Charles Darwin

"The love for all living creatures is the most noble attribute of man." Charles Darwin

Sunday, May 24, 2015

Post-traumatic Stress Disorder



I guess knowing you have a disorder is something. I mean, knowing that you are not alone in what you are experiencing; knowing that what you are experiencing is real and not imagined; knowing that—all things being relative—you are still normal.

As soon as it was physically possible, I went right back to where it happened, choosing to face down my fears—we have nothing to fear but fear itself, right?— rather than to avoid them. 

So determined was I to get back on the horse, figuratively speaking, that I remember getting angry when others raised eyebrows about my return to work. If you need more time ...

Panic, cold sweats, flashes of color and pain.

It's the constant peripheral fear that's the worst: fear of another accident (my euphemism), fear of forever being labelled as the girl who that happened to, fear of being judged as incapable or even worse, fear of people thinking that what happened was in some way my fault. Fear, and a sense of life interrupted, of things I could do before that I would never be able to do again.
  
"So long as the organism is in perfect order it responds accurately to the agents that prompt it, but the moment that there is some derangement in any individual, his self-preservative power is impaired. Everybody understands, of course, that if one becomes deaf, has his eyesight weakened, or his limbs injured, the chances for his continued existence are lessened."  Nikola Tesla, My Inventions

Written in so matter-of-fact a manner by the genius, the words, like many things Tesla said and did resonated very strongly with me. I lingered. I dwelt. Though in truth, these words, written in the context in which they were written would have probably gone unremarked by me had I not been reading them in a post-accident state of mind. 

Are the chances of my continued existence now lessened?

I remember sometime later—later being a few months after the accident—sitting across from the Ministry approved physician and answering his questions exactly how I thought they should be answered, all smiles and positivity—whilst having no idea why I was inclined to do so:

Any nightmares, or difficulty sleeping? Nope.
Changes in behaviour? Irritability? Nope. No more than usual.
Flashbacks? Nope.
Difficulty concentrating? Nope.
Exaggerated startle response? Me? Nope, none whatsoever, heck, I’m even back at work, what more proof do you need that I’m doing fine, yup, I'm doing just fine. 


What is done cannot be undone, but it can be denied and for quite some time I lived in denial of my fear. Whether that was ultimately damaging or healing I cannot say. What I do know is that it drove me to the stark realization that simultaneously attempting to face down my fears whilst denying them was not the healthiest option; and that the course I had chosen was only going to take me so far on my road to recovery. 

And now, after some life changes, the discovery of something new to be passionate about, and of course, the altered perspective granted by the passage of time, I have found my own contentment. In fact, I'm now more contented than I think I've ever been. The accident has left me forever changed yes, but it's not all negative. For instance, I am now (after much introspection) far more comfortable in my skin than I would have thought possible before the accident; my priorities have assumed a new order; and things that frazzled, frustrated and angered me before now just slide off my back.

The experience, accident, trauma, attack, has, through the process of healing given me a new perspective on life; an appreciation for nature and authenticity, and the preciousness of time. 

That said, I don’t think the sense of an imminent ambush will ever go away. And as such, I’ll probably never stop looking over my shoulder, nor will I cease to scream (and I mean scream) when people brush hurriedly past me on the sidewalk, looking back at me like I’m Crazy Joe Davola, clown suit and all. 

And I will probably continue to cry way too easily at acts of kindness and in the presence of beauty (true beauty). But I can laugh and love and appreciate things in a way I never could before. And I have managed to compress all the negative things into something I can manage, which in and of itself is perhaps something of an accomplishment.






