What is Post-Traumatic Stress Disorder?

A National Center for PTSD Fact Sheet

Post-Traumatic Stress Disorder, or PTSD, is a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair the personís daily life.

PTSD is marked by clear biological changes as well as psychological symptoms. PTSD is complicated by the fact that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health. The disorder is also associated with impairment of the personís ability to function in social or family life, including occupational instability, marital problems and divorces, family discord, and difficulties in parenting.

Understanding PTSD

PTSD is not a new disorder. There are written accounts of similar symptoms that go back to ancient times, and there is clear documentation in the historical medical literature starting with the Civil War, where a PTSD-like disorder was known as "Da Costaís Syndrome." There are particularly good descriptions of post-traumatic stress symptoms in the medical literature on combat veterans of World War II and on Holocaust survivors.

Careful research and documentation of PTSD began in earnest after the Vietnam War. The National Vietnam Veterans Study estimated in 1988 that the prevalence of PTSD in that group was 15.2% at that time, and that 30% had experienced the disorder at some point since returning from Vietnam.

PTSD has subsequently been observed in all veteran populations that have been studied, including World War II, Korean conflict, and Persian Gulf, and in United Nations peacekeeping forces deployed to other war zones around the world. PTSD also appears in military veterans in other countries with remarkably similar findings ó that is, Australian Vietnam veterans experience much the same symptoms as American Vietnam veterans.

PTSD is not only a problem for veterans, however. Although there are unique cultural- and gender-based aspects to the disorder, it occurs in both men and women, adults and children, Western and non-Western cultural groups, and all socioeconomic strata. A national study of American civilians conducted in 1995 estimated that the lifetime prevalence of PTSD was 5% in men and 10% in women.

How does PTSD develop?

Most people who are exposed to a traumatic, stressful event experience some of the symptoms of PTSD in the days and weeks following exposure. Available data suggest that about 8% of men and 20% of women go on to develop PTSD, and roughly 30% of these individuals develop a chronic form that persists throughout their lifetimes.

The course of chronic PTSD usually involves periods of symptom increase followed by remission or decrease, although for some individuals symptoms may be unremitting and severe. Some older veterans who report a lifetime of only mild symptoms have experienced significant increases following retirement, severe medical illness in themselves or their spouses, or reminders of their military service such as reunions or media broadcasts of the anniversaries of war events.

How is PTSD assessed?

In recent years a great deal of research has been aimed at development and testing of reliable assessment tools. It is generally thought that the best way to diagnose PTSD ó or any psychiatric disorder, for that matter ó is to combine findings from structured interviews and questionnaires with physiological assessments. A multi-method approach is especially helpful to address concerns that some patients might be either denying or exaggerating their symptoms.

How Common is PTSD?

An estimated 7.8 percent of Americans will experience PTSD at some point in their lives, with women (10.4%) twice as likely as men (5%) to have PTSD. About 3.6 percent of U.S. adults ages 18 to 54 (5.2 million people) have PTSD during the course of a given year. This represents a small proportion of those who have experienced a traumatic event at some point in their lives, for 60.7% of men and 51.2% of women reported at least one traumatic event. The traumatic events most often associated with PTSD are: for men: rape, combat exposure, childhood neglect, and childhood physical abuse. For women: rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.

About 30 percent of the men and women who have spent time in war zones experience PTSD. An additional 20 to 25 percent have had partial PTSD at some point in their lives. Thus more than half of all male Vietnam veterans and almost half of all female Vietnam veterans have experienced "clinically serious stress reaction symptoms." PTSD has also been detected among veterans of the Gulf War, with some estimates running as high as 8 percent.

Who is Most Likely to Develop PTSD?

 1. Those who experience greater stressor magnitude and intensity, unpredictability, uncontrollability , sexual (as opposed to nonsexual) victimization, real or perceived responsibility, and betrayal.

 2. Those with prior vulnerability factors such as genetics, early age of onset and longer-lasting childhood trauma, lack of functional social support, and concurrent stressful life events.

 3. Those who report greater perceived threat or danger, suffering or being upset, terror, and horror or fear.

 4. Those with a social environment, which produces shame, guilt, stigmatization, or self-hatred. 

What are the Consequences Associated with PTSD?

PTSD is associated with a number of distinctive neurobiological and physiological changes. PTSD may be associated with stable neurobiological alterations in both the central and autonomic nervous systems, such as altered brainwave activity, decreased volume of the hippocampus, and abnormal activation of the amygdala. Both of these brain structures are involved in the processing and integration of memory . The amygdala has also been found to be involved in coordinating the body's fear response.

Psychophysiological alterations associated with PTSD include hyper arousal of the sympathetic nervous system, increased sensitivity of the startle reflex, and sleep abnormalities.

People with PTSD tend to have abnormal levels of key hormones involved in response to stress. Thyroid function seems to be enhanced in people with PTSD. Some studies have shown that cortisol levels are lower than normal and epinephrine and nor epinephrine are higher than normal. People with PTSD also continue to produce higher than normal levels of natural opiates after the trauma has passed. An important finding is that the neurohormonal changes seen in PTSD are distinct from, and actually opposite to, those seen in major depression; also, the distinctive profile associated with PTSD is seen in individuals who have both PTSD and depression.

