��POST TRAUMATIC STRESS DISORDER

Nathan Milkins

POST TRAUMATIC STRESS DISORDER (PTSD)��

WHAT IS POST TRAUMATIC STRESS DISORDER (PTSD)��BIOPSYCHOSOCIAL CONSIDERATIONS��DIAGNOSTIC/EVALUATIVE CONSIDERATIONS��THERAPEUTIC CONSIDERATIONS��CONCLUSION

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Symptoms

Typically, someone diagnosed with PSTD:

• Experience flashbacks, reoccurring memories
• Avoid places, events and people that remind them of the trauma event
• Become easily startled, become tense or on edge
• Have trouble remembering the event details
• Have negative thoughts about themselves or the people around them
• Outburst, sometime violent

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Who can experience PTSD?

Anyone can suffer from a traumatic event that can cause PTSD. Typically associated with combat veterans, PTSD is also possible for those who have empierce or witnessed an assault, accident or disaster. Sometime even just hearing about an event can cause PTSD. Not every traumatic event causes PTSD, but a fear response may occur based on an individuals “fight or flight” response.

“According to the National Center for PTSD, a program of the U.S. Department of Veterans Affairs, about six out of every 100 people will experience PTSD at some point in their lives. Women are more likely to develop PTSD than men. Certain aspects of the traumatic event and some biological factors (such as genes) may make some people more likely to develop PTSD.” (Post-Traumatic Stress Disorder, 2023)

��PART ONE:

BIOPSYCHOSOCIAL CONSIDERATIONS

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Biological

• Hormonal changes: People with PTSD often have altered levels of stress hormones.
• Changes in the brain structure: Neuroimaging studies have shown changes in the size and activity of certain areas in the brain of people with PTSD. Some of the most consistently reported changes are seen in the amygdala, the hippocampus, and the prefrontal cortex.
• Genetics: Certain genes and gene variations might make individuals more susceptible to PTSD following a traumatic event.
• Inflammatory responses: Some recent research suggests that individuals with PTSD might have elevated levels of certain markers of inflammation in their bodies.

Psychological

• Re-experiencing symptoms: This is a key feature of PTSD and includes recurrent, intrusive, and distressing memories, dreams, or flashbacks of the traumatic event. This re-experiencing can lead to psychological distress and physical reactions.
• Avoidance: Another characteristic of PTSD is the avoidance of stimuli associated with the trauma. This can include places, people, thoughts, feelings, or reminders of the event. Avoidance can impact a person's daily functioning and quality of life.
• Mood Changes: This may include persistent negative beliefs about oneself, others, or the world, persistent negative emotional states, and diminished interest in significant activities. People with PTSD may also experience feelings of detachment from others and an inability to experience positive emotions.
• Hyperarousal: PTSD can lead to changes in arousal and reactivity that were not present before the trauma. This may manifest as irritability, anger, recklessness or self-destructive behavior, hypervigilance, exaggerated startle response, difficulty concentrating, or sleep disturbances.
• Dissociation: Some people with PTSD may experience dissociation, a psychological process that causes a lack of connection in a person's thoughts, memories, feelings, actions, or sense of identity. This can manifest as flashbacks during which the person feels as if the traumatic event is happening again.

Social

• Social support: The presence or absence of a supportive social network can significantly impact the development and course of PTSD.
• Stigmatization: Mental health stigma can prevent people from seeking help or receiving appropriate treatment, worsening the course of PTSD. Stigma can also increase feelings of isolation, shame, and guilt, which can exacerbate PTSD symptoms.
• Relationships: PTSD can impact a person's ability to form and maintain healthy relationships. Those with PTSD might experience difficulty with trust, intimacy, and communication. Additionally, their symptoms can also impact their loved ones, who might struggle to understand and cope with the changes in behavior.
• Employment: PTSD can affect a person's career, potentially leading to job loss or decreased productivity. Symptoms like concentration problems, difficulty with sleep, and heightened stress levels can affect job performance and stability.
• Military service: Veterans and active duty military personnel are at an increased risk of PTSD due to their increased likelihood of exposure to traumatic events.
• Traumatic events in the public sphere: Large-scale traumatic events like natural disasters, terrorist attacks, or pandemics can lead to widespread PTSD in affected communities. The social response to these events can play a significant role in mitigating or exacerbating PTSD symptoms.

