PTSD or Post-Traumatic Stress Disorder results from experiencing or witnessing a severely traumatic event. Women are a higher risk of PTSD than men.

Post Traumatic Stress Disorder(PTSD)

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Iqra Mazhar

Overview

Post-Traumatic Stress Disorder or PTSD is a psychiatric mental illness that is common in all regions of the world. The disorder is caused by experiencing or witnessing a severely traumatic event<a href="#accordion">[1]</a>.

PTSD has had many different names throughout the years. It was regarded as &lsquo;shell shock&rsquo; and &lsquo;combat fatigue&rsquo; in World War II. The disorder has been severely misunderstood throughout the years up until now. It is not essential to develop PTSD after a traumatic event.&nbsp;

The chances of women getting PTSD are double that of men. This is because most cases of rape, sexual assault, and physical violence at all ages are against women all over the world regardless of the region.&nbsp;

However, it is reported that around 6 of 100 people, or approximately 6% of the population are bound to get PTSD at some point in their lives<a href="#accordion">[13]</a>.&nbsp;However, when it comes to Pakistan, we have seen a lot more traumatizing things from a very young age - national disasters, gun violence, foreign attacks and so much more. To a large extent, this has desensitized a big chunk of the population due to how often it has happened, but at the same time, a bigger chunk lives with undiagnosed PTSD or has adopted certain living practices unknowingly that have been greatly impacted by their traumatic past. The 2010 floods serve as a great example of how large populations can develop PTSD. Research conducted by Hamdard University, Karachi, indicated that 59.2% of the tested individuals (that is,&nbsp;more than half of the affected population)&nbsp;were suffering from severe PTSD, whereas 26.3% were moderately affected by PTSD and only 14.5% were slightly affected by PTSD<a href="#accordion">[11]</a>.

&nbsp;

PTSD is a highly complex disorder that can be experienced in multiple ways with different stages varying in severity and triggers. The disorder can also give rise to other issues as well if not treated on time. Stress disorders and PTSD can be very similar, but PTSD on its own has a broad spectrum of types. They include:

&nbsp;

<ul>
	<li>
	<h5>Secondary Trauma</h5>
	</li>
</ul>

This occurs in people who have not gone through the actual trauma itself; rather, they take care of someone who has. Due to the repetition of the event or getting overwhelmed by too many people going through the same trauma, the caretakers/loved ones tend to develop similar symptoms, albeit of lesser intensity. It can be cured with the right treatment. 
&nbsp;

<ul>
	<li>
	<h5>Normal Stress Response</h5>
	</li>
</ul>

A normal stress response involves the stimulation of the body&rsquo;s fight-or-flight response. In many cases, this is short-termed and can easily be managed through support from friends and family. However, not all normal stress responses lead to PTSD; in some cases, it could be a starting point.

&nbsp;

<ul>
	<li>
	<h5>Acute Stress Disorder</h5>
	</li>
</ul>

More similar to the conventional classification of PTSD, acute stress disorder can prevail from any time between 3 days to a month after the traumatic event has occurred. It is often characterized by repeated mental exposure to the event or graphic details of it. It is very common for rape survivors or car accident survivors to experience this. In most cases, it is combatted through psychotherapy to avoid the worsening of the condition into PTSD.

&nbsp;

<ul>
	<li>
	<h5>Uncomplicated PTSD</h5>
	</li>
</ul>

A relatively simpler form of PTSD, this is often related to one major traumatic event and is mostly related to mass violence or a natural disaster. The person often gets flashbacks, nightmares, or reminders of that one event. This may cause irritability, aggression, and several changes in relationships. War veterans commonly go through this type of PTSD.

&nbsp;

<ul>
	<li>
	<h5>Complex PTSD</h5>
	</li>
</ul>

People in abusive or violent households with recurring events of physical violence, assault, and rape, suffer from complex PTSD. Repeated exposure to traumatic events can also occur in wars, cults, etc. The treatment, in this case, is very intensive and requires medications coupled with psychotherapy targeted towards acknowledgment, acceptance, and then dealing with the triggers. However, people with complex PTSD are not always open to the idea of treatment and, in many cases, adopt self-destructive behavior that may involve self-medication or even drug abuse.