PTSD is associated with increased likelihood of co-occurring psychiatric disorders. In a large-scale study, 88 percent of men and 79 percent of women with PTSD met criteria for another psychiatric disorder. The co-occurring disorders most prevalent for men with PTSD were alcohol abuse or dependence (51.9 percent), major depressive episode (47.9 percent), conduct disorder (43.3 percent), and drug abuse and dependence (34.5 percent). The disorders most frequently co morbid with PTSD among women were major depressive disorder (48.5 percent), simple phobia (29 percent), social phobia (28.4 percent) and alcohol abuse/dependence (27.9 percent).

 PTSD also makes a significant impact on psychosocial functioning, independent of co morbid conditions. For instance, Vietnam veterans with PTSD were found to have profound and pervasive problems in their daily lives. This included problems in family and other interpersonal relationships, employment, and involvement with the criminal justice system.

 Headaches, gastrointestinal complaints, immune system problems, dizziness, chest pain, or discomfort in other parts of the body are common in people with PTSD. Often, medical doctors treat the symptoms without being aware that they stem from PTSD.

What is the Course of PTSD?

Most people who are exposed to a traumatic stressor experience some of the symptoms of PTSD in the days and weeks following exposure. Available data suggest that among individuals who go on to develop PTSD, roughly 30 percent develop a chronic form that persists throughout an individualís lifetime. The course of chronic PTSD usually has periods of symptom exacerbation and remission or decrease, although for some individuals symptoms may persist at an unremitting, severe level. Some older veterans who report a lifetime of no or only mild symptoms have experienced symptom exacerbations following retirement, severe medical illness in themselves or their spouses, or exposure to reminders of their military service (such as reunions or media broadcasts of the anniversaries of war events).

How is PTSD Treated?

PTSD is treated by a variety of forms of psychotherapy and drug therapy. There is no definitive treatment, and no cure, but some treatments appear to be quite promising, especially cognitive-behavioral therapy, group therapy, and exposure therapy, in which the patient repeatedly relives the frightening experience under controlled conditions to help him or her work throughout the trauma. Studies have also shown that medications help ease associated symptoms of depression and anxiety and help ease sleep. The most widely-used drug treatments for PTSD are the selective serotonin reuptake inhibitors, such as Prozac and Zoloft. At present, cognitive-behavioral therapy appears to be somewhat more effective than drug therapy, but it would be premature to conclude that drug therapy is less effective overall since drug trials for PTSD are at a very stage. Drug therapy definitely appears to be highly effective for some individuals and is helpful for many more. Also, the recent findings on the biological changes associated with PTSD have spurred new research into drugs that target these biological changes, which may lead to much increased efficacy. 

Post-Traumatic Stress Disorder: An Overview

by Matthew J. Friedman, M.D., Ph.D. Executive Director, National Center for PTSD Professor of Psychiatry and Pharmacology, Dartmouth Medical School

The risk of exposure to trauma has been a part of the human condition since we have evolved as a species. Attacks by saber tooth tigers or twentieth century terrorists have probably produced similar psychological sequelae in the survivors of such violence. Shakespeare's Henry IV appears to have met many, if not all, of the diagnostic criteria for post-traumatic stress disorder (PTSD), as have other heroes and heroines throughout the world's literature. The history of the development of the PTSD concept is described by Trimble (1985).

In 1980, the American Psychiatric Association added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) nosologic classification scheme. Although a controversial diagnosis when first introduced, PTSD has filled an important gap in psychiatric theory and practice. From an historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual him or herself (i.e., the traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). The key to understanding the scientific basis and clinical expression of PTSD is the concept of "trauma."

In its initial DSM-III formulation, a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience. The framers of the original PTSD diagnosis had in mind events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters (such as earthquakes, hurricanes, and volcano eruptions) and human-made disasters (such as factory explosions, airplane crashes, and automobile accidents). They considered traumatic events as clearly different from the very painful stressors that constitute the normal vicissitudes of life such as divorce, failure, rejection, serious illness, financial reverses and the like. (By this logic adverse psychological responses to such "ordinary stressors" would, in DSM-III terms, be characterized as Adjustment Disorders rather than PTSD.) This dichotomization between traumatic and other stressors was based on the assumption that although most individuals have the ability to cope with ordinary stress, their adaptive capacities are likely to be overwhelmed when confronted by a traumatic stressor.

PTSD is unique among other psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion" which means that he or she has been exposed to an historical event that is considered traumatic. Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress so that while some people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have prompted a recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat. Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations. Although there is a renewed interest in subjective aspects of traumatic exposure, it must be emphasized that exposure to events such as rape, torture, genocide, and severe war zone stress, are experienced as traumatic events by nearly everyone.

The DSM-III diagnostic criteria for PTSD were revised in DSM-III-R (1987) and DSM-IV (1994). A very similar syndrome is classified in ICD-10. Diagnostic criteria for PTSD include a history of exposure to a "traumatic event" and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms and hyper arousal symptoms. A fifth criterion concerns duration of symptoms. One important finding, which was not apparent when PTSD was first proposed as a diagnosis in 1980, is that it is relatively common. Recent data from the national co morbidity survey indicates PTSD prevalence rates are 5% and 10% respectively among American men and women (Kessler et al,1996).