Cultural Variation

• Perceptions of Trauma: What is considered a "traumatic event" can also be influenced by culture. For example, in some cultures, events like migration or significant societal changes may be perceived as traumatic.
• Stigma and Mental Health Literacy: Cultural attitudes towards mental health can influence the likelihood of a person seeking help or even acknowledging their symptoms. In some cultures, there may be a significant stigma around mental health, which can prevent individuals from seeking help.
• Coping Mechanisms and Resilience: Cultural beliefs and practices can impact how individuals cope with stress and trauma. Some cultures might emphasize community support and collective coping mechanisms, while others might value individual resilience.
• Help-Seeking Behaviors: Different cultures might have different beliefs about the types of treatments that are acceptable or beneficial. In some cultures, people might be more likely to seek help from spiritual or traditional healers rather than mental health professionals.
• Language and Communication: Some cultures may lack specific language or terms to describe psychological distress, leading to potential difficulties in identifying and diagnosing PTSD.

Treatment

• Treatment Acceptance: Different cultures might have varying levels of acceptance for specific types of treatments. For instance, Western-style psychotherapy might not be accepted or effective in some cultures, and it could even be seen as a foreign or intrusive concept. It might be necessary to adapt treatment models to respect cultural traditions and values.
• Cultural Adaptations to Therapeutic Techniques: Evidence-based therapies such as cognitive-behavioral therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) might need to be modified to consider cultural nuances. For instance, the emphasis on verbalizing thoughts and feelings in CBT might not align with cultural norms that value privacy or indirect communication about personal matters.
• Help-Seeking Behaviors: In some cultures, individuals may prefer to seek help from traditional or spiritual healers. Mental health professionals should respect these beliefs and could consider ways to incorporate traditional healing practices into treatment, if appropriate and helpful.
• Understanding of Illness and Wellness: Cultural beliefs about the causes of illness and pathways to health can influence the way individuals engage with treatment. Understanding these beliefs can help clinicians build a stronger therapeutic alliance and create more effective treatment plans.
• Use of Social Supports: Some cultures may place a high value on community and social support networks. In these cases, involving the wider community, family, or other important social networks in treatment can be very beneficial.
• Communication and Language: Therapy may need to be conducted in the individual's native language for it to be effective. Even when a person is bilingual, emotional and nuanced discussions are often better conducted in their first language. The use of interpreters or bilingual therapists may be necessary.

Community

• Reducing Stigma: Community awareness campaigns can help reduce the stigma around PTSD and mental health issues. By promoting understanding and acceptance, these initiatives can make it easier for individuals to seek help when they need it.
• Education and Awareness: Community programs can educate people about the signs and symptoms of PTSD, as well as the availability and benefits of treatment. This knowledge can help individuals recognize symptoms in themselves and others, and it can also dispel misconceptions about the disorder.
• Peer Support: Communities can create and support groups for individuals affected by PTSD, providing a safe space for them to share experiences, learn from others, and feel understood. Peer support can supplement formal treatment and provide ongoing support.
• Advocacy: Community leaders and groups can advocate for better access to mental health services, influencing policy, and resource allocation. Advocacy can also help ensure that services are tailored to the needs of the community, considering factors like cultural appropriateness and accessibility for those with disabilities.
• Community Mental Health Services: Local services such as community health centers, outreach programs, and telehealth services can provide accessible and affordable mental health care. These services are particularly important in communities where there might be a lack of psychologists or psychiatrists.
• Collaboration with Other Services: Collaborations between mental health services and other community services such as schools, workplaces, and social services can help identify individuals at risk and ensure they are connected with the help they need. It can also ensure that those around the person with PTSD (like teachers or colleagues) are supportive and understanding.
• Promotion of Healthy Coping Mechanisms: Communities can promote activities that help individuals manage stress and reduce symptoms, such as exercise, meditation, or creative activities.
• Crisis Intervention: In the aftermath of a community-wide traumatic event (like a natural disaster or violent event), community-based interventions can provide immediate support and connect individuals with further resources if needed

PART TWO:

DIAGNOSTIC/EVALUATIVE CONSIDERATIONS

Clinical Assessments

A typical Clinical Assessment is an interview process or self-reported assessment

