Kathleen Roach – California Southern University – Psy87700 – Psychopharmacology – March, 2020
What is PTSD?
Post-Traumatic Stress Disorder (PTSD) is a disorder that is associated with the witnessing or experiencing of a traumatic event. That event may have occurred in the greater community, an event such as a terrorist attack or natural disaster, or it might be personal, like witnessing or experiencing a violent assault. PTSD was initially associated with veterans of war. The term shell-shock was an early reference to PTSD (DSM V). More recently it has been determined that PTSD may also result from hearing, in detail, about an event that might have been experienced by a relative or close family friend (APA, 2013). While exposure to a traumatic event does not always lead to PTSD, exposure to such an event, either directly or indirectly, is always a factor in the diagnosis of PTSD (Friedman, 2000).
Originally PTSD represented a new concept in psychology – the idea that the cause came from outside of the individual rather than being an inherent trait. The definition in DSM 3 suggested that PTSD was caused by exposure to a traumatic event and went on to distinguish traumatic events from what was referred to as ordinary stressors, or day to day stresses of life (Friedman, 2000). In more recent times, there has been evidence that the offspring of individuals who were traumatized are affected by the post-traumatic state of their parent(s). Many studies were undertaken to explore the environmental impact on offspring if one or both parents had been traumatized. The outcome of some studies suggests that those children will often over‐identify with their parents and often exhibit a diminished sense of self‐esteem, or worry that parental traumas will be repeated, disturbances that are a result of impaired parenting (Yehuda & Lehrner, 2018).
Further research looked beyond environment, and it was established that maltreatment in early childhood could result in lower levels of cortisol. More current claims further suggest that the effect of the traumatic experience is passed from one generation to the next, possibly through epigenetic mechanisms that alter DNA function or gene transcription. Such transmission of the impacts of exposure to traumatic events has been established in animals, but studies with humans have yet to determine if the effects are heritable (Yehuda & Lehrner, 2018).
The following is the criteria outlined in the DSM-5 to be used in diagnosing PTSD.For diagnosis of PTSD, there must first be a threatening event. The patient will have experienced either direct exposure or have witnessed the event. In addition, the patient may have been told about an event that affected someone close to them, such as a violent act against a family member. In the case of police or other front-line workers, repeated exposure to details of traumatic events like child abuse, or other work related situations, may lead to PTSD. The client must show intrusive symptoms related to the event such as recurring memories or dreams whose content is related to the event. Dissociative reactions, like flashbacks, may also occur, leaving the individual feeling like they are re-experiencing the event. In some cases, exposure to cues that are reminders of the event may result in physiological reactions.
Another symptom area is the avoidance of stimuli that might be associated with the event such as avoidance of memories, thoughts or feelings associated with the event, or avoidance of people or places that might stir memories. The patient might also express two or more of the following changes in cognition and mood associated with the event – being unable to remember a key element of the event, having persistent negative beliefs about themselves such as ideas that may lead to self-blame, living in a persistent negative emotional state, or being unable to experience positive emotions.
Having a diminished interest in activities or detachment or estrangement from others might also be present for some. The client may show notable changes in arousal reactivity, like irritable behaviors or angry outbursts, self-destructive behavior, hypervigilance, or an exaggerated startle response. Problems with concentration or sleep disturbances may also occur. The duration of the disturbances described in the above (BCDE) must be one month or longer.The disturbances result in clinically significant distress or impairment, either socially and/or occupationally. The disturbances are not the result of effects associated with substance use or a medical condition.
It is important to note whether the type of dissociative symptom being exhibited. Depersonalization is defined by the client appearing somewhat detached while ifthe client appears to be in a more dreamlike state, the symptom is referred to as derealization. In addition, it is of note if the client is experiencing delayed expression, in which case the full diagnostic criteria was not met until at least six months after the event (DSM-5). There are a variety of assessment instruments available to assist in diagnosing a client with PTSD such as PTSD Symptom Scale Interview (PSS-I and PSS-I-5), Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), Structured Clinical Interview; and PTSD Module (SCID PTS Module) (APA, 2013).