As noted above the "A" stressor criterion specifies that a person has been exposed to a catastrophic event involving actual or threatened death or injury, or a threat to the physical integrity of him/herself or others. During this traumatic exposure, the survivor's subjective response was marked by intense fear, helplessness or horror.

The "B" or intrusive recollection criterion includes symptoms that are perhaps the most distinctive and readily identifiable symptoms of PTSD. For individuals with PTSD, the traumatic event remains, sometimes for decades or a lifetime, a dominating psychological experience that retains its power to evoke panic, terror, dread, grief, or despair as manifested in daytime fantasies, traumatic nightmares, and psychotic reenactments known as PTSD flashbacks. Furthermore, trauma mimetic stimuli that trigger recollections of the original event have the power to evoke mental images, emotional responses, and psychological reactions associated with the trauma. Researchers, taking advantage of this phenomenon, can reproduce PTSD symptoms in the laboratory by exposing affected individuals to auditory or visual trauma mimetic stimuli (Keane, et. al., 1987).

The "C" or avoidant/numbing criterion consists of symptoms reflecting behavioral, cognitive, or emotional strategies by which PTSD patients attempt to reduce the likelihood that they will either expose themselves to trauma mimetic stimuli, or if exposed, will minimize the intensity of their psychological response. Behavioral strategies include avoiding any situation in which they perceive a risk of confronting such stimuli. In its most extreme manifestation, avoidant behavior may superficially resemble agoraphobia because the PTSD individual is afraid to leave the house for fear of confronting reminders of the traumatic event(s). Dissociation and psychogenesis amnesia are included among avoidant/numbing symptoms by which individuals cut off the conscious experience of trauma-based memories and feelings. Finally, since individuals with PTSD cannot tolerate strong emotions, especially those associated with the traumatic experience, they separate the cognitive from the emotional aspects of psychological experience and perceive only the former. Such "psychic numbing" is an emotional anesthesia that makes it extremely difficult for people with PTSD to participate in meaningful interpersonal relationships.

Symptoms included in the "D" or hyper arousal criterion most closely resemble these seen in panic and generalized anxiety disorder. Whereas symptoms such as insomnia and irritability are generic anxiety symptoms, hyper vigilance and startle are more unique. The hyper vigilance in PTSD may sometimes become so intense as to appear like frank paranoia. The startle response has a unique neurobiological substrate and may actually be the most pathognomonic PTSD symptom (Friedman, 1991,).

The "E" or duration criterion specifies how long symptoms must persist in order to qualify for the (chronic or delayed) PTSD diagnosis. In DSM-III the mandatory duration was six months. In DSM-III-R the duration was shortened to one month, where it has remained in DSM-IV.

The new "F" or significance criterion specifies that the survivor must experience significant social, occupational, or other distress as a result of these symptoms.

Since 1980 there has been a great deal of attention devoted to the development of instruments for assessing PTSD. Keane and associates (1987) working with Vietnam war zone veterans have developed both psychometric and psycho physiologic assessment techniques that have proven to be both reliable and valid. Other investigators have modified such assessment instruments and used them with natural disaster victims, rape/incest survivors, and other traumatized cohorts. Research using such techniques has been used in the epidemiological studies mentioned above and in other research protocols.

Neurobiological research indicates that PTSD may be associated with stable neurobiological alterations in both the central and autonomic nervous systems. Psychophysiological alterations associated with PTSD include hyper arousal of the sympathetic nervous system, increased sensitivity and augmentation of the acoustic-startle eye blink reflex, a reducer pattern of auditory evoked cortical potentials, and sleep abnormalities. Neuropharmacologic and neuroendocrine abnormalities have been detected in the noradrenergic, hypothalamic-pituitary-adrenocortical, and endogenous opioid systems. These data are reviewed extensively elsewhere (Friedman, Charney & Deutch,1995).

Longitudinal research has shown that PTSD can become a chronic psychiatric disorder that can persist for decades and sometimes for a lifetime. Patients with chronic PTSD often exhibit a longitudinal course marked by remissions and relapses. There is a delayed variant of PTSD in which individuals exposed to a traumatic event do not exhibit the PTSD syndrome until months or years afterwards. Usually, the immediate precipitant is a situation that resembles the original trauma in a significant way; (for example, a war veteran whose child is deployed to a war zone or a rape survivor who is sexually harassed or assaulted years later).

If an individual meets diagnostic criteria for PTSD, it is likely that he or she will meet DSM-IV criteria for one or more additional diagnoses (Kulka, et. al., 1990; Davidson & Foa, 1993). Most often these co-morbid diagnoses include major affective disorders, dysthymia, alcohol or substance abuse disorders, anxiety disorders, or personality disorders. There is a legitimate question whether the high rate of diagnostic co-morbidity seen with PTSD is an artifact of our current decision rules for making the PTSD diagnosis since there are not exclusionary criteria in DSM-III-R. In any case, high rates of co-morbidity complicate treatment decisions concerning patients with PTSD since the clinician must decide whether to treat the co-morbid disorders concurrently or sequentially.

