Post-traumatic Stress Disorder (PTSD)

Nature

The defining characteristic of a traumatic event is its capacity to provoke fear, helplessness, or horror in response to the threat of injury or death.

A child or adolescent who experiences a catastrophic event may develop ongoing difficulties known as posttraumatic stress disorder (PTSD). The stressful or traumatic event involves a situation where someone’s life has been threatened or severe injury has occurred. Examples include: being the victim or a witness of physical abuse, sexual abuse, violence in the home or in the community, automobile accidents, natural disasters (such as flood, fire, earthquakes), and being diagnosed with a life-threatening illness. A child’s risk of developing PTSD is related to the seriousness of the trauma, whether the trauma is repeated, the child’s proximity to the trauma, and his/her relationship to the victim(s).

PTSD typically develops immediately after the trauma. In some cases, symptoms may not emerge until years have passed since the event. Additionally, a traumatic incident may cause mild PTSD symptoms in one individual while chronically debilitating another. Duration of symptoms also varies, with some people recovering from trauma naturally in the first 3 months, and others experiencing symptoms for months or years.

Examples of traumatic events include:

  • Serious accidents
  • Diagnosis of a life-threatening illness
  • Bereavement and grief
  • Violent personal assault, such as a physical attack, sexual assault, burglary, robbery, or mugging
  • Military combat
  • Miscarriage
  • House fires
  • Natural or man-made disasters
  • Terrorist attack
  • Prolonged bullying
  • Childhood neglect

Exposure to traumatic event can happen in one or more of these ways:

  • Experiencing the traumatic event first-hand
  • Witnessing, in person, the traumatic event
  • Learning someone close to the individual experienced or was threatened by the traumatic event
  • Being exposed repeatedly to graphic details of traumatic events (i.e. first responder to the scene of traumatic events)

Experience

The Experience of PTSD typically includes three principal areas.
  1. Re-Experiencing of The Traumatic Event as indicated by intrusive distressing recollections of the event. In addition, the person may experience flashbacks., nightmares and overall hypersensitive and exaggerated emotional and physical reactions to triggers that remind the person of the event.
  2. Avoidance and Emotional Numbing as indicated by extensive avoidance of activities, places, thoughts, feelings, or conversations related to the trauma. The person is likely to have a loss of interest in activities, feel detached from others, and present with restricted emotions.
  3. Increased Arousal as indicated by difficulty sleeping, irritability, outbursts of anger, hypervigilance and an exaggerated startled response which can look like jumpiness or being on edge.

Children do not exhibit the same reliving of the experience as adults. The progression of PTSD may initially involve dreams about the traumatic event, however, these dreams frequently transform into more generalized nightmares about monsters or different threatening situations where they or another person is in danger. It is more difficult for children to express their sentiments verbally. Therefore, it is necessary for parents or other adult observers to recognize behavioral changes such as a decreased interest in activity or an altered sense of the future (i.e. the child now believing that he/she will no longer live to become an adult). Other signs of childhood PTSD may occur in the form of repetitive play if the child begins to recreate the incident with toys or may occur through the emergence of physical symptoms such as headaches or stomach aches.

Impact

Following the trauma, adolescents may initially show agitated or confused behavior.

They also may show intense fear, helplessness, anger, sadness, horror or denial. Children who experience repeated trauma may develop a kind of emotional numbing to deaden or block the pain and trauma. This is called dissociation. Children with PTSD avoid situations or places that remind them of the trauma. They may also become less responsive emotionally, depressed, withdrawn, and more detached from their feelings. 

A child with PTSD may also re-experience the traumatic event by:

  • Having frequent memories of the event, or in young children, play in which some or all the trauma is repeated
  • Having upset and frightening dreams 
  • Acting or feeling like the experience is happening again 
  • Developing repeated physical or emotional symptoms when the child is reminded of the event 

Children with PTSD may also show the following symptoms:

  • Worry about dying at an early age 
  • Losing interest in activities 
  • Having physical symptoms such as headaches and stomachaches 
  • Showing more sudden and extreme emotional reactions 
  • Having problems falling or staying asleep 
  • Showing irritability or angry outbursts 
  • Having problems concentrating
  • Acting younger than their age (for example, clingy or whiny behavior, thumb sucking) 
  • Showing increased alertness to the environment 
  • Repeating behavior that reminds them of the trauma 

An individual’s PTSD might include symptoms such as feelings of shame, or less commonly, compulsive or aggressive behaviors, or self-destructive behavior. These cases often interfere with an individual’s personal life and are also associated with certain social patterns such as sexual dysfunction, relationship conflicts, and inability to perform daily activities, such as going to school. There are also strong feelings of guilt and despair that lead to social withdrawal and substance abuse.

