulties (e.g. mood swings, anger outbursts, temper tantrums) and post-traumatic stress symptoms, independent of age, gender, or type of trauma.[40]
Moral injury the feeling of moral distress such as a shame or guilt following a moral transgression is associated with PTSD but is distinguished from it. Moral injury is associated with shame and guilt, while PTSD is associated with anxiety and fear.[41]: 2,8,11
In a population based study examining veterans of the
Risk factors
Persons considered at risk for developing PTSD include combat military personnel, survivors of natural disasters, concentration camp survivors, and survivors of violent crime. Persons employed in occupations that expose them to violence (such as soldiers) or disasters (such as emergency service workers) are also at risk.[44] Other occupations at an increased risk include police officers, firefighters, ambulance personnel, health care professionals, train drivers, divers, journalists, and sailors, as well as people who work at banks, post offices or in stores.[45] The intensity of the traumatic event is also associated with a subsequent risk of developing PTSD, with experiences related to witnessed death, or witnessed or experienced torture, injury, bodily disfigurement, traumatic brain injury being highly associated with the development of PTSD. Similarly, experiences that are unexpected or in which the victim cannot escape are also associated with a high risk of developing PTSD.[34]
Trauma
PTSD has been associated with a wide range of traumatic events. The risk of developing PTSD after a traumatic event varies by trauma type[46][47] and is the highest following exposure to sexual violence (11.4%), particularly rape (19.0%).[48] Men are more likely to experience a traumatic event (of any type), but women are more likely to experience the kind of high-impact traumatic event that can lead to PTSD, such as interpersonal violence and sexual assault.[49]
Motor vehicle collision survivors, both children and adults, are at an increased risk of PTSD.[50][51] Globally, about 2.6% of adults are diagnosed with PTSD following a non-life-threatening traffic accident, and a similar proportion of children develop PTSD.[48] Risk of PTSD almost doubles to 4.6% for life-threatening auto accidents.[48] Females were more likely to be diagnosed with PTSD following a road traffic accident, whether the accident occurred during childhood or adulthood.[50][51]
Post-traumatic stress reactions have been studied in children and adolescents.[52] The rate of PTSD might be lower in children than adults, but in the absence of therapy, symptoms may continue for decades.[53] One estimate suggests that the proportion of children and adolescents having PTSD in a non-wartorn population in a developed country may be 1% compared to 1.5% to 3% of adults.[53] On average, 16% of children exposed to a traumatic event develop PTSD, with the incidence varying according to type of exposure and gender.[54] Similar to the adult population, risk factors for PTSD in children include: female gender, exposure to disasters (natural or man-made), negative coping behaviors, and/or lacking proper social support systems.[55]
Predictor models have consistently found that childhood trauma, chronic adversity, neurobiological differences, and familial stressors are associated with risk for PTSD after a traumatic event in adulthood.[56][57][58] It has been difficult to find consistently aspects of the events that predict, but peritraumatic dissociation has been a fairly consistent predictive indicator of the development of PTSD.[59] Proximity to, duration of, and severity of the trauma make an impact. It has been speculated that interpersonal traumas cause more problems than impersonal ones,[60] but this is controversial.[61] The risk of developing PTSD is increased in individuals who are exposed to physical abuse, physical assault, or kidnapping.[62][63] Women who experience physical violence are more likely to develop PTSD than men.[62]
Intimate partner violence
Those who have experienced sexual assault or rape may develop symptoms of PTSD.[65][66] The likelihood of sustained symptoms of PTSD is higher if the rapist confined or restrained the person, if the person being raped believed the rapist would kill them, the person who was raped was very young or very old, and if the rapist was someone they knew. The likelihood of sustained severe symptoms is also higher if people around the survivor ignore (or are ignorant of) the rape or blame the rape survivor.[67]
War-related trauma
Military service in combat is a risk factor for developing PTSD.[34] Around 78% of people exposed to combat do not develop PTSD; in about 25% of military personnel who develop PTSD, its appearance is delayed.[34]
Refugees are also at an increased risk for PTSD due to their exposure to war, hardships, and traumatic events. The rates for PTSD within refugee populations range from 4% to 86%.[68] While the stresses of war affect everyone involved, displaced persons have been shown to be more so than others.[69]
Challenges related to the overall psychosocial well-being of refugees are complex and individually nuanced. Refugees have reduced levels of well-being and a high rate of mental distress due to past and ongoing trauma. Groups that are particularly affected and whose needs often remain unmet are women, older people and unaccompanied minors.[70] Post-traumatic stress and depression in refugee populations also tend to affect their educational success.[70]
Unexpected death of a loved one