Although PTSD continues to be classified as an Anxiety Disorder, areas of disagreement about its nosology and phenomenology remain. Questions about the syndrome itself include: what is the clinical course of untreated PTSD; are there different subtypes of PTSD; what is the distinction between traumatic simple phobia and PTSD; and what is the clinical phenomenology of prolonged and repeated trauma. With regard to the latter, Herman (1992) has argued that the current PTSD formulation fails to characterize the major symptoms of PTSD commonly seen in victims of prolonged, repeated interpersonal violence such as domestic or sexual abuse and political torture. She has proposed an alternative diagnostic formulation that emphasizes: multiple symptoms, excessive somatization, dissociation, changes in affect, pathological changes in relationships and pathological changes in identity.

PTSD has also been criticized from the perspective of cross-cultural psychology and medical anthropology, because it has usually been diagnosed by clinicians from Western industrialized nations working with patients from a similar background. Major gaps remain in our understanding of the effects of ethnicity and culture on the clinical phenomenology of post-traumatic syndromes. We have only just begun to apply vigorous ethnocultural research strategies to delineate possible differences between Western and non-Western societies regarding the psychological impact of traumatic exposure and the clinical manifestations of such exposure (Marsella, et. al., 1996).

Before closing, it is necessary to discuss treatment. The many therapeutic approaches offered to PTSD patients are presented in Williams and Sommer's (1994) comprehensive book on treatment. The most successful interventions are those implemented immediately after a civilian disaster or war zone trauma. This is often referred to as critical incident stress debriefing (CISD) or some variant of that term. It is clear that the best outcomes are obtained when the trauma survivor receives CISD within hours or days of exposure. Such interventions not only attenuate the acute response to trauma but often forestall the later development of PTSD.

Results with chronic PTSD patients are often less successful. Perhaps the best therapeutic option for mild-to-moderately affected PTSD patients is group therapy. In such a setting the PTSD patient can discuss traumatic memories, PTSD symptoms and functional deficits with others who have had similar experiences. This approach has been most successful with war veterans, rape/incest victims and natural disaster survivors. For many severely affected patients with chronic PTSD a number of treatment options are available (often offered in combination) such as psychodynamic psychotherapy, behavioral therapy (direct therapeutic exposure) and pharmacotherapy. Results have been mixed and few well-controlled therapeutic trials have been published to date. It is important that therapeutic goals be realistic because in some cases, PTSD is a chronic and severely debilitating psychiatric disorder that is refractory to current available treatments. The hope remains, however, that our growing knowledge about PTSD will enable us to design more effective interventions for all patients afflicted with this disorder.

We regret that we were unable to obtain permission to include the text of the DSM-IV criteria for PTSD with this article.

REFERENCES

Davidson, J.R.T., & Foa, E.B (Eds.) (1993). Posttraumatic Stress Disorder: DSM-IV and Beyond. Washington, DC: American Psychiatric Press.

Foa, E.B., Zinbarg, R., & Rothbaum, B.O. (1992). Uncontrollability and unpredictability of post-traumatic stress disorder: An animal model. Psychological Bulletin, 112, 218-238.

Friedman, M.J., Charney, D.S. & Deutch, A.Y. (1995) Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to PTSD. Philadelphia: Lippincott-Raven.

Herman, J.L. (1992). Trauma and Recovery. New York: Basic Books.

Keane, T.M., Wolfe, J., & Taylor, K.I. (1987). Post-traumatic stress disorder: Evidence for diagnostic validity and methods of psychological assessment. Journal of Clinical Psychology, 43, 32-43.

Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M. & Nelson,C.B. (1996). Posttraumatic stress disorder in the National Co morbidity Survey. Archives of General Psychiatry, 52, 1048-1060.

Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R., & Weiss, D.S. (1990). Trauma and the Vietnam War Generation. New York: Brunner/Mazel.

Marsella, A.J., Friedman, M.J., Gerrity, E. & Scurfield R.M. (Eds.) (1996). Ethnocultural Aspects of Post-Traumatic Stress Disorders: Issues, Research and Applications. Washington: American Psychological Association.

Trimble, M.D. (1985). Post-traumatic stress disorder: History of a concept. In C.R. Figley (Ed.) Trauma and its Wake: The Study and Treatment of Post-Traumatic Stress Disorder. New York: Brunner/Mazel.

Williams, M.B., & Sommers, J.F. (Eds.) (1994). Handbook of Post-Traumatic Therapy. Westport, CT: Greenwood Press. Revised from Encyclopedia of Psychology, ed. R. Corsini (New York, Wiley, 1984, 1994.

Effects 0f Traumatic Experiences

A National Center for PTSD Fact Sheet
by Eve B. Carlson, Ph.D. and Joseph Ruzek, Ph.D.

