Post Traumatic Stress Disorder

Anna’s personal experience after being involved in a road accident offers a good example of mental disorder that sets in people after a life threatening event.  She experienced social, mental, physical and medical challenges. Of a particular interest is the onset of a disorder that significantly changed her way of life and how she related with people around her. Most people like Anna acquire a Post Traumatic Stress Disorder (PTSD) after surviving a crash. It is among the many types of mental disorders listed in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. It first appeared in the list in 1980 (Schnurr, Friedman & Bernardy, 2002). The National Center for Post Traumatic Stress Disorder (US Department of Veterans Affairs) estimated a 5% and 10% prevalence of Post Traumatic Stress Disorder (PSTD) in men and women respectively in the US population between mid and late 1990s. However, the prevalence rates were much higher among Vietnam veterans in the same period. A prevalence rate of 15.2 % was recorded in both men and women.

PTSD is a psychiatric disorder that is mostly expressed after someone witnesses or experiences a traumatic or life threatening event. They may include a horrific accident, a terrorist attack, violent crimes, natural and man-made disasters or military combat (Iribarren, Prolo, Neagos & Chiappelli, 2005). The risk of an imminent death, painful experience and shock or a repeat of the events triggers this condition. Striving not to remember is one among the things that you will strive to do so as to avoid remembering traumatic experience hence leading to  memory and cognitive problems.

Onset of the disease is unpredictable and symptoms start to appear at different times depending on the individuals but they generally appear during the first three months. Adolescents show lot resilience hence the condition will take a lot of time to be expressed. They are also exposed to more risks to events that are dangerous. Many have gone through this experience or have friends who have experienced these traumatic events. Unlike the children and adults, delay in symptoms of the disorder occurs in them years before they are diagnosed. This is referred to as “delayed expression” (APA, 2013).

The human brain stores a lot of information. Depending on the current situations, past memories can be triggered. PTSD condition triggers past anxious and painful memories. These are expressed in terms of nightmares at any time of the day and sleeping difficulties during the night.

Other related disorders that arise from PTSD are moments of depression which will result through isolation from friends and families. The traumatic events occur because of failure of preventing them. The idea of not being able to avoid or prevent them makes one feel hopeless and powerless. On several occasions, memories come uninvited or are triggered through hearing or experiencing a similar scenario. These are responded with fear, anxiety, horror or helplessness (Black and Andreasen, 2011). One method that has been used to avoid these memories is by avoiding talking or recalling life threatening events.  .

Both men and women are at risk of suffering from PTSD. Women have a very high risk of acquiring pre-traumatic condition while the men have a high risk of acquiring posttraumatic condition that eventually develop to PSTD. Very old and people and children are less resilient hence will tend to develop a full-blown stress disorder that takes long to heal. Some may become mild and show only transient symptoms. Other risk factors that might lead people in acquiring this disorder are having a history of mental illness, living a life that mostly revolves working in dangerous places or experiencing dangerous events and trauma, seeing people hurt or killed (mostly soldiers), having little or no social support after an event, dealing with extra stress after a painful event has occurred.

Diagnosis of PTSD is therefore very difficult due the varying symptoms expressed by PTSD. The symptoms look similar to other kinds of mental disorders. Not everyone with sleeping problems or experiences some form of irritability suffers from PTSD (Westgard, 2009). Khouzam (2001) describes a very simple mnemonic derived from the American Psychiatric Association that can be used as diagnostic criteria that can clinically express PTSD. It is designated “TRAUMA”.

First a Traumatic event is experienced and the person responds with helplessness, horror and intense fear. Secondly the person Re-experiences traumatic events by having nightmare, flashbacks, intrusive thoughts, traumatic memories and images of recurring activities that occurs during the event. This leads to the third diagnosis criterion that is characterized with Avoidance and emotional numbing by the affected person. He is detached from other people, loses interest and lacks motivation. More and more symptoms set in causing social, occupational and interpersonal functioning impairment. Patients are regarded as being Unable to function. The forth diagnostic criterion is the period at which the symptoms last. It has been found out that they last for more than 1 Month. Finally the person is increasingly Aroused through having poor concentration, irritable mood and being highly vigilant (American psychiatric Association, 2000). Though the above described diagnostic criteria can accurately diagnose PTSD, there are other additional psychological test tools that can reveal the identity of the PTSD condition (Khouzam , 1996).  Some examples are the primary care PTSDF Screen Trauma Screen, Trauma Screening Questionnaire and PTSD Checklist.

