POSTTRAUMATIC STRESS DISORDER: EVIDENCE BASED ADVANCES.
Netranee Anju Ramdinny-Purryag
St, Jeen Pharmacy, Mauritius
Posttraumatic stress disorder classified as an
anxiety disorder. In which occur severe condition that may develop after a
person is exposed to one or more traumatic events, such as sexual assault,
serious injury or the threat of death. The characteristic symptoms
are considered Acute if lasting less than three months, Chronic if persisting
three months or more, and With Delayed Onset if the symptoms first occur after
six months or some years later. Co morbid psychiatric diagnoses are present in
up to 80% of patients. Major depressive disorder (MDD) is among both men and
women, affecting nearly 50%. Alcohol abuse and conduct disorder (over 40%) are
also highly co morbid in men.
Posttraumatic stress disorder
Posttraumatic stress disorder is a severe
condition that may develop after a person is exposed to one or more traumatic
events, such as sexual assault, serious injury or the threat of death.1
In the early 19th century, military
doctors started diagnosing soldiers with exhaustion after the stress of battle.
This exhaustion was characterized by mental shutdown due to individual or group
trauma. Prior to the 20th century, soldiers were expected always to
be emotionally tough and show no fear in the midst of combat. The only treatment
for this exhaustion was to relieve the afflicted from frontline duty until
symptoms subsided and then they would return to battle. During the intense and
frequently repeated stress, the soldiers became fatigued as a part of their
body's natural shock reaction.
The psychopathological effect to traumatic
events has long been recognised, particularly in the context of war.
Descriptions of the emotional sequelae of combat date back to thousand of years
as revealed, for example, in the epic account of Achilles in Homer’s Illiad.
Modern wars have engendered their own unique labels for these sequelae, for
example, “nostalgia” or “combat neurosis”( Civil War), “”shell shock”(World War
1), “battle fatigue” or “combat neurosis”(World War 11), and delayed stress
(Vietnam War). However, stress disorders were largely ignored as a formal
psychiatric nosological category and were relegated to “transient” phenomena
until the publication of the Diagnostic and Statistical Manual of Mental
Disorders, Third Edition (DSM-111) in 1980. It is now recognised as a major
psychiatric disorder with social and occupational impairment.
On September 11, 2001, a terrorist activity
destroyed the World
in New York City and damaged the Pentagon in Washington. It resulted
in more than 3500 deaths and injuries and left many citizens in need of
therapeutic intervention. One survey found a prevance of 11.4% for PTSD and 9.7%
for depression in US citizens 1 month after 9/11. As of 2004, it is estimated
that more than 25000 people continue to suffer from symptoms of PTSD related to
the 9/11 attacks beyond the 1 year mark.
In October 2001, the
United States, along with
Australia, Canada, and the
United Kingdom, began the invasion of Afghanistan in the wake of the
September 11, 2001 attacks. On March 20, 2003, US forces, along with allies,
marking the beginning of the Iraq War. Both wars are ongoing and PTSD is a
rising problem with an estimated 17 percent of returning soldiers having PTSD.
The rate of PTSD is higher in women soldiers. Women account for 11 percent of
those who served in Iraq and
and for14 percent of patients at Veterans Affairs hospitals and clinics. Women
soldiers are more likely to seek help than men soldiers.
The National Co morbidity Survey Replication
(NCS-R) conducted between February 2001 and April 2003, estimated the lifetime
prevalence of PTSD among adult Americans to be 6.8%. The lifetime
prevalence of PTSD among men was 3.6% and among women was 9.7%.
To date, no population based epidemiological
study has examined the prevalence of PTSD among children. However, studies have
examined the prevalence of PTSD among high-risk children who have experienced
specific traumatic events, such as abuse or natural disasters. Prevalence
estimates from studies of this type vary greatly. However, research indicates
that children exposed to traumatic events may have a higher prevalence of PTSD
than adults in the general population.2
In general, the estimates for lifetime PTSD
prevalence range from a low of 0.3% in
China to 6.1% in New Zealand.
The Asian earthquake and subsequent tsunami of
December 2004, one of the largest natural disasters in recent history resulted
in the deaths of over 250,000 people and massive destruction in 8 countries. One
area particularly affected by this disaster was Southern
India. A survey conducted revealed a prevalence of 70.7% for acute
PTSD and 10.9% for delayed onset PTSD. PTSD was more prevalent among girls and
more severe among adolescents exposed to loss of life or property. 3
Abnormalities in the
hypothalamic-pituitary-adrenal axis, including hypocortisolaemia and super
suppression in the dexamethasone suppression test, the opposite to that seen in
the dexamethasone suppression test, the opposite to that seen in depression,
together with abnormalities in regional blood flow in the basal ganglia and
orbit frontal cortex, as seen in obsessive compulsive disorder, have been found,
as have increased noradrenergic and serotonergic central activity.