Sudden, unexpected death of a loved one is the most common traumatic event type reported in cross-national studies.[48][71] However, the majority of people who experience this type of event will not develop PTSD. An analysis from the WHO World Mental Health Surveys found a 5.2% risk of developing PTSD after learning of the unexpected death of a loved one.[71] Because of the high prevalence of this type of traumatic event, unexpected death of a loved one accounts for approximately 20% of PTSD cases worldwide.[48]
Life-threatening illness
Medical conditions associated with an increased risk of PTSD include cancer,[72][73][74] heart attack,[75] and stroke.[76] 22% of cancer survivors present with lifelong PTSD like symptoms.[77] Intensive-care unit (ICU) hospitalization is also a risk factor for PTSD.[78] Some women experience PTSD from their experiences related to breast cancer and mastectomy.[79][80][72] Loved ones of those who experience life-threatening illnesses are also at risk for developing PTSD, such as parents of a child with chronic illnesses.[81]
Research exists which demonstrates that survivors of psychotic episodes, which exist in diseases such as schizophrenia, schizoaffective disorder, bipolar I disorder, and others, are at greater risk for PTSD due to the experiences one may have during and after psychosis. Such traumatic experiences include, but are not limited to, the treatment patients experience in psychiatric hospitals, police interactions due to psychotic behavior, suicidal behavior and attempts, social stigma and embarrassment due to behavior while in psychosis, frequent terrifying experiences due to psychosis, and the fear of losing control or actual loss of control. The incidence of PTSD in survivors of psychosis may be as low as 11% and as high at 67%.[82][83][84]
Pregnancy-related trauma
Women who experience miscarriage are at risk of PTSD.[85][86][87] Those who experience subsequent miscarriages have an increased risk of PTSD compared to those experiencing only one.[85] PTSD can also occur after childbirth and the risk increases if a woman has experienced trauma prior to the pregnancy.[88][89] Prevalence of PTSD following normal childbirth (that is, excluding stillbirth or major complications) is estimated to be between 2.8 and 5.6% at six weeks postpartum,[90] with rates dropping to 1.5% at six months postpartum.[90][91] Symptoms of PTSD are common following childbirth, with prevalence of 24–30.1%[90] at six weeks, dropping to 13.6% at six months.[92] Emergency childbirth is also associated with PTSD.[93]
Natural disasters
Genetics
There is evidence that susceptibility to PTSD is
Several biological indicators have been identified that are related to later PTSD development. Heightened
Pathophysiology
Neuroendocrinology
PTSD symptoms may result when a traumatic event causes an over-reactive adrenaline response, which creates deep neurological patterns in the brain. These patterns can persist long after the event that triggered the fear, making an individual hyper-responsive to future fearful situations.[29][97] During traumatic experiences, the high levels of stress hormones secreted suppress hypothalamic activity that may be a major factor toward the development of PTSD.[98]
PTSD causes
Most people with PTSD show a low secretion of cortisol and high secretion of catecholamines in urine,[101] with a norepinephrine/cortisol ratio consequently higher than comparable non-diagnosed individuals.[102] This is in contrast to the normative fight-or-flight response, in which both catecholamine and cortisol levels are elevated after exposure to a stressor.[103]
Brain catecholamine levels are high,
The maintenance of fear has been shown to include the HPA axis, the
The HPA axis is responsible for coordinating the hormonal response to stress.[59] Given the strong cortisol suppression to dexamethasone in PTSD, HPA axis abnormalities are likely predicated on strong negative feedback inhibition of cortisol, itself likely due to an increased sensitivity of glucocorticoid receptors.[109]
PTSD has been hypothesized to be a maladaptive learning pathway to fear response through a hypersensitive, hyperreactive, and hyperresponsive HPA axis.[110]
Low cortisol levels may predispose individuals to PTSD: Following war trauma, Swedish soldiers serving in Bosnia and Herzegovina with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels.[111] Because cortisol is normally important in restoring homeostasis after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD.
It is thought that the locus coeruleus-noradrenergic system mediates the over-consolidation of fear memory. High levels of cortisol reduce noradrenergic activity, and because people with PTSD tend to have reduced levels of cortisol, it has been proposed that individuals with PTSD cannot regulate the increased noradrenergic response to traumatic stress.[98] Intrusive memories and conditioned fear responses are thought to be a result of the response to associated triggers. Neuropeptide Y (NPY) has been reported to reduce the release of norepinephrine and has been demonstrated to have anxiolytic properties in animal models. Studies have shown people with PTSD demonstrate reduced levels of NPY, possibly indicating their increased anxiety levels.[59]
Other studies indicate that people with PTSD have chronically low levels of serotonin, which contributes to the commonly associated behavioral symptoms such as anxiety, ruminations, irritability, aggression, suicidality, and impulsivity.[112] Serotonin also contributes to the stabilization of glucocorticoid production.