American Museum of Natural History via YouTube



  • Post-traumatic Stress Disorder (PTSD) is classified as a trauma and stress related disorder. [10]
  • PTSD may develop after a person is exposed to one or more traumatic events, such as major stress, sexual assault, terrorism, or other threats on a person's life. [10]
  • An estimated 7% of the general population suffer from PTSD. [11]
  • Most people having experienced a traumatizing event will not develop PTSD. [15]
  • People who experience assault-based trauma are more likely to develop PTSD, as opposed to people who experience non-assault based trauma such as witnessing trauma, accidents, and fire events. [16]
  • Children are less likely to experience PTSD after trauma than adults, especially if they are under ten years of age. [15]
  • In the typical case, the individual with PTSD persistently avoids all thoughts and emotions, and discussion of the stressor event and may experience amnesia for it. 
  • However, the event is commonly relived by the individual through intrusive, recurrent recollections, flashbacks, and nightmares. [1]


SYMPTOMS  

According to the Mayo Clinic Website, PTSD symptoms are generally grouped into 4 types: [12]

INTRUSIVE MEMORIES
  • Recurrent, unwanted distressing memories of the traumatic event
  • Reliving the traumatic event as if it were happening again (flashbacks)
  • Upsetting dreams about the traumatic event
  • Severe emotional distress or physical reactions to something that reminds you of the event


AVOIDANCE
  • Trying to avoid thinking or talking about the traumatic event
  • Avoiding places, activities or people that remind you of the traumatic event


NEGATIVE CHANGES IN THINKING & MOOD
  • Negative feelings about yourself or other people
  • Inability to experience positive emotions
  • Feeling emotionally numb
  • Lack of interest in activities you once enjoyed
  • Hopelessness about the future
  • Memory problems, including not remembering important aspects of the traumatic event
  • Difficulty maintaining close relationships


CHANGES IN EMOTIONAL REACTIONS (AROUSAL SYMPTOMS)
  • Irritability, angry outbursts or aggressive behavior
  • Always being on guard for danger
  • Overwhelming guilt or shame
  • Self-destructive behavior
  • Trouble concentrating
  • Trouble sleeping
  • Being easily startled or frightened




DIAGNOSIS 

  • Standardized screening  tools such as the Trauma Screening Questionnaire [13] and the PTSD Symptom Scale [14] can be used to detect possible symptoms of post-traumatic stress disorder and help determine if a formal diagnostic assessment is necessary.


The following is a summary [10] of the diagnostic criteria for PTSD as stipulated in the International Statistical Classification of Diseases and Related Health Problems 10 (ICD-10): [38]  

  • Exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.
  • Persistent remembering or "reliving" the stressor by intrusive flash backs, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor.
  • Actual or preferred avoidance of circumstances resembling or associated with the stressor (not present before exposure to the stressor).

Either (1) or (2):
  1. Inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor.
  2. Persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor) shown by any two of the following:
  • Difficulty in falling or staying asleep
  • Irritability or outbursts of anger
  • Difficulty in concentrating
  • Hyper-vigilance
  • Exaggerated startle response




CAUSES

The cause of PTSD may be a complex combination of several factors, including: [12]

  • Inherited mental health risks, such as an increased risk of anxiety and depression. 
  • Inherited aspects of your personality (temperament).
  • Family and twin studies have found that risk for PTSD is associated with an underlying genetic vulnerability, and that more than 30% of the variance associated with PTSD is related to a heritable component. [1][2][3]

  • Life experiences, including the amount and severity of trauma you have gone through since early childhood.


  • The way your body regulates the release of stress hormones.
  • Studies have indicated that people suffering from PTSD have chronically low levels of serotonin, which contributes to commonly associated behavioral symptoms such as anxiety, irritability, aggression, suicidal tendencies, and impulsivity. [5][41]
  • Having a shorter version of the serotonin transporter gene may increase the risk for PTSD. This same gene variant has been shown to increase activation of the amygdala (responsible for emotional regulation). [42][43]

  • Although PTSD has been associated with lower basal cortisol levels, [4] and enhanced negative feedback suppression of the *hypothalamic-pituitary-adrenal axis (HPA axis) by dexamethasone (corticosteroid), significant discrepancies remain among reports on the relationship between cortisol levels and PTSD. [3][6][8][9]


*The HPA axis is a complex set of direct influences and feedback interactions among three endocrine glands: the hypothalamus, the pituitary gland, and the adrenal glands. [7]




NEUROLOGICAL CHANGES CAUSED BY THE PSYCHOLOGICAL EXPERIENCE OF TRAUMA [40]


Regions of the brain associated with stress and post-traumatic stress disorder include: the prefrontal cortexamygdala, and hippocampus. [39]


Image Credit: National Institute of Mental Health



AMYGDALA
  • In some individuals with PTSD the amygdala enlarges.