Reduced hippocampal volume was reported in
posttraumatic stress disorder in Vietnam
veterans. The hippocampus mediates conscious memory, inclusive of traumatic
events, while the amygdala mediates unconscious memories, for example autonomic
aspects of trauma. Decreased medial prefrontal and anterior cingulated areas
have been found in neuroimaging studies, which correlate with increased activity
in the amygdala, resulting in hypersensitivity to external threats, which is
seen in posttraumatic stress disorder.4
Presence of childhood trauma
Borderline, antisocial, dependent or
paranoid personality traits.
Inadequate family or peer relationships
Genetic vulnerability to psychiatric
Recent stressful life events
Perception of an external locus of control
(natural cause) rather than an internal one (human one).
Recent excessive alcohol intake
Posttraumatic stress disorder is classified as
an anxiety disorder.
The characteristic symptoms are considered
Acute if lasting less than three months, Chronic if persisting three
months or more, and With Delayed Onset if the symptoms first occur after
six months or some years later.
PTSD is distinct from the briefer acute stress
Co morbid psychiatric diagnoses are present in
up to 80% of patients.
Major depressive disorder (MDD) is among the
most common of co-morbid conditions for both men and women, affecting nearly
50%. Alcohol abuse (in the majority) and conduct disorder (over 40%) are also
highly co morbid in men. Additionally, there is a threefold to sevenfold
increased risk for both men and women to be diagnosed with other anxiety
disorders, including, generalized anxiety disorder (GAD), panic disorder, and
specific phobias. Most studies have failed to find an increased risk of MDD or
drug abuse for trauma-exposed individuals who are not diagnosed with PTSD.6
The same has been found for alcohol abuse or dependence in males, but not
females. This suggests that MDD and substance abuse (with the exception of
alcohol abuse in women) are not likely to be psychiatric conditions that
independently occur outside of PTSD in response to trauma; rather they appear
more likely either to be the result of PTSD or to share antecedent genetic or
Recovery from PTSD appears to be most pronounced
within the first year following trauma exposure. Large scale epidemiological
studies suggest a remission rate of approximately 25% at 6months and 40% at 1
year.7 Regardless of treatment, more than 30% of individuals
diagnosed with PTSD appear never to remit. If PTSD remission has not occurred
within 6 to 7 years after the trauma, the chance for significant recovery
thereafter appears to be quite small.8 An estimated 10% to 15% of all
Vietnam combat veterans, and nearly 30% of those with high or very high combat
exposure, were found to have PTSD 12 years following the cessation of combat.9
Twenty-eight percent of adult survivors of the Buffalo Creek flood failed to
show remission from PTSD after 14 years. Many of the risk factors for the
development of PTSD also appear to be relevant to increased risk for a chronic
course (eg co morbidity, multiple trauma exposures, negative social support and
trauma severity). In addition, the presence and intensity of avoidance and
numbing symptoms may specifically predispose towards a chronic, rather than a
remitting course of illness in PTSD.10
In the majority of cases, the appearance of PTSD
occurs shortly following traumatic exposure. Approximately 94% of rape victims
meet the full PTSD symptom criteria 1 week following the traumatic event.11
In prisoners of war from World War 11 and the
Korean War, increased rates of PTSD have been observed in older veterans as they
age, with over 10% reporting an increase in PTSD symptoms some 40 years
following discharge from the war despite having experienced relative remission
during the preceding 25 to 30 years.12
Central to most treatment approaches is the
rehearsal of the trauma story, either in a cognitive-behavioural approach, which
may include imaginal or in vivo exposure and may be combined with adjunctive
anxiety management, or in a technique called testimony. The aim is to rehearse
the trauma and reawaken associated emotions, but in a way that can be tolerated
and processed without leading to avoidance. Verbal recall represents behavioural
exposure to a traumatic event, and the aim is to achieve habituation to it.
Audiotape desensitisation using the individual’s own account of the trauma may
also be of value.
For survivors of torture, the pain is often
compounded by guilt and fear, for instance over actions they may have been
forced to carry out. They are encouraged to reframe their thinking and to see
that such actions were due not to their betrayal of others but to the conditions
to which they were subjected.