Sometimes, when they find themselves suddenly in danger, people are overcome with feelings of fear, helplessness, or horror. These events are called traumatic experiences. Some common traumatic experiences include being physically attacked, being in a serious accident, being in combat, being sexually assaulted, and being in a fire or a disaster like a hurricane or a tornado. After traumatic experiences, people can find themselves having problems that they didn't have before the event. If these problems are severe and the survivor does not get help for them, they can begin to cause problems in the survivor's family. This brochure will begin by explaining how traumatic experiences affect people who go through them. Next family members' reactions to the traumatic event and to the trauma survivor's symptoms and behaviors will be described. Finally, suggestions will be made about what a veteran and his or her family can do to get help for PTSD.

How Do Traumatic Experiences Affect People ?

People who go through traumatic experiences often have symptoms and problems afterwards. How serious the symptoms and problems are depends on many things, including a person's life experiences before the trauma, a person's own natural ability to cope with stress, how serious the trauma was, and what kinds of help and support a person gets from family, friends, and professionals immediately following the trauma.

Because most trauma survivors don't know how trauma usually affects people, they often have trouble understanding what is happening to them. They may think it is their fault that the trauma happened, that they are going crazy, or that there is something wrong with them because other people who were there don't seem to have the same problems. They may turn to drugs or alcohol to make them feel better. They may turn away from friends and family who don't seem to understand. They may not know what they can do to get better.

What Do Trauma Survivors Need to Know ?

What are Common Basic Effects of Trauma?

Because they get overwhelmed with fear during a trauma, survivors often have particular symptoms that begin soon after the traumatic experience. The main symptoms are re-experiencing of the trauma - mentally and physically - and avoidance of trauma reminders. Together, these symptoms create a problem that is called Posttraumatic Stress Disorder (PTSD). PTSD is a specific set of problems resulting from a traumatic experience that is recognized by medical and mental health professionals.

Re-experiencing Symptoms:

Trauma survivors commonly continue re-experiencing their traumas. Re-experiencing means that the survivor continues to have the same mental, emotional, and physical experiences that occurred during or just after the trauma. This includes thinking about the trauma, seeing images of the event, feeling agitated, and having physical sensations like those that occurred during the trauma. Trauma survivors find themselves feeling and acting as if the trauma is happening again: feeling as if they are in danger, experiencing panic sensations, wanting to escape, getting angry, thinking about attacking or harming someone else. Because they are anxious and physically agitated, they may have trouble sleeping and trouble concentrating. These experiences are not usually voluntary; the survivor usually can't control them or stop them from happening. Mentally re-experiencing the trauma can include:

People also can have physical reactions to trauma reminders such as:

Because they have these upsetting feelings, trauma survivors often act as if they are in danger again when they get stressed or reminded of their trauma. They might get overly concerned about keeping safe in situations that really aren't very dangerous. For example, a person living in a good neighborhood might still feel that he has to have an alarm system, double locks on the door, a locked fence, and a guard dog. Because traumatized people often feel like they are in danger even when they aren't, they may be overly aggressive, lashing out to protect themselves when there is no need. For example, a person who was attacked might be quick to yell at or hit someone who seems to be threatening. This happens because, when threatened, people have a natural physical "fight or flight" reaction that prepares them to respond to them danger.

Although reexperiencing symptoms are unpleasant, they are a sign that the body and mind are actively struggling to cope with the traumatic experience. These symptoms are automatic, learned responses to trauma reminders: trauma has become associated with lots of things so that they remind the person of the trauma and give them feeling that they are in danger again. It is also possible that reexperiencing symptoms are actually part of the mindís attempt to make sense of what has happened.

Avoidance Symptoms:

Because thinking about the trauma and feeling as if you are in danger is so upsetting, people who have been through traumas want to avoid reminders of trauma. Sometimes they are aware of this and avoid trauma reminders on purpose and sometimes they do it without realizing what they are doing.

Avoiding thinking about trauma or avoiding treatment for your trauma-related problems may keep a person from feeling upset in the short run. But avoiding treatment of continuing trauma symptoms prevents progress on coping with trauma so that people's trauma symptoms don't go away.

What are Common Secondary and Associated Post-Traumatic Symptoms ?

Secondary symptoms are problems that come about because of having post-traumatic re-experiencing and avoidance symptoms. For example: because a person wants to avoid talking about a traumatic event that happened, she might get cut off from friends and begin to feel lonely and depressed. As time passes after a traumatic experience, more and more secondary symptoms may develop. Over time, secondary symptoms can become more troubling and disabling than the original re-experiencing and avoidance symptoms.

Associated symptoms are problems that don't come directly from being overwhelmed with fear, but happen because of other things that were going on at the time of the trauma. For example: a person who gets psychologically traumatized in a car accident might also get physically injured and then get depressed because he can't work or leave the house.

All of these problems can be secondary or associated trauma symptoms:

Depression: can happen when a person has losses connected with the trauma situation or when a person avoids other people and becomes isolated.

Despair and hopelessness: can happen when a person is afraid that he or she will never feel better again.

Loss of important beliefs: can happen when a traumatic event makes a person lose faith that the world is a good and safe place.

Aggressive behavior toward oneself or others: can happen due to frustration over the inability to control PTSD symptoms (feeling that PTSD symptoms "run your life"). It can also happen when other things that happened at the time of trauma made the person angry (the unfairness of the situation). Some people are aggressive because they grew up with people who lashed out when they were angry and never taught them how to cope with angry feelings. Because angry feelings keep people away, they also stop a person from having positive connections and getting help. Anger and aggression can cause job problems, marital and relationship problems, and loss of friendships.