&nbsp;

<ul>
	<li>
	<h5>Comorbid PTSD</h5>
	</li>
</ul>

This occurs when the patient suffers from multiple disorders with the root cause being PTSD. Substance abuse issues are very common in this case and many people have the tendency to transition to dissociative PTSD where they are in such a mental state that they tend to either dissociate from their body, their surroundings, or in severe cases, may even dissociate into another personality.

&nbsp;

Signs And Symptoms

Depending on the severity of the condition, the symptoms may vary greatly. PTSD has been the root cause of many other severe mental illnesses. The onset of these symptoms can vary from a few days to several months, but in some cases, PTSD may get triggered ages after the traumatic event. The symptoms are often characterized into several categories due to the wide spectrum of issues PTSD can cause. These include: 
&nbsp;

Re-Experiencing -&nbsp;In this, the patient relives the graphic memory repeatedly through:

<ul>
	<li>Flashbacks</li>
	<li>Nightmares</li>
	<li>Distressing image or a similar story</li>
	<li>Physical reactions to a trigger similar to the event that happened 
	&nbsp;</li>
</ul>

Emotional Numbing Or Avoidance -&nbsp;This involves complete avoidance of any factors that may be a trigger. This can be a very limiting aspect of PTSD as in many cases people are unable to go places or perform activities; especially in cases of rape, the victims find it very difficult to indulge in sexual acts. They tend to serve as a reminder of the incident. 
&nbsp;

Hyperarousal -&nbsp;It is common to develop anxiety alongside PTSD. People often find themselves having severe outbursts, insomnia, and issues concentrating.&nbsp; 
&nbsp;

Negative Changes -&nbsp;These changes are commonly observed in terms of mood, attitude towards self or others, detachment from friends and family, memory issues, and signs of depression<a href="#accordion">[5]</a>.

<div>&nbsp;</div>

Causes

PTSD can be caused by several types of events that may include:

<ul>
	<li>Rape or sexual assault</li>
	<li>Car accidents</li>
	<li>Abuse &ndash; harassment, bullying, racism, sexism, transphobia, or any other abuse targeting the person&#39;s identity</li>
	<li>Getting kidnapped or held hostage in a scary situation</li>
	<li>Experiencing violence, like mugging, war, terrorist attacks, etc.&nbsp;</li>
	<li>Childbirth experiences, such as losing a baby or twins</li>
	<li>Witnessing or experiencing terrorism&nbsp;</li>
	<li>Natural disasters, etc. 
	&nbsp;</li>
</ul>

PTSD itself is a broad-spectrum disorder that can be an issue of its own or, in many cases, can serve as a symptom e.g. in dissociative identity disorder. The right screening tools make all the difference for catching it early and to avoid it worsening into dissociative PTSD. Following are some of the screening tests commonly employed for PTSD: 
&nbsp;

<ul>
	<li>Primary Care PTSD Screen For DSM-5 (PC-PTSD-5): This is a 5-item screening test that assesses lifetime exposure to traumatic events. A score of 0 denotes that the respondent has not had any exposure to a traumatic event. In case of the respondent saying that they have had trauma, they are then further instructed to take a 5-item yes/no questionnaire. 
	 