PTSD occurs after a person experiences or witnesses a traumatic event or is told of a disturbing event that affected someone close to them. Not everyone who experiences a traumatic event develops PTSD, however. Vulnerability to PTSD may be attributable to biological factors, having a genetic predisposition to PTSD, or epigenetic mechanisms (Ryan, Chadieu, Ancelin & Saffrey, 2016).Why do some people develop PTSD after exposure to a traumatice situation and others not? A few reasons have been suggested. One thought is that the symptoms of PTSD like flashbacks occur instinctively as a reminder thought to help the individual to survive future traumatic experiences. The flashback forces them to think about the event in detail in order to be better prepared if it happens again. Similarly, the hyperarousal that is evident in some clients may develop instinctively to ensure a quick reaction in another crisis. While these responses may be intended to help with survival, they, in fact, inhibit the ability of the patient to process the traumatic experienceand hence to move on (NHS.UK).
Some studies have shown that people with PTSD have abnormal levels of stress hormones. When in the presence of a dangerous situation, the fight or flight response kicks in and rhe body produces stress hormones like adrenaline. This deadens the sense and dulsl the pain. People with PTSD have been found to continue to produce high amounts of fight or flight hormones, regardless of the presence of danger and possibly resulting in numbed emotions and the sense of hyperarousal often experienced with PTSD (NHS.UK).
There are a variety of risk factors that might lead to the development of PTSD. First, the characteristics of the stressor are a contributor. The nature and intensity of the trauma will have an impact, although that alone is not a determinant. Psychological factors, which include a person’s response to stress, are factors. Individuals who tend to experience more negative emotions in response to a stressor are at greater risk for PTSD (Ryan, et al., 2016). Social factors are also a consideration. A person’s environment, including their family life and community are also contributors. An individual who has experienced depression or anxiety in the past has greater susceptibilty to PTSD after experiencing a traumatic event. Also PTSD is more commonly found in those who have previously experienced traumatic events and particularly with indivdiual who lack the supports needed to help them cope.
A family history of mental health conditions may be a contributor to the development of PTSD. Family linkage studies have provided evidence of the heritability of PTSD. Studies conducted amongst holocaust survivors, for example, showed that those with PTSD were more likely to have children who developed PTSD after exposure to traumatic events (Ryan, et al., 2016). The difficulty with such research is that the risk is tied to the occurrence of trauma in the life of the offspring. As a result, it is not possible to estimate the likelihood of developing PTSD, until after the child has been exposed (Ryan, et al., 2016). Identifying risk has value in that, if treatment for PTSD is initiated earlier, it may be possible to diminish or even prevent the adverse consequences of PTSD.
New research suggests that administering a simple blood test with individuals who are being treated for trauma may help to predict whether the trauma victim is likely to develop PTSD. Individuals in this study who had low levels of two pro-inflammatory molecules (TNFa and IFNy) had a notably higher risk of developing symptoms of PTSD within one year after the teauma exposure, compared to those whose levels of those molecules were not low. While the underlying mechanisms for the correlation between those molecules and development of PTSD is still unknown, the study suggests that it is possible to identify changes in the immune system that occur as a result of exposure to a trauma. By being able to predict the possibility of PTSD amongst trauma victims, it might be possible to begin treatment at once with the most vulnerable patients (Nemeroff, Ressler & Rothbaum, 2019).
Neuroimaging, Genetics and Epigenetics
There have been notable advances in the past decade in neuroimaging which have contributed to our understanding of the physiology of fear and the disordered psyioogical processes associated with PTSD. Neuroimaging studies have demonstrated significant changes in the processing of information and mediation of behaviours in clients with PTSD. There appear to be three areas of the brain that differ in patients with PTSD compared to control subjects: the hippocampus, the amygdala, and the medial frontal cortex. In PTSD patients, the amygdala appears to be hyperreactive when exposed to trauma-related stimuli.
Notable symptoms of PTSD, include exaggerated startle response and flashbacks, which may be a result of the inability of higher brain regions (i.e., the hippocampus and the medial frontal cortex) to diminish the exaggerated symptoms of arousal and distress that the amygdala mediates in response to reminders of the traumatic event (Nutt & Malizia, 2004). Many studies have attempted to explain the genetic pathways, and a number of novel loci and genes have been identified, but the role of those genes has not yet been elucidated. In the studies that have uncovered important findings, those findings have not been clearly replicated, leaving a gap that requires further research. Heredity is related to the transmission of DNA-encoded genetic information to the next generation. Apart from the inherited genetic code, there is another element – the epigenome, which creates modifications and alterations to gene regulation and expression. These alterations originate during the sensitive periods of development. Epigenetic research studies whether environmentally induced epigenetic alterations can pass into the next generation (Daskalakis, Rijal, King, Huckins & Ressler, 2018).