Dopamine levels in a person with PTSD can contribute to symptoms: low levels can contribute to anhedonia, apathy, impaired attention, and motor deficits; high levels can contribute to psychosis, agitation, and restlessness.[112]
Several studies described elevated concentrations of the
adaptation may contribute to increased sensitivity to catecholamines and other stress mediators.Hyperresponsiveness in the norepinephrine system can also be caused by continued exposure to high stress. Overactivation of norepinephrine receptors in the prefrontal cortex can be connected to the flashbacks and nightmares frequently experienced by those with PTSD. A decrease in other norepinephrine functions (awareness of the current environment) prevents the memory mechanisms in the brain from processing the experience, and emotions the person is experiencing during a flashback are not associated with the current environment.[112]
There is considerable controversy within the medical community regarding the neurobiology of PTSD. A 2012 review showed no clear relationship between cortisol levels and PTSD. The majority of reports indicate people with PTSD have elevated levels of corticotropin-releasing hormone, lower basal cortisol levels, and enhanced negative feedback suppression of the HPA axis by dexamethasone.[59][114]
Neuroanatomy
A
People with PTSD have decreased brain activity in the dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex, areas linked to the experience and regulation of emotion.[119]
The amygdala is strongly involved in forming emotional memories, especially fear-related memories. During high stress, the
The amygdalocentric model of PTSD proposes that the amygdala is very much aroused and insufficiently controlled by the medial prefrontal cortex and the hippocampus, in particular during extinction.[121] This is consistent with an interpretation of PTSD as a syndrome of deficient extinction ability.[121][122]
The
While as a whole, amygdala hyperactivity is reported by meta analysis of functional neuroimaging in PTSD, there is a large degree of heterogeniety, more so than in social anxiety disorder or phobic disorder. Comparing dorsal (roughly the CeA) and ventral (roughly the BLA) clusters, hyperactivity is more robust in the ventral cluster, while hypoactivity is evident in the dorsal cluster. The distinction may explain the blunted emotions in PTSD (via desensitization in the CeA) as well as the fear related component.[123]
In a 2007 study, Vietnam War combat veterans with PTSD showed a 20% reduction in the volume of their hippocampus compared with veterans who did not have such symptoms.[124] This finding was not replicated in chronic PTSD patients traumatized at an air show plane crash in 1988 (Ramstein, Germany).[125]
Evidence suggests that endogenous cannabinoid levels are reduced in PTSD, particularly anandamide, and that cannabinoid receptors (CB1) are increased in order to compensate.[126] There appears to be a link between increased CB1 receptor availability in the amygdala and abnormal threat processing and hyperarousal, but not dysphoria, in trauma survivors.
A 2020 study found no evidence for conclusions from prior research that suggested low IQ is a risk factor for developing PTSD.[127]
Diagnosis
PTSD can be difficult to diagnose, because of:
- the subjective nature of most of the diagnostic criteria (although this is true for many mental disorders);
- the potential for over-reporting, e.g., while seeking disability benefits, or when PTSD could be a mitigating factor at criminal sentencing[128]
- the potential for under-reporting, e.g., stigma, pride, fear that a PTSD diagnosis might preclude certain employment opportunities;
- symptom overlap with other mental disorders such as obsessive compulsive disorder and generalized anxiety disorder;[129]
- association with other mental disorders such as major depressive disorder and generalized anxiety disorder;
- substance use disorders, which often produce some of the same signs and symptoms as PTSD; and
- substance use disorders can increase vulnerability to PTSD or exacerbate PTSD symptoms or both; and
- PTSD increases the risk for developing substance use disorders.[130]
- the differential expression of symptoms culturally (specifically with respect to avoidance and numbing symptoms, distressing dreams, and somatic symptoms)[131]
Screening
There are a number of PTSD screening instruments for adults, such as the PTSD Checklist for DSM-5 (PCL-5)[132][133] and the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5).[134] The 17 item PTSD checklist is also capable of monitoring the severity of symptoms and the response to treatment.[34]
There are also several screening and assessment instruments for use with children and adolescents. These include the Child PTSD Symptom Scale (CPSS),[135][136] Child Trauma Screening Questionnaire,[137][138] and UCLA Post-traumatic Stress Disorder Reaction Index for DSM-IV.[139][140]
In addition, there are also screening and assessment instruments for caregivers of very young children (six years of age and younger). These include the Young Child PTSD Screen,[141] the Young Child PTSD Checklist,[141] and the Diagnostic Infant and Preschool Assessment.[142]
Assessment
Evidence-based assessment principles, including a multimethod assessment approach, form the foundation of PTSD assessment.[143][144][145]: 25 Those who conduct assessments for PTSD may use various clinician-administered interviews and instruments to provide an official PTSD diagnosis.[146] Some commonly used, reliable, and valid assessment instruments for PTSD diagnosis, in accordance with the DSM-5, include the Clinician-Administered PTSD Scale for the DSM-5 (CAPS-5), PTSD Symptom Scale Interview (PSS-I-5), and Structured Clinical Interview for DSM-5 – PTSD Module (SCID-5 PTSD Module).[147][148][149][150]
Diagnostic and statistical manual
PTSD was classified as an anxiety disorder in the DSM-IV, but has since been reclassified as a "trauma- and stressor-related disorder" in the DSM-5.[1] The DSM-5 diagnostic criteria for PTSD include four symptom clusters: re-experiencing, avoidance, negative alterations in cognition/mood, and alterations in arousal and reactivity.[1][4]
International classification of diseases
The International Classification of Diseases and Related Health Problems 10 (ICD-10) classifies PTSD under "Reaction to severe stress, and adjustment disorders."[151] The ICD-10 criteria for PTSD include re-experiencing, avoidance, and either increased reactivity or inability to recall certain details related to the event.[151]
The ICD-11 diagnostic description for PTSD contains three components or symptom groups (1) re-experiencing, (2) avoidance, and (3) heightened sense of threat.[152][153] ICD-11 no longer includes verbal thoughts about the traumatic event as a symptom.[153] There is a predicted lower rate of diagnosed PTSD using ICD-11 compared to ICD10 or DSM-5.[153] ICD-11 also proposes identifying a distinct group with complex post-traumatic stress disorder (CPTSD), who have more often experienced several or sustained traumas and have greater functional impairment than those with PTSD.[153]
Differential diagnosis
A diagnosis of PTSD requires that the person has been exposed to an extreme stressor. Any stressor can result in a diagnosis of adjustment disorder and it is an appropriate diagnosis for a stressor and a symptom pattern that does not meet the criteria for PTSD.