Self-blame, guilt, and shame: can happen when PTSD symptoms make it hard to fulfill current responsibilities. It can also happen when people fall into the common trap of second-guessing what they did or didn't do at the time of a trauma. Many people, in trying to make sense of their experience, blame themselves. This is usually completely unfair. At best, it fails to take into account the other reasons why the events occurred. Self-blame causes a lot of distress and can prevent a person from reaching out for help. Society sometimes takes a "blame-the-victim" attitude, and this is wrong.

Problems in relationships with people: can happen because people who have been through traumas often have a hard time feeling close to people or trusting people. This may be especially likely to happen when the trauma was caused or worsened by other people (as opposed to an accident or natural disaster).

Feeling detached or disconnected from others: can happen when a person has difficulty in feeling or expressing positive feelings. After traumas, people can get wrapped up in their problems or get numb and then stop putting energy into their relationships with friends and family.

Getting into arguments and fights with people: can happen because of the angry or aggressive feelings that are common after a trauma. Also, a person's constant avoidance of social situations (such as family gatherings) may annoy family members.

Less interest or participation in things the person used to like to do: can happen because of depression following a trauma. Spending less time doing fun things and being with people means a person has less of a chance to feel good and have pleasant interactions.

Social isolation: can happen because of social withdrawal and a lack of trust in others. This often leads to loss of support, friendship, and intimacy, and grows fears and worries.

Problems with identity: can happen when PTSD symptoms change important things in a person's life, like relationships or whether a person can do your work well. It can also happen when other things that happened at the time of trauma make a person confused about their own identity. For instance a person who thinks of himself as unselfish might think he acted selfishly by saving himself during a disaster. This might make him question whether he is really who he thought he was.

Feeling permanently damaged: can happen when trauma symptoms don't go away and a person doesn't think they will get better.

Problems with self-esteem: can happen because PTSD symptoms make it hard for a person to feel good about him or herself. Sometimes, because of things they did or didn't do at the time of trauma, survivors feel that they are bad, worthless, stupid, incompetent, evil, and so on.

Physical health symptoms and problems: can happen because of long periods of physical agitation or arousal from anxiety. Trauma survivors may also avoid medical care because it reminds them of their trauma and causes anxiety, and this may lead to poorer health. Habits used to cope with post-traumatic stress, like alcohol use, can also cause health problems. Also, other things that happened at the time of trauma may cause health problems (for example, an injury).

Alcohol and/or drug abuse: can happen when a person wants to avoid bad feelings that come with PTSD symptoms, or when other things that happened at the time of trauma lead a person to take drugs. This is a common way to cope with upsetting trauma symptoms, but it actually leads to more problems.

Remember:

Although PTSD symptoms and other trauma-related problems may take up most of a person's attention when they are suffering, people who have PTSD also have strengths, interests, commitments, relationships with others, past experiences that were not traumatic, desires, and hopes for the future.

Treatments are available for individuals with PTSD and associated trauma-related symptoms.

Understanding the effects of trauma on relationships can also be an important step for family members or friends the effects of trauma.

PTSD and The Family

A National Center for PTSD Fact Sheet

Can PTSD in one family member affect the entire family?

The entire family is profoundly affected when any family member experiences psychological trauma and suffers posttraumatic stress disorder (PTSD). Some traumas are directly experienced by only one family member, but other family members may experience shock, fear, anger, and pain in their own unique ways simply because they care about and are connected to the survivor.

Living with an individual who has PTSD does not automatically cause PTSD, but it can produce "vicarious" or "secondary" traumatization. Whether family members live together or apart, are in contact often or rarely, and feel close or distant emotionally from one another, PTSD affects each member of the family in several ways.

Epidemiological Facts About PTSD

A National Center for PTSD Fact Sheet

What causes post-traumatic stress disorder? How common is it? Who gets it?

These questions are asked by epidemiologists, and two major epidemiological studies have produced some answers. The National Vietnam Veterans Readjustment Survey (NVVRS), conducted between November 1986 and February 1988, interviewed 3,016 American veterans selected to provide a representative sample of those who served in the armed forces during the Vietnam era. The National Co morbidity Survey (NCS), conducted between September 1990 and February 1992, interviewed a representative national sample of 8,098 Americans aged 15 to 54 years.

The following information on PTSD in the general adult population is taken from the National Co morbidity Survey Report:

The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives. This represents a small proportion of those who have experienced at least one traumatic event, for 60.7% of men and 51.2% of women reported at least one traumatic event. The most frequently experienced traumas were :

The majority of these people experienced two or more types of trauma. More than 10% of men and 6% of women reported four or more types of trauma during their lifetimes.

The traumatic events most often associated with PTSD in men were: rape, combat exposure, childhood neglect, and childhood physical abuse. For women, the most common events were: rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.

But none of these events invariably produced PTSD in those exposed to it, and a particular type of traumatic event does not necessarily affect different sectors of the population in the same way.