  • Situations that remind an individual suffering from PTSD of the traumatic event or events can trigger excessive release of stress hormones and over-activation of the amygdala which further augments stress hormone release. The result is severe emotional distress - racing thoughts, anger, and hyper-vigilance. [11] 


HIPPOCAMPUS
  • Studies have shown that in some individuals suffering from PTSD, the hippocampus (responsible for memory and experience assimilation) actually shrinks in volume. [17][18][31]


  • Functional imaging studies have demonstrated abnormal cerebral blood flow to the hippocampus [19][20] during declarative memory tasks (memories that can be consciously recalled such as facts and knowledge).
  • These same studies found that childhood sexual abuse survivors with PTSD showed decreased left hippocampal blood flow during emotional word retrieval versus neutral word retrieval. (As compared to healthy individual unexposed to trauma.) [20]

  • However, researchers have not been able to consistently demonstrate a correlation between declarative memory performance and hippocampal function.
  • The pattern of memory impairments in PTSD demonstrates that the disorder is less associated with problems in memory retention, a process mediated by the hippocampus, and more associated with problems in acquisition and learning, processes more associated with prefrontal system dysfunction. [21] 




FRONTAL CORTEX
  • Magnetic resonance imaging (MRI) studies have reported decreased frontal cortex volume in individuals with PTSD [22-24] and decreased volume in medial prefrontal regions[25-28]

  • Functional imaging studies have revealed an under-activation of the frontal cortex during paired-associate learning tasks in patients with PTSD. [29] 
  • Particularly in children, findings of frontal dysfunction are more robust than findings of hippocampal dysfunction. [22,23, 30]


MILITARY COMBAT AND MENTAL HEALTH

The National Bureau of Economic Research 2011 study, The Psychological Costs of War: Military Combat and Mental Health, found that: [32][33]


  • Military personnel serving in combat were 12.1% 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% more likely to be diagnosed with PTSD than those who served less than one year.
  • Experiencing an enemy firefight was associated with a 10.4% increase in the likelihood of suicidal thoughts and an 18.3% increase in the probability of PTSD. 
  • For troops who believed they had killed someone there was a 12% increase in the probability of suicidal thoughts and a 22.2% increase in the likelihood of PTSD, compared to rates for service members who did not believe they had killed another person.
  • Being wounded or injured in combat was associated with a 23.9% increase in the likelihood of a PTSD diagnosis.



TREATMENT



  • Cognitive behavioral therapy (CBT) seeks to change the way a trauma victim feels and acts by changing the patterns of thinking or behavior, or both, responsible for negative emotions. 
  • 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.[34]
  
  • Eye movement desensitization and reprocessing is a form of psychotherapy based on the theory that eye movement can be used to facilitate emotional processing of memories. [35]

  • Exposure Therapy (re-imaging events in a safe environment), Group Therapy, Art Therapy, Play Therapy for children and Therapy dogs are other ways individuals may try to manage the symptoms of PTSD. [10]



A therapy dog trained to help combat veterans
with conditions like PTSD




Art therapy project created by a U.S. Marine
with PTSD

Scientists are testing MDMA as a PTSD treatment for veterans / theverge.com / April 24, 2015




***
FIN



AND JUST BECAUSE ... LAUGHTER IS AN IMPORTANT PART OF ANY HEALING ...