The symptom pattern for
In extreme cases of prolonged, repeated traumatization where there is no viable chance of escape, survivors may develop complex post-traumatic stress disorder.[154] This occurs as a result of layers of trauma rather than a single traumatic event, and includes additional symptomatology, such as the loss of a coherent sense of self.[155]
Prevention
Modest benefits have been seen from early access to
Psychological debriefing
Trauma-exposed individuals often receive treatment called psychological debriefing in an effort to prevent PTSD, which consists of interviews that are meant to allow individuals to directly confront the event and share their feelings with the counselor and to help structure their memories of the event.[162] However, several meta-analyses find that psychological debriefing is unhelpful, is potentially harmful and does not reduce the future risk of developing PTSD.[34][162][163][164] This is true for both single-session debriefing and multiple session interventions.[158] As of 2017 the American Psychological Association assessed psychological debriefing as No Research Support/Treatment is Potentially Harmful.[165]
Early intervention
Trauma focused intervention delivered within days or weeks of the potentially traumatic event has been found to decrease PTSD symptoms.[166] Similar to psychological debriefing, the goal of early intervention is to lessen the intensity and frequency of stress symptoms, with the aim of preventing new-onset or relapsed mental disorders and further distress later in the healing process.[167]
Risk-targeted interventions
Risk-targeted interventions are those that attempt to mitigate specific formative information or events. It can target modeling normal behaviors, instruction on a task, or giving information on the event.[168][169]
Management
Reviews of studies have found that combination therapy (psychological and pharmacotherapy) is no more effective than psychological therapy alone.[17]
Counselling
The approaches with the strongest evidence include behavioral and cognitive-behavioral therapies such as prolonged exposure therapy,[170] cognitive processing therapy, and eye movement desensitization and reprocessing (EMDR).[171][172][173] There is some evidence for brief eclectic psychotherapy (BEP), narrative exposure therapy (NET), and written exposure therapy.[174][175]
A 2019 Cochrane review evaluated couples and family therapies compared to no care and individual and group therapies for the treatment of PTSD.[176] There were too few studies on couples therapies to determine if substantive benefits were derived, but preliminary RCTs suggested that couples therapies may be beneficial for reducing PTSD symptoms.[176]
A meta-analytic comparison of EMDR and cognitive behavioral therapy (CBT) found both protocols indistinguishable in terms of effectiveness in treating PTSD; however, "the contribution of the eye movement component in EMDR to treatment outcome" is unclear.[177] A meta-analysis in children and adolescents also found that EMDR was as efficacious as CBT.[178]
Children with PTSD are far more likely to pursue treatment at school (because of its proximity and ease) than at a free clinic.[179]
Cognitive behavioral therapy
CBT seeks to change the way a person feels and acts by changing the patterns of thinking or behavior, or both, responsible for negative emotions. Results from a 2018 systematic review found high strength of evidence that supports CBT-exposure therapy efficacious for a reduction in PTSD and depression symptoms, as well as the loss of PTSD diagnosis.[180] CBT has been proven to be an effective treatment for PTSD and is currently considered the standard of care for PTSD by the United States Department of Defense.[181][182]
In CBT, individuals learn to identify thoughts that make them feel afraid or upset and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.[183][184] A study assessing an online version of CBT for people with mild-to-moderate PTSD found that the online approach was as effective as, and cheaper than, the same therapy given face-to-face.[185][186] A 2021 Cochrane review assessed the provision of CBT in an Internet-based format found similar beneficial effects for Internet-based therapy as in face-to-face. However, the quality of the evidence was low due to the small number of trials reviewed.[187]
Exposure therapy is a type of cognitive behavioral therapy[188] that involves assisting trauma survivors to re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders; this type of CBT has shown benefit in the treatment of PTSD.[189][34]
Some organizations[
Recent research on contextually based
Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed and studied by Francine Shapiro.[197] She had noticed that, when she was thinking about disturbing memories herself, her eyes were moving rapidly. When she brought her eye movements under control while thinking, the thoughts were less distressing.[197]
In 2002, Shapiro and Maxfield published a theory of why this might work, called adaptive information processing.