The NCS report concluded that "PTSD is a highly prevalent lifetime disorder that often persists for years. The qualifying events for PTSD are also common, with many respondents reporting the occurrence of quite a few such events during their lifetimes."

The following information on PTSD among Vietnam War veterans is taken from the National Vietnam Veterans Readjustment Survey (NVVRS) report:

The estimated lifetime prevalence of PTSD among American Vietnam theater veterans is 30.9% for men and 26.9% for women. An additional 22.5% of men and 21.2% of women have had partial PTSD at some point in their lives. Thus more than half of all male Vietnam veterans and almost half of all female Vietnam veterans -- About 1,700,000 Vietnam veterans in all -- have experienced "clinically serious stress reaction symptoms."

15.2% of all male Vietnam theater veterans (479,000 out of 3,140,000 men who served in Vietnam) and 8.1% of all female Vietnam theater veterans (610 out of 7,200 women who served in Vietnam) are current cases of PTSD. ["Current" means 1986-88 when the Survey was conducted.]

The NVVRS report also contains these figures on other problems of Vietnam veterans:

40% of Vietnam theater veteran men have been divorced at least once (10% had two or more divorces), 14.1% report high levels of martial problems, and 23.1% have high levels of parental problems.

Almost half [of male Vietnam theater veterans currently suffering from PTSD] had been arrested or in jail at least once -- 34.2% more than once -- and 11.5% had been convicted of a felony.

The estimated lifetime prevalence of alcohol abuse or dependence among male theater veterans is 39.2%, and the estimate for current alcohol abuse or dependence is 11.2%. The estimated lifetime prevalence of drug abuse or dependence among male theater veterans is 5.7%, and the estimate for current drug abuse or dependence is 1.8%.

Because the NVVRS sample size underrepresented members of certain ethnic minorities, the Matsunaga Vietnam Veterans Project undertook further epidemiological research among Native American, Asian American, and Pacific Islander veterans. These findings are summarized in a separate National Center for PTSD fact sheet.

THIS FACT SHEET WAS BASED ON

Richard A. Kulka (et al), Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study (New York: Brunner/Mazel, 1990; ISBN 0-87630-573-7) Ronald C. Kessler (et al), "Posttraumatic Stress Disorder in the National Co morbidity Survey Archives of General Psychiatry 52(12): 1048-1060 (December 1995)

How does PTSD affect Family Members?

Emotional Reactions

Family members may feel hurt, alienated, frustrated, or discouraged, if the survivor loses interest in family or intimate activities and is easily angered or emotionally isolated and detached.

Family members often end up feeling angry or distant toward the survivor, especially if he or she seems unable to relax and be companionable without being irritable, tense, anxious, worried, distractible, or controlling, overprotective, and demanding.

Even if the trauma occurred decades ago, survivors may act -- and family members may feel -- as if the trauma never stops happening. They may feel as if they're living in a war zone or a disaster if the survivor is excessively on-guard, tense, or easily startled or enraged.

Isolation/Avoidance

Family members can find themselves avoiding activities or people and becoming isolated from each other and from friends outside the family. They may feel that they have no one to talk to, and that no one that can understand.

Communication

Family members may find it very difficult to have a cooperative discussion with the survivor about important plans and decisions for the future, because s/he feels there is no future to look forward to, because s/he has difficulty listening and concentrating without becoming distracted, tense, or anxious, or because s/he becomes angry and overly suspicious toward the family member or toward others (hyper vigilant).

Family members may find it very difficult to discuss personal or family problems, because the survivor becomes either controlling, demanding, or overprotective, or unreasonably anxious and fearful about problems becoming terrible catastrophes.

Parenting

The person suffering from PTSD may become over involved with their children's lives due to feeling lonely and in need of some positive emotional feedback, or feeling that the partner can't be counted on as a reliable and responsible parent. For the survivor, this "discounting" of the their partner as a co-parent often is due to hyper vigilance and guilt because of trauma experiences involving children.

The partner may feel s/he must be the sole caregiver to their children if the survivor is uninvolved with their children (often due to trauma-related anxiety or guilt) or is overly critical, angry, or even abusive.

Sleep

Partners may find their sleep disrupted by the trauma survivor's sleep problems (reluctance to sleep at night, restlessness while sleeping, severe nightmares, or episodes of violent "sleepwalking." Family members also often find themselves having terrifying nightmares, afraid to go to sleep, or difficulty getting a full and restful night's sleep, as if they are reliving the survivor's trauma in their own feelings and sleep.

Ordinary activities, such as going shopping or to a movie, or taking a drive in the car, may feel like reliving of past trauma when the survivor experiences trauma memories or flashbacks. The survivor may go into "survival mode" or on "automatic pilot," suddenly and without explanation shutting down emotionally, becoming pressured and angry, or going away abruptly and leaving family members feeling shocked, stranded, helpless, and worried.

Abuse

Trauma survivors with PTSD often struggle with intense anger or rage, and can have difficulty coping with an impulse to lash out verbally or physically -- especially if their trauma involved physical abuse or assault, war, domestic or community violence, or being humiliated, shamed and betrayed by people they needed to trust. Family members can feel frightened of and betrayed by the survivor, despite feeling love and concern.