	The questionnaire contains assessment of the person&rsquo;s sleep - if they have any nightmares, their behavior towards certain thoughts, places or events, their attitude towards themselves and others, and if they have a constant feeling of guilt in any way<a href="#accordion">[7]</a>.&nbsp;A test with a higher score is then followed up by an extensive interview like Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)<a href="#accordion">[12]</a>. 
	&nbsp;</li>
	<li>SPAN: This is a 4-item self-report test that originated from the Davidson Trauma Scale. The name itself stands for the 4 aspects that are assessed, that is, startle, physically upset, anger, and numbness.&nbsp; 
	&nbsp;</li>
	<li>SPRINT: This is an 8-item self-assessment test that determines the person&#39;s overall mental state based on the core symptoms of PTSD involving avoidance, intrusion, numbing, arousal, etc. These are all assessed on a scale of 0 to 4, with 4 suggesting that the symptoms are severe. SPRINT has been a viable screening test providing a reliable score that is later followed up by a structured interview when scores are above<a href="#accordion">[14]</a>. 
	&nbsp;</li>
	<li>Trauma Screening Questionnaire (TSQ): A lengthy 10-item assessment is used for the survivors of all kinds of traumatic stress. This screening test is based on the PTSD symptom scale self-report (PSS-SR). It asks the respondents about their experience with their emotions and surroundings over a period of 2 weeks. This test is best used after at least 3-4 weeks from the traumatic event to allow the respondent to register and deal with the issue on their own<a href="#accordion">[3]</a>. 
	&nbsp;</li>
</ul>

Diagnosis

PTSD cannot be immediately diagnosed. It is best to at least wait a month to start the screening process and then follow up with a diagnosis based on the results<a href="#accordion">[4]</a>.&nbsp;The doctor will first conduct a physical exam to look for any signs of possible injuries that may be causing any of the symptoms. This will then be followed by a psychological evaluation in which you are diagnosed with the help of the set DSM-5 criteria approved and published by the American Psychiatric Association<a href="#accordion">[6]</a>. 
&nbsp;

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Treatment

The usual therapy for PTSD involves medications coupled with psychotherapy depending on the severity of the symptoms. When it comes to therapies, there are three main types that are commonly employed in people with PTSD: 
&nbsp;

<ul>
	<li>Cognitive Behavioral Therapy (CBT): This type of therapy is targeted towards the patient&#39;s thought process and how it impacts their actions. It starts off with helping the survivor acknowledge and come to terms with the traumatic event. The ideal target is to allow the patient to gain control of their fear and review any conclusions that they may have about the incident, which in many cases involves blaming themselves<a href="#accordion">[8]</a>. 
	&nbsp;</li>
	<li>Brief Eclectic Psychotherapy: Rooted in CBT, eclectic psychotherapy refers to the process where the patient is conditioned to change their emotions of shame and guilt. The therapy also focuses a lot on the relationship between the patient and the therapist, ensuring that the patient fully trusts the therapist and is able to form a connection with the therapist and then with the outside world. 
	&nbsp;</li>
	<li>Eye Movement Desensitization And Reprocessing (EMDR): Known to be very effective for the treatment of PTSD, this type of therapy involves recalling the trauma with complete details as the patient is following the movement of the therapist&rsquo;s finger with their eyes. This simulation can be achieved through different means as well and is termed as bilateral simulation. 
	&nbsp;</li>
	<li>Narrative Exposure Therapy (NET): NET is generally used to treat people with trauma disorders. The therapy focuses on the traumatic experiences faced by the individual, but also brings to light the positive experiences that the person has had in their life<a href="#accordion">[10]</a>. 
	&nbsp;</li>
	<li>Medications: Every person has their own process of dealing with the trauma. This leads to several different symptoms that vary from person to person. This is why the medications may differ based on the symptoms. Most of these medicines are anxiolytics and affect neurotransmitters. Examples of prescribed medications are:&nbsp; fluoxetine, paroxetine, sertraline, venlafaxine, etc. Also, Paroxetine and Sertraline are FDA approved for treating PTSD<a href="#accordion">[14]</a>. 
	&nbsp;</li>
</ul>

PTSD can lead to a plethora of complications as it serves as a root cause of many other mental disorders, especially dissociative disorders. However, on a smaller and much more common level, these complications may include:

<ul>
	<li>Mood disorders, including bipolar behavior&nbsp;</li>
	<li>Panic attacks and other severe <a href="https://www.merisehat.pk/disease/anxiety" target="_blank">anxiety </a>issues</li>
	<li>Substance abuse disorders</li>
	<li>Eating disorders</li>
	<li>Suicidal thoughts and self-harming tendencies</li>
	<li>Increased risk of heart diseases 
	&nbsp;</li>
</ul>