There have been several small, controlled trials of four to eight weeks of EMDR in adults[202] as well as children and adolescents.[200] There is moderate strength of evidence to support the efficacy of EMDR "for reduction in PTSD symptoms, loss of diagnosis, and reduction in depressive symptoms" according to a 2018 systematic review update.[180] EMDR reduced PTSD symptoms enough in the short term that one in two adults no longer met the criteria for PTSD, but the number of people involved in these trials was small and thus results should be interpreted with caution pending further research.[202] There was not enough evidence to know whether EMDR could eliminate PTSD in adults.[202]
In children and adolescents, a recent meta-analysis of
The eye movement component of the therapy may not be critical for benefit.[53][199] As there has been no major, high quality randomized trial of EMDR with eye movements versus EMDR without eye movements, the controversy over effectiveness is likely to continue.[201] Authors of a meta-analysis published in 2013[172] stated, "We found that people treated with eye movement therapy had greater improvement in their symptoms of post-traumatic stress disorder than people given therapy without eye movements.... Secondly, we found that in laboratory studies the evidence concludes that thinking of upsetting memories and simultaneously doing a task that facilitates eye movements reduces the vividness and distress associated with the upsetting memories."[203]
Interpersonal psychotherapy
Other approaches, in particular involving social supports,[204][205] may also be important. An open trial of interpersonal psychotherapy[206] reported high rates of remission from PTSD symptoms without using exposure.[207]
Medication
While many medications do not have enough evidence to support their use, four (sertraline, fluoxetine, paroxetine, and venlafaxine) have been shown to have a small to modest benefit over placebo.[19] With many medications, residual PTSD symptoms following treatment is the rule rather than the exception.[208]
Antidepressants
Benzodiazepines
Benzodiazepines are not recommended for the treatment of PTSD due to a lack of evidence of benefit and risk of worsening PTSD symptoms.[213] Some authors believe that the use of benzodiazepines is contraindicated for acute stress, as this group of drugs can cause dissociation.[214] Nevertheless, some use benzodiazepines with caution for short-term anxiety and insomnia.[215][216][217] While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop the development of PTSD and may actually increase the risk of developing PTSD 2–5 times.[18] Benzodiazepines should not be used in the immediate aftermath of a traumatic event as they may increase symptoms related to PTSD.[34]
Benzodiazepines may reduce the effectiveness of psychotherapeutic interventions, and there is some evidence that benzodiazepines may actually contribute to the development and chronification of PTSD. For those who already have PTSD, benzodiazepines may worsen and prolong the course of illness, by worsening psychotherapy outcomes, and causing or exacerbating aggression, depression (including suicidality), and substance use.
Due to a number of other treatments with greater efficacy for PTSD and fewer risks, benzodiazepines should be considered
Benzodiazepines also carry a risk of disinhibition (associated with suicidality, aggression and crimes) and their use may delay or inhibit more definitive treatments for PTSD.[6][219][220]
Prazosin
Prazosin, an alpha-1 adrenergic antagonist, has been used in veterans with PTSD to reduce nightmares. Studies show variability in the symptom improvement, appropriate dosages, and efficacy in this population.[221][222][26]
Glucocorticoids
Cannabinoids
Cannabis is not recommended as a treatment for PTSD because scientific evidence does not currently exist demonstrating treatment efficacy for cannabinoids.[224][225][c] However, use of cannabis or derived products is widespread among U.S. veterans with PTSD.[226]
The
Other
Exercise, sport and physical activity
Physical activity can influence people's psychological[229] and physical health.[230] The U.S. National Center for PTSD recommends moderate exercise as a way to distract from disturbing emotions, build self-esteem and increase feelings of being in control again. They recommend a discussion with a doctor before starting an exercise program.[231]
Play therapy for children
Play is thought to help children link their inner thoughts with their outer world, connecting real experiences with abstract thought.[232] Repetitive play can also be one way a child relives traumatic events, and that can be a symptom of trauma in a child or young person.[233] Although it is commonly used, there have not been enough studies comparing outcomes in groups of children receiving and not receiving play therapy, so the effects of play therapy are not yet understood.[53][232]
Military programs
Many veterans of the wars in
Nightmares
In 2020, the United States Food and Drug Administration granted marketing approval for an Apple Watch app call NightWare. The app aims to improve sleep for people suffering from PTSD-related nightmares, by vibrating when it detects a nightmare in progress based on monitoring heart rate and body movement.[237]
The "colour cure"
Towards the end of the
Epidemiology
There is debate over the rates of PTSD found in populations, but, despite changes in diagnosis and the criteria used to define PTSD between 1997 and 2013, epidemiological rates have not changed significantly.[239][240] Most of the current reliable data regarding the epidemiology of PTSD is based on DSM-IV criteria, as the DSM-5 was not introduced until 2013.