Rare cases of PTSD may involve auditory hallucinations, paranoid thoughts, or tinnitus, a constant ringing in one’s ears. Individuals who are experiencing paranoid thoughts are highly guarded and constantly suspicious of being harmed and harassed by those around them. When the trauma involves violent death, symptoms of both complicated grief and PTSD may be present.

Prevalence of PTSD

The lifetime prevalence of PTSD is 5.8% in the 17-18 year old demographic and 6.3% in the 18-29 year old demographic. About 37% of annual cases of PTSD are classified as severe. The average age of onset is 23 years old. Females have about a 20% higher likelihood to be impacted by PTSD than males.

Treatment

The best approach is prevention of trauma. However, once the trauma has occurred, early intervention is essential.

The symptoms of PTSD may last from several months to many years. Support from parents, school, and peers is important. Emphasis needs to be placed on establishing a feeling of safety. Psychotherapy (individual, group, or family) which allows the child to speak, draw, play, or write about the event is helpful. Medication may also be useful to deal with agitation, anxiety, or depression.

Cognitive Behavioral Therapy is the gold standard in treating PTSD. Trauma focused Cognitive Behavior Therapy (TF-CBT) is an evidenced-based treatment model that has been proven to reduce trauma related symptoms.  Using TF-CBT, clinicians work collaboratively with the individual and their family to provide psychoeducation about the impact of trauma experiences. The client and their family will learn to manage distressing thoughts, feelings, and behaviors that are linked to the traumatic event. The family will also learn effective communication skills and strategies to increase safety.  

The goal of therapy is to understand, process, and reframe the memories of the traumatic event. In turn, this will change the unhelpful coping behaviors and thinking patterns associated with the trauma. The two types of CBT typically used are Exposure and Response Prevention (ERP) and Cognitive Restructuring. ERP involves the gradual exposure and habituation to triggering events (a feared object, situation, or obsession) to help the PTSD sufferer learn new ways of coping with the anxiety associated with the trauma. The goal is to modify the learned response (hence the name “response prevention”) so more healthy behaviors and thoughts take their place. ERP takes intensive practice through repeated exposures over many months. Cognitive Restructuring helps people better understand the traumatic event in a fact-based manner, dislodging the often-held distorted memories of the event. This helps to alleviate the shame and guilt which is often associated with trauma.

Additionally, scientific research has categorized Eye Movement Desensitization and Reprocessing (EMDR) an evidenced-based therapy, as effective for the treatment of PTSD. EMDR is a treatment technique that facilitates the reprocessing of traumatic memory. In this treatment, the patient focuses on sound, movement, or lights to guide eye movements, while recalling the traumatic event using gradual exposure. This method helps reprocess the memory and how the PTSD sufferer reacts to it.

Resources

Blanco, C., Xu, Y., Brady, K., Pérez-Fuentes, G., Okuda, M., & Wang, S. (2013). Comorbidity of posttraumatic stress disorder with alcohol dependence among US adults: results from National Epidemiological Survey on Alcohol and Related Conditions. Drug and Alcohol Dependence, 132(3), 630-638.

Eisen SA, Griffith KH, Xian H, et al. Lifetime and 12-month prevalence of psychiatric disorders in 8,169 male Vietnam war era veterans. Mil Med. 2004;169(11):896–902.

International Society for Traumatic Stress Studies (ISTSS) – A society for professionals to share information about the effects of trauma;
https://www.istss.org/

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048-1060.

National Center for PTSD (NCPTSD) – A center established by the U.S. Department of Veteran Affairs to improve the well-being of U.S. veterans through PTSD research and education;
www.ncptsd.va.gov/

National Institute of Mental Health (NIMH) – An organization with the National Institute of health dedicated to mental health research;
http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml

Thomas, J. L., Wilk, J. E., Riviere, L. A., McGurk, D., Castro, C. A., & Hoge, C. W. (2010). Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry, 67(6), 614-623.

Ralevski, E., Olivera-Figueroa, L. A., & Petrakis, I. (2014). PTSD and comorbid AUD: a review of pharmacological and alternative treatment options. Substance Abuse and Rehabilitation, 5, 25.

Stecker T, Fortney J, Owen R, McGovern MP, Williams S. Co-occurring medical, psychiatric, and alcohol-related disorders among veterans returning from Iraq and Afghanistan. Psychosomatics. 2010;51(6): 503–507.

Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study.
Kulka RA, Schlenger WE, Fairbank JA, et al, editors. Brunner/Mazel. (1990).
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