• Strengths:
• Standardization: Clinical assessments provide a standardized way to identify symptoms and make a diagnosis, ensuring consistency across different healthcare providers.
• Use of Established Criteria: These assessments are based on the diagnostic criteria established in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which helps ensure the accuracy of diagnosis.
• Comprehensive Evaluation: Many assessment tools are designed to cover all aspects of PTSD, including the type of trauma experienced, the range of symptoms (re-experiencing, avoidance, negative cognition/mood, hyperarousal), and the impact of these symptoms on the individual's life.
• Measurement of Severity: Clinical assessments can help determine the severity of PTSD symptoms, which can be useful in creating a treatment plan and tracking progress over time.
• Limitations:
• Reliance on Self-Report: Many assessments rely heavily on self-reporting, which can be influenced by recall bias, the current emotional state of the individual, or a reluctance to disclose certain information due to stigma or discomfort.
• Cultural Sensitivity: Not all assessment tools may be applicable or appropriate for people from different cultural backgrounds. They may not account for cultural variations in symptom expression, trauma interpretation, or levels of stigma associated with mental health issues.
• Limited Scope: While PTSD assessments are designed to capture symptoms of PTSD specifically, they might not fully capture other mental health issues that often co-occur with PTSD, like depression or substance use disorders.While clinical assessments can measure the current symptom severity, they may not adequately capture fluctuations in symptoms over time.

Reliability and Validity

Reliability Challenges:

• Temporal Consistency: PTSD symptoms can fluctuate over time due to a variety of factors including external stressors, coping strategies, and therapeutic interventions. This means a person's symptoms might vary between assessments, which can challenge the reliability of the measure.
• Inter-Rater Reliability: Different clinicians may interpret a patient's symptoms or the severity of symptoms differently, leading to inconsistencies in the diagnosis or assessment of the severity of PTSD.
• Test-Retest Reliability: A person's response to assessment questions may change over time due to memory factors, changes in insight, or therapeutic impact. This poses challenges for consistency when using the same assessment tool over time.

Validity Challenges:

• Cultural Validity: As PTSD symptoms can manifest differently across cultures, a measure that has been validated in one cultural context may not necessarily be valid in another. Failure to account for cultural differences can lead to misdiagnosis or missed diagnoses.
• Comorbidity: PTSD often occurs alongside other mental health disorders, such as depression, anxiety, and substance use disorders. These can complicate the diagnosis and challenge the validity of assessments, as it may be difficult to distinguish symptoms of PTSD from symptoms of co-occurring disorders.
• Criterion Validity: The criteria used to diagnose PTSD, as outlined in the DSM-5, may not perfectly capture the condition in all individuals. Some people may experience significant distress and impairment from trauma without meeting the full criteria for PTSD.
• Self-Report Bias: Many PTSD assessments rely on self-reporting. Patients might underreport or overreport symptoms due to stigma, misunderstanding, recall biases, or the desire to please the clinician (social desirability bias). This can impact the validity of the results.

Diagnosis by Exclusion

• PTSD is typically diagnosed using the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These criteria include experiencing a traumatic event, exhibiting specific symptoms in the aftermath of the event (such as intrusive memories, avoidance behaviors, negative changes in thoughts and mood, and changes in arousal and reactivity), and experiencing significant distress or functional impairment due to these symptoms.
• However, in some cases, a diagnosis by exclusion may be used in the assessment of PTSD. This is particularly true when the individual's symptoms overlap with other mental health conditions. For example, PTSD shares many symptoms with other disorders such as Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), Acute Stress Disorder (ASD), and others. Symptoms such as re-experiencing trauma (common in PTSD) might also be mistaken for psychotic symptoms.