The United Nations' World Health Organization publishes estimates of PTSD impact for each of its member states; the latest data available are for 2004. Considering only the 25 most populated countries ranked by overall age-standardized Disability-Adjusted Life Year (DALY) rate, the top half of the ranked list is dominated by Asian/Pacific countries, the US, and Egypt.[238] Ranking the countries by the male-only or female-only rates produces much the same result, but with less meaningfulness, as the score range in the single-sex rankings is much-reduced (4 for women, 3 for men, as compared with 14 for the overall score range), suggesting that the differences between female and male rates, within each country, is what drives the distinctions between the countries.[241][242]
As of 2017, the cross-national lifetime prevalence of PTSD was 3.9%, based on a survey where 5.6% had been exposed to trauma.[243] The primary factor impacting treatment-seeking behavior, which can help to mitigate PTSD development after trauma was income, while being younger, female, and having less social status (less education, lower individual income, and being unemployed) were all factors associated with less treatment-seeking behavior.[243]
Region | Country | PTSD DALY rate, overall[238] |
PTSD DALY rate, females[241] |
PTSD DALY rate, males[242] |
---|---|---|---|---|
Asia / Pacific | Thailand | 59 | 86 | 30 |
Asia / Pacific | Indonesia | 58 | 86 | 30 |
Asia / Pacific | Philippines | 58 | 86 | 30 |
Americas | USA | 58 | 86 | 30 |
Asia / Pacific | Bangladesh | 57 | 85 | 29 |
Africa | Egypt | 56 | 83 | 30 |
Asia / Pacific | India | 56 | 85 | 29 |
Asia / Pacific | Iran | 56 | 83 | 30 |
Asia / Pacific | Pakistan | 56 | 85 | 29 |
Asia / Pacific | Japan | 55 | 80 | 31 |
Asia / Pacific | Myanmar | 55 | 81 | 30 |
Europe | Turkey | 55 | 81 | 30 |
Asia / Pacific | Vietnam | 55 | 80 | 30 |
Europe | France | 54 | 80 | 28 |
Europe | Germany | 54 | 80 | 28 |
Europe | Italy | 54 | 80 | 28 |
Asia / Pacific | Russian Federation | 54 | 78 | 30 |
Europe | United Kingdom | 54 | 80 | 28 |
Africa | Nigeria | 53 | 76 | 29 |
Africa | Dem. Republ. of Congo | 52 | 76 | 28 |
Africa | Ethiopia | 52 | 76 | 28 |
Africa | South Africa | 52 | 76 | 28 |
Asia / Pacific | China | 51 | 76 | 28 |
Americas | Mexico | 46 | 60 | 30 |
Americas | Brazil | 45 | 60 | 30 |
United States
PTSD affects about 5% of the US adult population each year.[244] The
Military combat
The United States Department of Veterans Affairs estimates that 830,000 Vietnam War veterans had symptoms of PTSD.[246] The National Vietnam Veterans' Readjustment Study (NVVRS) found 15% of male and 9% of female Vietnam veterans had PTSD at the time of the study. Life-time prevalence of PTSD was 31% for males and 27% for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans had PTSD symptoms (but not the disorder itself). Four out of five reported recent symptoms when interviewed 20–25 years after Vietnam.[247]
A 2011 study from Georgia State University and San Diego State University found that rates of PTSD diagnosis increased significantly when troops were stationed in combat zones, had tours of longer than a year, experienced combat, or were injured. Military personnel serving in combat zones were 12.1 percentage points more likely to receive a PTSD diagnosis than their active-duty counterparts in non-combat zones. Those serving more than 12 months in a combat zone were 14.3 percentage points more likely to be diagnosed with PTSD than those having served less than one year.[248]
Experiencing an enemy firefight was associated with an 18.3 percentage point increase in the probability of PTSD, while being wounded or injured in combat was associated with a 23.9 percentage point increase in the likelihood of a PTSD diagnosis. For the 2.16 million U.S. troops deployed in combat zones between 2001 and 2010, the total estimated two-year costs of treatment for combat-related PTSD are between $1.54 billion and $2.69 billion.[248]
As of 2013, rates of PTSD have been estimated at up to 20% for veterans returning from Iraq and Afghanistan.
Human-made disasters
The
When comparing traditional responders to non-traditional responders (volunteers), the probable PTSD prevalence 2.5 years after the initial visit was greater in volunteers with estimates of 11.7% and 17.2% respectively.[251] Volunteer participation in tasks atypical to the defined occupational role was a significant risk factor for PTSD.[252] Other risk factors included exposure intensity, earlier start date, duration of time spent on site, and constant, negative reminders of the trauma.[251][252]
Additional research has been performed to understand the social consequences of the September 11 attacks. Alcohol consumption was assessed in a cohort of
Anthropology
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Trauma (and resulting PTSD) is often experienced through the outermost limits of suffering, pain and fear. The images and experiences relived through PTSD often defy easy description through language. Therefore, the translation of these experiences from one language to another is problematic, and the primarily Euro-American research on trauma is necessarily limited.