REFERENCES

[2] True WR, Rice J, Eisen SA, Heath AC, Goldberg J, Lyons MJ, Nowak J (1993). "A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms". Arch. Gen. Psychiatry 50 (4): 257–64.
[3] Skelton K, Ressler KJ, Norrholm SD, Jovanovic T, Bradley-Davino B (2012). "PTSD and gene variants: New pathways and new thinking". Neuropharmacology 62 (2): 628–637.doi:10.1016/j.neuropharm.2011.02.013PMC 3136568.PMID 21356219.
[4] Aardal-Eriksson E, Eriksson TE, Thorell LH (2001). "Salivary cortisol, posttraumatic stress symptoms, and general health in the acute phase and during 9-month follow-up". Biol. Psychiatry 50 (12): 986–93. doi:10.1016/S0006-3223(01)01253-7.PMID 11750895.
[5] Olszewski TM, Varrasse JF (2005). "The neurobiology of PTSD: implications for nurses". Journal of Psychosocial Nursing and Mental Health Services 43 (6): 40–7. PMID 16018133.
[6] Yehuda R (2002). "Clinical relevance of biologic findings in PTSD".Psychiatr Q 73 (2): 123–33. doi:10.1023/A:1015055711424.PMID 12025720.
[8]Lindley SE, Carlson EB, Benoit M (2004). "Basal and dexamethasone suppressed salivary cortisol concentrations in a community sample of patients with posttraumatic stress disorder".Biol. Psychiatry 55 (9): 940–5.doi:10.1016/j.biopsych.2003.12.021PMID 15110738.
[10] American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. pp. 271–280. ISBN 978-0-89042-555-8.
[13] Brewin CR, Rose S, Andrews B, Green J, Tata P, McEvedy C, Turner S, Foa EB (2002). "Brief screening instrument for post traumatic stress disorder". British Journal of Psychiatry 181: 158–162. PMID 12151288.
[14]  Foa EB, Cashman L, Jaycox L, Perry K (1997). "The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale". Psychological Assessment 9 (4): 445–451. doi:10.1037/1040-3590.9.4.445.
[15] National Collaborating Centre for Mental Health (UK) (2005). "Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care".NICE Clinical Guidelines, No. 26. Gaskell (Royal College of Psychiatrists). Lay summary – Pubmed Health (plain English). 
[16]  Zoladz, Phillip (June 2013). "Current status on behavioral and biological markers of PTSD: A search for clarity in a conflicting literature". Neuroscience and Biobehavioral Reviews 37 (5): 860-895. doi:10.1016/j.neubiorev.2013.03.024.
[17] Karl A., Schaefer M., Malta L., Dorfel D., Rohleder N., Werner A. A metaanalysis of structural brain abnormalities in PTSD. Neurosci Biobehav Rev.2006;30:1004–1031. 
[18] Kitayama N., Vaccarino V., Kutner M., Weiss P., Bremner JD. Magnetic resonance imaging (MRI) measurement of hippocampal volume in posttraumatic stress disorder: a meta-analysis. J Affect Disord. 2005;88:79–86. 
[19] Shin LM., Shin PS., Heckers S., et al. Hippocampal function in posttraumatic stress disorder. Hippocampus. 2004;14:292–300. [PubMed]
[21] . Shimamura AP. Memory and frontal lobe function. In: Gazzaniga MS, ed. The Cognitive Neurosciences. Cambridge, MA: MIT Press; 1996:803–814.
[22] De Bellis M., Keshavan. M., Shifflett H., et al. Brain structures in pediatric maltreatment-related post-traumatic stress disorder: a sociodemographically matched study. Biol Psychiatry. 2002;52:1066–1078. 
[23] Carrion V., Weems C., Eliez S., et al. Attenuation of frontal asymmetry in pediatric posttraumatic stress disorder. Bio Psychiatry. 2001;50:943–951.
[24]  Fennema-Notestine C., Stein M., Kennedy C., et al. Brain morphometry in female victims of intimate partner violence with and without posttraumatic stress disorder. Biol Psychiatry. 2002;52:1089–1101. 
[25] Rauch SL., Shin LM., Segal E., et al. Selectively reduced regional cortical volumes in post-traumatic stress disorder. Neuroreport. 2003;14:913–916.
[26] Yamasue H., Kasai K., Iwanami A., et al. Voxel-based analysis of MRI reveals anterior cingulate gray-matter volume reduction in posttraumatic stress disorder due to terrorism. Proc Natl Acad Sci USA. 2003;100:9039–9043.
[27] Woodward SH., Kaloupek DG., Street CC., et al. Decreased anterior cingulate volume in combat-related PTSD. Biol Psychiatry. 2006;59:582–587. 
[29] Geuze E., Vermetten E., Ruf M., et al. Neural correlates of associative learning and memory in veterans in posttraumatic stress disorder. J Psychiatr Res.2008;42:659–669. 
[30] De Bellis M., Keshavan M., Spencer S., Hall J. N- Acetylaspartate concentration in the anterior cingulate of maltreated children and adolescents with PTSD. Am J Psychiatry. 2000;157:1175–1177. 
[31] Samuelson, K. W. (2011). Post-traumatic stress disorder and declarative memory functioning: a review. Dialogues in Clinical Neuroscience, 13(3), 346–351.
[33] Resul Cesur Joseph J. Sabia Erdal Tekin  THE PSYCHOLOGICAL COSTS OF WAR: MILITARY COMBAT AND MENTAL HEALTH NBER WORKING PAPER SERIES (2011)
[34] Hassija, CM; Gray, MJ (2007). "Behavioral Interventions for Trauma and Posttraumatic Stress Disorder". International Journal of Behavioral Consultation and Therapy (Behavior Analyst Online) 3(2): 166–175. doi:10.1037/h0100797.
[35] The Management of Post-Traumatic Stress Working Group (2010). "VA/DoD clinical practice guideline for management of post-traumatic stress". Department of Veterans Affairs, Department of Defense. p. Version 2.0.
[36] Berger W, Mendlowicz MV, Marques-Portella C, Kinrys G, Fontenelle LF, Marmar CR, Figueira I (Mar 2009). "Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: a systematic review". Prog Neuropsychopharmacol Biol Psychiatry33 (2): 169–80. doi:10.1016/j.pnpbp.2008.12.004.PMC 2720612PMID 19141307.
[37] Cooper J, Carty J, Creamer M (Aug 2005). "Pharmacotherapy for posttraumatic stress disorder: empirical review and clinical recommendations". Aust N Z J Psychiatry 39 (8): 674–82.doi:10.1111/j.1440-1614.2005.01651.xPMID 16050921.
[38] "The ICD-10 Classification of Mental and Behavioural Disorders" (PDF). World Health Organization. pp. 120–121. 
Davis, L. L., Suris, A., Lambert, M. T., Heimberg, C., & Petty, F. (1997). Post-traumatic stress disorder and serotonin: new directions for research and treatment. Journal of Psychiatry and Neuroscience, 22(5), 318–326.
[43] "Preliminary Evidence of the Short Allele of the Serotonin Transporter Gene Predicting Poor Response to Cognitive Behavior Therapy in Posttraumatic Stress Disorder", appears in Biological Psychiatry, Volume 67, Issue 12 (June 15, 2010), published by Elsevier.