Weathers, Blake, Schnurr, Kaloupek, Marx and Keane (2013) describe the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) which was approved to diagnose and assess PSTD. It is a structured interview comprising 30 items that are administered by paraprofessionals and clinicians. It diagnoses current and lifetime PTSD and any symptoms that arise in the previous week. Administration of the interview assessment and diagnosis takes 45 to 60 minutes.  PTSD Checklist for DSM-5 (PCL-5) assesses 20 DSM-5 symptoms of PTSD. It takes 5 to 10 minutes to monitor symptom change before and after treatment, PTSD screening and summarizing provisional PTSD diagnosis. Another tool is the Life Events Checklist for DSM-5 (LEC-5) screens for any traumatic events that occur in a patient’s lifetime. It assesses individuals’ exposure to 16 events that are known that are more likely to result in PTSD and extraordinary event.  Positive results from the assessment tools conclude presence of the following nursing diagnosis: ineffective coping, sleep pattern disturbance, dysfunctional grieving, impaired social interaction, and risk for suicide, impaired individual resilience and powerlessness.

Several interventions have been identified in managing and reducing the effects of PTSD. They have been divided into two, Psychotherapy and Pharmacology. In addition to these, there are other treatment modalities. Different patients respond in different ways to the treatment procedures. Some respond positively to one treatment modality while some require a combination of different treatment modalities. One medical goal with all these treatment modalities is to ensure that the patient is able to regain control over life (Swan, 2014).

One very important Psycotherapy treatment procedure is administering cognitive restructuring (CR) together with prolonged Imaginal exposure (IE) to the patient. This treatment reduces the PTSD symptoms. The treatment goes through 8 weeks with weekly sessions plus homework. Independent assessment is carried out during pretreatment, post treatment together with a 6-month follow-up (Bryant, Moulds, Guthrie, Dang, & Nixon, 2003). Cognitive restructuring is one among the four main parts of the Cognitive Processing Therapy (CPT). During the cognitive restructuring, the patients are guided into changing their thoughts and feelings towards the experienced traumatic event. They learn new skills that will challenge their previous thoughts and feelings.

IE is a part of Prolonged Exposure Therapy (PE) whereby adults between the ages 18 to 65+ go through a cognitive-behavioral treatment. PE involves four main parts of treatment; education, Breathing retraining, in vivo exposure and Imaginal exposure (IE). In education people are guided into understanding symptoms and goals of treatment. Breathing retraining helps the patient relax and manage their short term distress while in vivo exposure introduces the patients into real world situations that not harmful. Imaginal Exposure involves having a repeatedly conversation with the patients through the trauma experience. The event is revisited again and again both in a loud voice and in detail. The conversation is sometimes recorded so that the patient can listen to it later. This treatment modality helps the patient have control of his thoughts, be sensible and have reduced negative thoughts about the traumatic event.

The other three parts of the CPT apart from the cognitive restructuring are education about the symptoms of PTSD and treatment, developing patients thoughts and feelings, and helping the patients learn the  changes in the beliefs about the trauma. The patients are required to have constant regular meetings with their therapists and have assignments that they do at home so as to “improve their skills outside of therapy” (NCPTSD, 2013).

Cognitive-Behavioral Therapy (CBT) has proven to be the most effective psychotherapy treatment for PTSD. Victims of traumatic events tend to have negative perceptions about themselves feeling guilty and shameful. This cognitive-behavioral therapy involves counseling. Here is re-evaluation of the negative beliefs and perceptions. During the therapy sessions, patients talk of their experiences about the trauma as the therapist help the patients develop a better understanding of his reasoning.

Eye Movement Desensitization and Reprocessing (EMDR) is a form of CBT. EMDR and CBT have been studied and discovered to be the most effective types of psychotherapy treatment.  EMDR treatment is administered in 4 to 12 sessions. During these sessions, the patient talks about the traumatic events while making hand movements or tapping. The principle behind this treatment is to allow the eyes make rapid movements as the brain is easily triggered into recalling traumatic memories. EMDR treatment works through four main parts. It identifies a target memory or the image related with the trauma. T6he therapist manipulates the eye movement of the patients so as to guide him into desensitizing and reprocessing of the mental images. The guided eye movements are maintained until the negative thoughts or traumatic images are replaced by positive thoughts and images. The body is eventually scanned to identify any part that might have been affected by the disorder. It might include tension or unusual sensitization (Staggs 2013).

Lynn, Malakataris, Condon, Maxwell and Cleere (2012) agree that hypnotherapy can act as cognitive-behavioral therapy in treating PTSD. Hypnosis releases any stored emotion to enable traumatic experience be revisited but from a different perspective. The patients see the events in a very different way that is not personal. The treatment is mostly used with evidence-based practices for the treatment of PSTD.

Different approaches have been developed to lessen the damages that are caused by PTSD. Prevention approaches include the use of propranolol (Pitman, Sanders & Zusman, 2002) which is a beta-blocker that treats headaches, hypertension and anxiety. It also reduces psychological arousal.  The drugs block neurobiological pathways responsible for development of PTSD. Morphine, glucocortoids and drugs such as the selective serotonin-reuptake inhibitors (SSRIs) also play similar roles as propranolol (McCleery &Harvey, 2004; Sones, Thorp & Rashkind, 2011).