For example, ethnopsychology studies in Nepal have found that cultural idioms and concepts related to trauma often do not translate to western terminologies: piDaa is a term that may align to trauma/suffering, but also people who suffer from piDaa are considered paagal (mad) and are subject to negative social stigma, indicating the need for culturally appropriate and carefully tailored support interventions.[257] More generally, different cultures remember traumatic experiences within different linguistic and cultural paradigms. As such, cultural and medical anthropologists have questioned the validity of applying the diagnostic criteria of PTSD cross-culturally, as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III),[needs update] and constructed through the Euro-American paradigm of psychology.[254]
There remains a dearth of studies into the conceptual frameworks that surround trauma in non-Western cultures.[254] There is little evidence to suggest therapeutic benefit in synthesizing local idioms of distress into a culturally constructed disorder of the post-Vietnam era, a practice anthropologist believe contributes to category fallacy.[clarification needed][254] For many cultures there is no single linguistic corollary to PTSD, psychological trauma being a multi-faceted concept with corresponding variances of expression.[257]
Designating the effects of trauma as an affliction of the spirit is common in many non-Western cultures where idioms such as "soul loss" and "weak heart" indicate a preference to confer suffering to a spirit-body or heart-body diametric. These idioms reflect the emphasis that collectivist cultures place on healing trauma through familial, cultural and religious activities while avoiding the stigma that accompanies a mind-body approach.[254] Prescribing PTSD diagnostics within these communities is ineffective and often detrimental.[citation needed] For trauma that extends beyond the individual, such as the effects of war, anthropologists believe applying the term "social suffering" or "cultural bereavement" to be more beneficial.[258]
Every facet of society is affected by conflict; the prolonged exposure to mass violence can lead to a 'continuous suffering' among civilians, soldiers, and bordering countries.[259] Entered into the DSM in 1980, clinicians and psychiatrists based the diagnostic criteria for PTSD around American veterans of the Vietnam War.[260] Though the DSM gets reviewed and updated regularly, it is unable to fully encompass the disorder due to its Americanization (or Westernization).[261] That is, what may be considered characteristics of PTSD in western society, may not directly translate across to other cultures around the world. Displaced people of the African country Burundi experienced symptoms of depression and anxiety, though few symptoms specific to PTSD were noted.[262]
In a similar review, Sudanese refugees relocated in Uganda were 'concerned with material [effects]' (lack of food, shelter, and healthcare), rather than psychological distress.[262] In this case, many refugees did not present symptoms at all, with a minor few developing anxiety and depression.[262] War-related stresses and traumas will be ingrained in the individual,[259] however they will be affected differently from culture to culture, and the "clear-cut" rubric for diagnosing PTSD does not allow for culturally contextual reactions to take place.[citation needed]
Veterans
United States
The United States provides a range of benefits for veterans that the VA has determined have PTSD, which developed during, or as a result of, their military service. These benefits may include tax-free cash payments,[263] free or low-cost mental health treatment and other healthcare,[264] vocational rehabilitation services,[265] employment assistance,[266] and independent living support.[267][268]
United Kingdom
In the UK, there are various charities and service organisations dedicated to aiding veterans in readjusting to civilian life.
Canada
Veterans Affairs Canada offers a new program that includes rehabilitation, financial benefits, job placement, health benefits program, disability awards, peer support[271][272][273] and family support.[274]
History
Aspects of PTSD in soldiers of ancient Assyria have been identified using written sources from 1300 to 600 BCE. These Assyrian soldiers would undergo a three-year rotation of combat before being allowed to return home, and were reported to have faced immense challenges in reconciling their past actions in war with their civilian lives.[275]
Connections between the actions of Viking
Psychiatrist
A study based on personal letters from soldiers of the 18th-century Prussian Army concludes that combatants may have had PTSD.[279]
Many historical wartime diagnoses such as railway spine, stress syndrome, nostalgia, soldier's heart, shell shock, battle fatigue, combat stress reaction, and traumatic war neurosis are now associated with PTSD.[280][281]
The correlations between combat and PTSD are undeniable; according to Stéphane Audoin-Rouzeau and Annette Becker, "One-tenth of mobilized American men were hospitalized for mental disturbances between 1942 and 1945, and, after thirty-five days of uninterrupted combat, 98% of them manifested psychiatric disturbances in varying degrees."[282]
The DSM-I (1952) includes a diagnosis of "gross stress reaction", which has similarities to the modern definition and understanding of PTSD.[283] Gross stress reaction is defined as a normal personality using established patterns of reaction to deal with overwhelming fear as a response to conditions of great stress.[284] The diagnosis includes language which relates the condition to combat as well as to "civilian catastrophe".[284]
The addition of the term to the DSM-III was greatly influenced by the experiences and conditions of U.S. military veterans of the Vietnam War.[285] In fact, much of the available published research regarding PTSD is based on studies done on veterans of the war in Vietnam.