Treatment of PTSD
Psychotherapy is the most effective approach to treatment of PTSD. Psychotherapy can be used to assist patients in gradually facing the memories associated with their trauma. Care must be taken during the therapeutic process to ensure that the patient is not re-traumatized, so the process is slow. The American Psychological Association recommends four different interventions. These interventions are all variations of Cognitive Behavioral Therapy (CBT). Cognitive behavioral therapy focuses on changing the distorted thoughts, feelings and behaviors, and developing coping strategies that target behaviours that result in poor functioning of the individual (APA, 2013). A study conducted amongst individuals who were diagnosed with PTSD supports the effectiveness of CBT both from a symptomatic point of view as well as improvement in autobiographical memory (Akbarian, et al., 2015).
Cognitive processing therapy is a type of therapy thatincludes elements of CBT. It is designed to help patients learn how to change unhelpful beliefs related to the trauma. It is typically a 12-session process and has been used successfully with veterans and refugees (Monson, et al., 2006). Cognitive therapy is a short term process that is derived from CBT. It involves modifying the pessimistic thoughts and inaccurate memories associated with the trauma. The goal of this therapy is to interrupt the behavioral and/or thought patterns regarding the trauma that are interfering with the person’s daily life (APA, 2013). Prolonged exposure is also a type of cognitive behavioral therapy designed to help individuals approach trauma-related memories gradulally without being re-traumatized. By facing what they have been avoiding, the process helps the patient to realize that the trauma-related memories are not threatening and do not need to be avoided (APA, 2013).
In addition, the following therapies might be considered. Brief eclectic psychotherapy is usually 16 sessions held over a 16-week period and combines elements of cognitive behavioral therapy with a psychodynamic approach. Its focus is on the shame and guilt associated with PTSD. In one study conducted amongst police officers who met the criteria for PTSD, this therapy approach was successful in treating specific symptoms like anxiety, depression, obsessive compulsive behaviours and more for up to three months after completion of the therapy. However, there was no follow-up to determine the long term effects of this therapy (Garsons, et al., 2000). Eye Movement Desensitization and Reprocessing (EMDR) Therapy is a structured therapy that helps the client to briefly focus on a trauma memory while, at the same time,experiencing bilateral stimulation (typically eye movements). This process reduces the vividness of memories and strength of emotion associated with the trauma. Narrative exposure therapy is helpful in group treatment for refugees. It helps individuals establish a logical, consistent life narrative through which to examine and understand traumatic experiences.
While long term therapy is important, there are barriers to such treatment; and, in some cases, patients start and drop out because of the slow process. An intensive therapy model is sometimes utilized, specifically in cases where an individual avoids or encounters obstacles to long term therapy. Intensive therapy is short term, consistent, outpatient therapy. One study, which explored the efficacy of intensive therapy (Rothbaum, et al., 2012), developed an outpatient program for veterans and active duty service members. In this study, participants received either prolonged exposure therapy or cognitive processing therapy consistently over a two to three week period. The results showed that 89% of participants felt that the program helped them to overcome obstacles or barriers to seeking care for their condition.
Psychotropic medications are often used in addition to psychotherapeutic approaches for patients with PTSD. Psychotropic medications are used to target some of the symptoms of PTSD, but not as a primary treatment. SSRI antidepressants might be used to help with intrusive thoughts or experiences, or avoidance and numbing. In addition, antidepressants may target depression, panic attacks, and hyperarousal. Currently only the SSRIs sertraline (Zoloft) and paroxetine (Paxil) are FDA-approved for the treatment of PTSD. While SSRIs are typically the primary medications used in PTSD treatment, exceptions may be made for patients dependent on whether they have had side effects from such drugs in the past,their current response to the particular medication or determined by the comorbidities they are experiencing.