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Assessments

• Structured Clinical Interviews: A structured clinical interview allows the clinician to systematically assess for a range of symptoms across different disorders, not just PTSD. Through this process, the clinician can determine if the symptoms align more closely with another mental health condition such as depression, anxiety disorders, or a psychotic disorder.
• Psychological Testing: Psychological tests can be used to further evaluate the nature of the symptoms and potentially rule out other conditions. For example, some measures may assess for symptoms of depression, which could be causing distress that may be mistaken for or overlapping with PTSD symptoms.
• Medical Evaluation: A thorough medical evaluation can rule out medical conditions that might be contributing to the symptoms. For example, certain neurological conditions, endocrine disorders, or substance misuse might cause symptoms like anxiety, mood changes, or sleep disturbances.
• Functional Assessment: By assessing the individual's level of functioning in different areas of life (e.g., work, social, daily activities), it can help to distinguish between PTSD and other conditions that might cause similar impairments.
• Assessment of Trauma History: A thorough assessment of the individual's history of traumatic experiences is a key part of diagnosing PTSD. If there's no history of trauma, the symptoms might be better explained by another disorder.
• Assessment of Symptom Onset and Course: Understanding when symptoms began and how they have progressed can also help differentiate PTSD from other disorders. For example, symptoms of Acute Stress Disorder occur immediately after the traumatic event and last for a maximum of one month, whereas PTSD symptoms typically persist longer.

Publication Process

The Diagnostics and Statistical Manual of Mental Disorders (DSM) is the primary resources used by mental health professional for diagnosing mental health disorders. It provides a list of mental disorders and the common symptoms that may occur with each disorder and the variations that might exist.

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PART THREE: THERAPEUTIC CONSIDERATIONS

Therapeutic Approaches

Non-Pharmacological Approaches

• Addressing Root Causes: Non-pharmacological therapies can help individuals explore and address the root causes of their PTSD symptoms. Therapies such as Cognitive Behavioral Therapy (CBT) or Eye Movement Desensitization and Reprocessing (EMDR) help individuals process traumatic memories and restructure maladaptive thoughts and beliefs associated with the trauma.
• Improving Coping Strategies: Through non-pharmacological therapies, individuals can learn effective coping strategies to manage their symptoms. This might include techniques for managing anxiety, tools for improving sleep, or methods for addressing and reducing avoidance behaviors.
• Building Resilience: Therapy can help to build resilience and personal growth following trauma, a concept known as post-traumatic growth. Therapy can help individuals develop a stronger sense of self, better interpersonal relationships, and a greater appreciation for life.
• Reducing Stigma and Empowering Individuals: Some people may feel stigmatized by taking medication for mental health problems, or they may prefer not to because of potential side effects. Non-pharmacological treatments can be a good alternative or addition for these individuals.

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Duty to Treat

Do No Harm: This principle ensures that healthcare providers avoid causing harm to their patients, whether through action or inaction. For example, clinicians need to consider potential side effects and risks of treatments, ensure they have the right skills and competence to provide treatment, and avoid re-traumatization or worsening symptoms in therapies like exposure therapy for PTSD.

Duty to Treat: This principle entails an obligation to act in the best interest of the patients, which involves providing effective treatments and helping to alleviate their suffering. In the context of PTSD, the duty to treat might mean providing evidence-based therapies or medications to help manage symptoms and improve the patient's quality of life.

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CONCLUSION

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WATCH FOR THE SIGNS OF PTSD AFTER SOMEONE YOU KNOW HAS SUFFERED OR WITNESSED A TRAUMATIC EVENT (I.E. ISOLATION, DEPRESSION, VIOLENT OUTBURSTS)��KNOWING THAT TREATMENT AND HELP IS AVAILABLE TO THOSE WHO NEED IT. HELP DIRECT THOSE IN NEED TOWARDS THE RESOURCES THAT WILL HELP THEM.

�BEING AWARE OF AND HELPING THOSE WITH PTSD STRENGTHENS OUR OVERALL COMMUNITY AND PEER GROUP.

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References & Sources

• Post-Traumatic Stress Disorder. (2023, May). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd#:~:text=Post%2Dtraumatic%20stress%20disorder%20(PTSD)%20is%20a%20disorder%20that
• Hooley, J., Nock, M., & Butcher, J. (2020). Abnormal Psychology. (18th ed.). Pearson Education. https://mbsdirect.vitalsource.com/reader/books/9780135191033/epubcfi/6/6
• Psychology Today. (2019). Post-Traumatic Stress Disorder | Psychology Today. Psychology Today. https://www.psychologytoday.com/us/conditions/post-traumatic-stress-disorder
• American Psychological Association. (2017, April). PTSD Assessment Instruments. Https://Www.apa.org. https://www.apa.org/ptsd-guideline/assessment
• ‌American Psychological Association. (2020, June). Treatments for PTSD. Https://Www.apa.org. https://www.apa.org/ptsd-guideline/treatments

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