Because of the initial overt focus on PTSD as a combat related disorder when it was first fleshed out in the years following the war in Vietnam, in 1975
Early in 1978, the diagnosis term "post-traumatic stress disorder" was first recommended in a working group finding presented to the Committee of Reactive Disorders.[287]
A USAF study carried out in 1979 focused on individuals (civilian and military) who had worked to recover or identify the remains of those who died in Jonestown. The bodies had been dead for several days, and a third of them had been children. The study used the term "dysphoria" to describe PTSD-like symptoms.[288]
After PTSD became an official American psychiatric diagnosis with the publication of DSM-III (1980), the number of
Professional discussions and debates in academic journals, at conferences, and between thought leaders, led to a more clearly-defined set of diagnostic criteria in DSM-IV (1994), particularly the definition of a "traumatic event".[289] The DSM-IV classified PTSD under anxiety disorders. In the ICD-10 (first used in 1994), the spelling of the condition was "post-traumatic stress disorder".[290]
In 2012, the researchers from the Grady Trauma Project highlighted the tendency people have to focus on the combat side of PTSD: "less public awareness has focused on civilian PTSD, which results from trauma exposure that is not combat related..." and "much of the research on civilian PTSD has focused on the sequelae of a single, disastrous event, such as the
The DSM-5 (2013) created a new category called "trauma and stressor-related disorders", in which PTSD is now classified.[1]
America's 2014 National Comorbidity Survey reports that "the traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women."[62]
Terminology
The Diagnostic and Statistical Manual of Mental Disorders does not hyphenate "post" and "traumatic", thus, the DSM-5 lists the disorder as posttraumatic stress disorder. However, many scientific journal articles and other scholarly publications do hyphenate the name of the disorder, viz., "post-traumatic stress disorder".[292] Dictionaries also differ with regard to the preferred spelling of the disorder with the Collins English Dictionary – Complete and Unabridged using the hyphenated spelling, and the American Heritage Dictionary of the English Language, Fifth Edition and the Random House Kernerman Webster's College Dictionary giving the non-hyphenated spelling.[293]
Some authors have used the terms "post-traumatic stress syndrome" or "post-traumatic stress symptoms" ("PTSS"),
The comedian
Research
Most knowledge regarding PTSD comes from studies in high-income countries.[297]
To recapitulate some of the neurological and neurobehavioral symptoms experienced by the
Stellate ganglion block is an experimental procedure for the treatment of PTSD.[300]
Researchers are investigating a number of experimental FAAH and MAGL-inhibiting drugs in hopes of finding a better treatment for anxiety and stress-related illnesses.[301] In 2016, the FAAH-inhibitor drug BIA 10-2474 was withdrawn from human trials in France due to adverse effects.[302]
Preliminary evidence suggests that MDMA-assisted psychotherapy might be an effective treatment for PTSD.[303][304] However, it is important to note that the results in clinical trials of MDMA-assisted psychotherapy might be substantially influenced by expectancy effects given the unblinding of participants.[305][306] Furthermore, there is a lack of trials comparing MDMA-assisted psychotherapy to existent first-line treatments for PTSD, such as trauma-focused psychological treatments, which seems to achieve similar or even better outcomes than MDMA-assisted psychotherapy.[307]
Psychotherapy
Trauma-focused psychotherapies for PTSD (also known as "exposure-based" or "exposure" psychotherapies), such as prolonged exposure therapy (PE), eye movement desensitization and reprocessing (EMDR), and cognitive-reprocessing therapy (CPT) have the most evidence for efficacy and are recommended as first-line treatment for PTSD by almost all clinical practice guidelines.[308][309][310] Exposure-based psychotherapies demonstrate efficacy for PTSD caused by different trauma "types", such as combat, sexual-assault, or natural disasters.[308] At the same time, many trauma-focused psychotherapies evince high drop-out rates.[311]
Most systematic reviews and clinical guidelines indicate that psychotherapies for PTSD, most of which are trauma-focused therapies, are more effective than pharmacotherapy (medication),[312] although there are reviews that suggest exposure-based psychotherapies for PTSD and pharmacotherapy are equally effective.[313] Interpersonal psychotherapy shows preliminary evidence of probable efficacy, but more research is needed to reach definitive conclusions.[314]
See also
- Childbirth-related posttraumatic stress disorder
- Internet-based treatments for trauma survivors
- Internet interventions for post-traumatic stress
- Post-traumatic stress disorder and substance use disorders
- Post-traumatic embitterment disorder
- Post-traumatic growth
- Post-traumatic stress disorder after World War II
- Symptoms of victimization
- Traumatic stress
Notes
- ^ At least 1 month of symptoms for clinical diagnosis is required, while symptoms may persist from 6 months to multiple years.[1][3]
- ^ Acceptable variants of this term exist; see the Terminology section in this article.
- ^ As an example of such research, see: Bonn-Miller MO, Sisley S, Riggs P, Yazar-Klosinski B, Wang JB, Loflin MJE, et al. (2021) The short-term impact of 3 smoked cannabis preparations versus placebo on PTSD symptoms: A randomized cross-over clinical trial. PLOS ONE 16(3): e0246990.
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This article incorporates text from a free content work. Licensed under CC BY-SA 3.0 IGO. Text taken from A Lifeline to learning: leveraging mobile technology to support education for refugees, UNESCO, UNESCO. UNESCO.
External links
- Post-traumatic stress disorder at Curlie
- Post traumatic stress disorder information from The National Child Traumatic Stress Network
- Information resources from The University of Queensland School of Medicine
- APA practice parameters for assessment and treatment for PTSD (Updated 2017)
- Resources for professionals from the VA National PTSD Center
- Psychiatry portal
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