There is no set criterion of risk factors since PTSD can occur in all ages and can affect anyone. However, there are still some factors that have been more prevalent in the masses suffering from PTSD than others and can be categorized as risk factors. These include:

<ul>
	<li>Experiencing recurring traumatic events that may be related to sexual abuse, harassment, and rape</li>
	<li>Having experienced trauma in childhood</li>
	<li>Being a part of the military or working as a first responder</li>
	<li>Having a history of substance abuse</li>
	<li>Lacking friends and family to support you through previous traumas&nbsp;</li>
	<li>Having a history of mental illness 
	&nbsp;</li>
</ul>

<ul>
	<li>Researchers at Tokyo University of science discovered the mechanism behind chemically induced suppression of traumatic or fearful memories. They used a mouse model and identified the stimulated biochemical pathways. This breakthrough will play a vital role in the development of medicines, especially for trauma-related disorders. The research further investigated the action of KNT-127 and its suppressive impact on the fearful memories<a href="#accordion">[2]</a>.</li>
	<li>Scientists at Brown University made a breakthrough by finding that theta-burst stimulation may treat PTSD effectively. The study was published in the American Journal of Psychiatry. It discussed a controlled study of 50 veterans with PTSD and how previously, transcranial magnetic stimulation showed improvement, but intermittent theta-burst stimulation is bound to show better and promising results and can be considered as a treatment for PTSD and depression<a href="#accordion">[9]</a>. 
	&nbsp;</li>
</ul>

Key Points

<ul><li>Post-Traumatic Stress Disorder (PTSD) refers to a psychiatric mental illness caused by a traumatic event that leads to the onset of several mental issues in the victim’s life in general.</li><li>Male war veterans suffer from this; generally, women are known to suffer more from PTSD as they are more vulnerable to sex crimes.</li><li>There are multiple types of PTSDs depending on the severity and the complexity of the condition. Complex PTSD is yet to be fully understood given the fact that its multifaceted and that people who have it are often reluctant to get treated.</li><li>There are multiple screening tests available for PTSD. These tests are under 10 points questionnaires to determine the patient’s current state and the need for further structured interviews.</li><li>The diagnosis is based on DSM-5 criteria after screening and extensive interviews.&nbsp;</li><li>The treatment involves several types of psychotherapies, but in some cases, medications are also prescribed to control symptoms like <a href="https://www.merisehat.pk/disease/anxiety" target="_blank">anxiety </a>and <a href="https://www.merisehat.pk/disease/depression" target="_blank">depression</a>.</li></ul>

[1] American Psychiatric Association, 2020. What is Posttraumatic Stress Disorder?. [Online]

[2] Ayako Kawaminami, D. Y. S. Y. M. S. K. I. H. N. A. S., 2022. Selective δ-Opioid Receptor Agonist, KNT-127, Facilitates Contextual Fear Extinction via Infralimbic Cortex and Amygdala in Mice. Frontiers in Behavioral Neuroscience, Volume 16, p. Published Online.

[3] Brewin, C. R., 2005. Systematic review of screening instruments for adults at risk of PTSD. Journal of Traumatic Stress, Volume 18, pp. 53-62.

[4] Matthew Tull, P., 2021. Symptoms and Diagnosis of PTSD. [Online]

[5] Mayo Clinic, 2018. Post-traumatic stress disorder (PTSD). [Online]

[6] Mayo Clinic, 2018. Post-traumatic stress disorder (PTSD). [Online]

[7] Michelle J. Bovin, P. et al., 2021. Diagnostic Accuracy and Acceptability of the Primary Care Posttraumatic Stress. e Diagnostic and Statistical Manual of Mental Disorders, Volume 5, pp. 1-11.

[8] NHS, 2022. Treatment - Post-traumatic stress disorder. [Online]

[9] Noah S. Philip, M. J. B. P. E. A. M. V. L. B. R. N. J. S. M. T. S. P. B. D. G. M. P. M. v. ’. W.-F. P., 2019. Theta-Burst Transcranial Magnetic Stimulation for Posttraumatic Stress Disorder. American Journal of Psyhciatry , p. Published online.