ADDITIONAL RESOURCES




IMAGE CREDITS

"The Scream" by Edvard Munch - WebMuseum at ibiblioPage: http://www.ibiblio.org/wm/paint/auth/munch/Image URL: http://www.ibiblio.org/wm/paint/auth/munch/munch.scream.jpg. Licensed under Public Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:The_Scream.jpg#/media/File:The_Scream.jpg

"HPA Axis Diagram (Brian M Sweis 2012)" by BrianMSweis - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:HPA_Axis_Diagram_(Brian_M_Sweis_2012).png#/media/File:HPA_Axis_Diagram_(Brian_M_Sweis_2012).png

"ProjectROVER Assistance Dog (12122659685)" by National Institute for Occupational Safety and Health (NIOSH) from USA - ProjectROVER Assistance Dog. Licensed under Public Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:ProjectROVER_Assistance_Dog_(12122659685).jpg#/media/File:ProjectROVER_Assistance_Dog_(12122659685).jpg
"USMC-120503-M-9426J-001" by Cpl. Andrew Johnston - This Image was released by the United States Marine Corps with the ID 120503-M-9426J-001 (next).This tag does not indicate the copyright status of the attached work. A normal copyright tag is still required. See Commons:Licensing for more information.বাংলা | Deutsch | English | español | euskara | فارسی | français | italiano | 日本語 | 한국어 | македонски | മലയാളം | Plattdüütsch | Nederlands | polski | português | Türkçe | 中文 | 中文(简体)‎ | +/−. Licensed under Public Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:USMC-120503-M-9426J-001.jpg#/media/File:USMC-120503-M-9426J-001.jpg