UK, NICE has made recommendations for
sequential treatment in primary and secondary care settings and recommended
either a CBT approach or eye movement desensitisation processing (EMDR). EMDR
involves involves rapid and rhythmic eye movements induced by the patient
visually tracking the therapist’s finger moving back and forward for about 20 s,
during which time the patient focuses on the traumatic image and associated
negative emotions, sensations and thoughts. Once the distress begins to reduce,
reference to positive thoughts for the event are encouraged. However, eye
movement may not, in fact be necessary, with the procedure merely inducing
desensitisation.13 Antidepressant medication, although not
recommended as a routine first-line treatment, has also been found to be
effective in the management of post-traumatic stress disorder, treating the
commonly associated depression, facilitating sleep and reducing intrusive
memories. SSRIs at high doses for 5-8 weeks have been cited as especially
Tricyclic antidepressants help the intrusive
symptoms of anxiety and depression. However, the MAOI phenelzine may be better
than the tricyclic imipramine. Response may be delayed for up to 8 weeks. NICE
recommends the noradrenergic and specific serotonergic antidepressant (NaSSA)
mirtazapine or the SSRI paroxetine.
Benzodiazepines should be avoided because of
their high dependency potential, especially in the first 2 weeks following the
trauma, as their use may interfere with the memory processing necessary to
Hospital disaster plans should take into account
the psychological responses of the victims.
Controversies and Future Directions
Is the incidence of PTSD overestimated? A recent
reanalysis of data from the National Vietnam Veterans Readjustment Survey
published in Science reduced the original lifetime incidence of PTSD from 31% to
19%, a two- fifths reduction. Will downward adjustments of other PTSD incidence
Is PTSD a discrete category, or is it at the far
end of a posttraumatic symptom severity spectrum? Preliminary taxometric
research supports the latter. Will this call for abandoning the categorical PTSD
diagnosis in favour of a dimensional approach?
Do mental disorders co-morbid with PTSD
represent different facets of the same, traumatically acquired
psychopathological condition, or discrete entities that share risk with PTSD?
Data are available regarding the incidence of
suicide attempts in PTSD, but what is the rate of completed suicide?
In validating biological measures in PTSD
research, the gold standard is the interview-based diagnosis. Will it eventually
become the other way around, as more is learned about the brain basis of this
American Psychiatric Association 2013. Diagnostic and Statistical
Manual of Mental Disorders (Fifth ed.).
VA: American Psychiatric
Publishing. pp. 271–280.
Gabbay V, Oatis MD, Silva RR, Hirsch G. Epidemiological aspects of PTSD
in children and adolescents. In Raul R. Silva (Ed); Posttraumatic Stress
Disorder in Children and Adolescents; Handbook 2004 (1-17).
New York: Norton.
John PB, Russell S, Russall PS. The prevalence of posttraumatic stress
disorder among children and adolescents affected by tsunami disaster inTamil
Nadu.Elsevier Science 2007;5(1):3-7.
Hall AM. Neuro-imaging finding in post traumatic stress disorder:
systematic review. British Journal of Psychiatry 2002; 181:102–10.
Kaplan HI, Sadock BJ, Grebb JA. Kaplan and Sadock's synopsis of
psychiatry: Behavioral sciences, clinical psychiatry 1994, 7th ed.
Baltimore: Williams & Williams pp. 606–609.
N, Reboussin BA, Anthony JC et al. The structure of posttraumatic stress
disorder: latent class analysis in 2 community samples. Arch Gen Psychiatry
2005; 62: 1343-1351.
Breslau N, Kessler RC, Chilcoat HD, et al. Trauma and posttraumatic
stress disorder in the community: the 1996 DetroitArea Survey of Trauma. Arch
Gen Psychiatry 1998; 55:626-632.
Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in
the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52:1048-1060.
9. Dohrenwend BP, Turner JB, Turse NA et al. The
psychological risks of
for US veterans: a revisit with new data and methods. Science 2006; 313:
10. Marshall RD, Turner JB, Lewis-Fernandez R, et
al. Symptom patterns associated with chronic PTSD in male veterans: new findings
from the National Vietnam Veterans Readjustment Study. J Nerv Ment Dis 2006;
11. Foa EB, Rothbaum BO, Riggs D, et al.
Treatment of posttraumatic stress disorder in rape victims: a comparison between
cognitive behavioural procedures and counselling. J Consult Clin Psychol 1991;
12. Port CL, Engdahl B, Frazier P. A longitudinal
and retrospective study of PTSD among older prisoners of war. Am J Psychiatry
2001; 158: 1474-1479.
13. Davidson PR, Parker KCH. Eye movement
desensitization and reprocessing (EDMR): a meta-analysis. Journal of Consulting
and Clinical Psychology 2001; 69: 305-16.