Other strategies that are used to reduce effects of PSTD are psychological first aid done to all traumatic individuals and targeted prevention to those who are at very high risk of developing PTSD. Debriefing can also be used though it is considered harmful because it prevents a natural process of grief. It is done hours or days after the event has occurred. Critical Incident Stress Debriefing (CISD) is done to people who are indirectly exposed to traumatic situations. This intervention is done through a 3 to 4 hour session (Barboza, 2005) with the aim of normalizing responses of patients to stress. Another preventive measure to development of PTSD is PFA. It works through eight core actions that include “contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connection with social supports, information on coping support and linkage with collaborative services” (Ruzek, Brymer, Jacobs, 2007). The method is portable and can be used immediately a traumatic event occurs.

People who have experienced traumatic events end up developing PTSD. PTSD is a mental condition that is characterized by moments of depression, memory and cognitive problems, nightmares, flashbacks and sleeping difficulties. Traumatic events that cause PTSD include a horrific accident, a terrorist attack, violent crimes, natural and man-made disasters or military combat. People involved in profession that exposes them to dangerous places are at high risk of developing the disease. The disease can be diagnosed by PTSDF Screen Trauma Screen, Trauma Screening Questionnaire, PTSD Checklist for DSM-5 (PCL-5), Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Life Events Checklist for DSM-5 (LEC-5).Treatment of the disease involves the use of psychotherapy and pharmacotherapy treatment methods. They include Cognitive Processing Therapy (CPT), hypnotherapy, Cognitive-Behavioral Therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR) and Prolonged Exposure Therapy (PE). Preventive approaches involve using beta-blocker drugs such as propanolol, psychological first aid, CISD and PFA.

Bibliography

American Psychiatric Association (2000). Diagnostic and Statistical manual of Mental disorders. Third edition. Washington, DC. American Psychiatric Association,

Barboza K. (2005). “Critical incident stress debriefing (CISD): Efficacy in question.” NSPB. Vol 3 Issue 2, pp. 49-70.

Black DW & Andreasen N. (2011). Introductory textbook of psychology. 5th Edition. Washington, DC: American Psychiatric Publishing

Bryant, R.A., Moulds, M.L., Guthrie, R.M., Dang, S.T., & Nixon, R.D.V. (2003). “Imaginal Exposure Alone and Imaginal Exposure with Cognitive Restructuring in Treatment of Posttraumatic Stress Disorder.” Journal of Consulting and Clinical Psychology. VOL. 71, pp. 706-712.

Iribarren, J., Prolo, P., Neagos, N. & Chiappelli, F. (2005). “Post-Traumatic stress Disorder: Evidence-Based research for the Third Millennium.” Evidence based Complementary and Alternative Medicine. Vol. 2, Issue 4. pp 503-512

Khouzam HR ((2001). “A Simple Mnemonic for the Diagnostic Criteria for Post-Traumatic Stress Disorder.” Western Journal of Medicine. Vol. 174 Issue 6, pp. 424

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Lynn, SJ., Malakataris, A., Condon, L., Maxwell, R. & Cleere, C. (2012). “Posttraumatic stress disorder:  cognitive hypnotherapy, mindfulness, and acceptance-based treatment approaches.” Am J Clin Hypn Vol. 54 Issue 4, pp.311-30

McCleery, J. & Harvey, A. (2004). “Integration of psychological and biological approaches to trauma memory: implications for pharmacological prevention of PSTD.” J trauma Stress. Vol. 17 Issue 6, pp. 485-96

National Center for PTSD (NCPTSD). (2014). “Understanding PTSD Treatment.” Retrieved from wwww.ptsd.va.gov

Pitman RK, Sanders KM, Zusman RM. (2002).” Pilot study of secondary prevention of posttraumatic stress disorder with propranolol.”  Biol Psychiatry. Vol. 51Issue 2, pp. 189-92.

 

Ruzek J. Brymer, M., Jacobs A. (2007). “Psychological first aid.” J Ment health Couns. Vol 29 Issue 1, pp 17-49

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Sones H., Thorp S. & Rashkind M. (2011). “Prevention of posttraumatic stress disorder.” Psychiatr Clin North Am. Vol. 34 Issue 1, pp 79-94

Staggs S. (2013). “Psychotherapy treatment for PSTD.” Psych central. Retrieved form psychcentral.com

Swan, J. & Hamilton PM. (2014). Posttraumatic Stress Disorder (PTSD). Wild Iris medical Education, Inc. available at  www.nursingceu.com

Weathers F., Litz B., Keane T., Palmieri P.,, Marx B. & Schnurr P. (2013). “The PTSD checklist for FDSM-5 (PCL-5) Scale.” Available from the National Center for PTSD at wwww.ptsd.va.gov

Westgard, E. (2009). “Coming Home with Posttraumatic Stress Disorder.” American Journal of Nursing. Vol. 109, Issue 5, pp 11

 

 

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