Addiction

Addiction exposes family members to emotional, financial, and (less often, but not uncommonly) domestic violence problems. Survivors experiencing PTSD may seek relief and escape with alcohol or other drugs, or through addictive behaviors such as gambling, workaholism, overeating or refusing to eat (bulimia and anorexia). Addictions offer false hope to the survivor, by seeming to help for a short time but then making PTSD's symptoms of fear, anxiety, tension, anger, and emotional numbness far worse. Addictions may be very obvious, such as when binge drinking or daily use of drugs occurs. However they may involve lighter or less frequent episodes of "using" that are a problem because the survivor is dependent ("hooked") on the habit and can't cope without it.

Suicide

When suicide is a danger, family members face these unavoidable strains: worry ("How can I know is suicide is going to happen, and what can I do to prevent it?"), guilt ("Am I doing something to make her/him feel so terrible, and should I be doing something to make her/him feel better?"), grief ("I have to prepare myself every day for losing her/him. In many ways I feel and have to live my life as if s/he's already gone."), and anger ("How can s/he be so selfish and uncaring?"). Trauma survivors with PTSD are more prone to contemplate and attempt suicide than similar people who have not experienced trauma or are not suffering from PTSD. For the family there is good and bad news in this respect. The good news is that very few trauma survivors, even those with PTSD, actually attempt or complete suicide. The bad news is that family members with a loved with PTSD often must deal with the survivorís feeling sufficiently discouraged, depressed, and even self- blame and self-loathing to seriously and frequently contemplate suicide.

What can families of trauma survivors with PTSD do to care for themselves and the survivor?

What can families of trauma survivors with PTSD do to care for themselves and the survivor? Continue to learn more about PTSD by attending classes, viewing films, or reading books. Encourage, but don't pressure, the survivor to seek counseling from a PTSD specialist. Seek personal, child, couples, or family counseling if troubled by "secondary" trauma reactions such as anxiety, fears, anger, addiction, or problems in school, work, or intimacy. Take classes on stress and anger management, couples communication, or parenting. Stay involved in positive relationships, in productive work and education, and with enjoyable pastimes.

If physical (domestic) violence actually is occurring, family members such as spouses, children, or elders must be protected from harm.

SUGGESTED READINGS

Patience Mason, Recovering from the War: A Woman's Guide to Helping Your Vietnam Vet, Your Family, and Yourself (Viking, 1990, ISBN 0-670-81587-X; Penguin, 1990, ISBN 0-14-009912-3) Aphrodite Matsakis, Vietnam Wives: Facing the Challenges of Life with Veterans Suffering Post Traumatic Stress (Sidran Press, 1996, ISBN 1-886968-00-4)

PTSD and Physical Health

A National Center for PTSD Fact Sheet
By Kay Jankowsi, Ph.D.

Exposure to traumatic events, such as military combat, physical and sexual abuse, and natural disaster, has been found to be related to poor physical health. Posttraumatic Stress Disorder (PTSD) also is related to health problems. The following fact sheet provides information on: the relationship between trauma, PTSD, and physical health; specific health problems associated with PTSD; health risk behaviors and PTSD; mechanisms that help explain how PTSD and physical health could be related; and a clinical agenda to address PTSD and health.

Before addressing these topics, it is first necessary to provide some basic information about the different ways that physical health has been measured in existing research studies. The most common way is for people to report about their own health conditions or symptoms, or to provide their perceptions of their overall physical health. Self-report measures of health can be valid indicators of actual illness, but should be interpreted with caution because they may be influenced by psychological as well. The most reliable measure of physical health is one that does not rely on self-report, but instead assesses illness through physician diagnosed medical disorder or by laboratory tests.

Is Trauma Related to Physical Health?

A considerable amount of research has accumulated that has found negative effects of trauma on physical health. Relationships between self-report of physical health and military trauma, sexual assault, childhood abuse, and motor vehicle accidents are most clear. When health status is measured by physician diagnosis, associations are not as consistent for both military trauma and sexual assault in adulthood, but a probable association is suggested for survivors of natural disaster. Two recent studies found that reports of abuse and neglect during childhood were related to increased risk of physician diagnosed disorders, including cancer, ischemic heart disease, and chronic lung disease. There is also a likely relationship between utilization of medical services for physical health problems and trauma. In addition, health care costs have been found to be higher among women who report a history of abuse or neglect during childhood as compared to women who report no history of child maltreatment.

What Is the Relationship between Physical Health and PTSD?

There is a growing body of literature that finds a link between PTSD and physical health. Some studies have found that PTSD explains the association between exposure to trauma and poor physical health. In other words, trauma may lead to poor health outcomes through PTSD. When health problems are measured by self-report, there is a clear association with PTSD for veterans and active duty personnel, civilian men and women, firefighters, and adolescents alike. Those who endorse PTSD are more likely to have a greater number of physical health problems than those who do not have PTSD. Similar results are found when physical health is measured by physician report or by laboratory tests. PTSD also has been found to be associated with greater medical service utilization for physical health problems. At present, however, an association between PTSD and illness via physician diagnosis and medical service utilization has only been examined in veteran populations. Further research is indicated to examine PTSD, physical illness, and medical service utilization in both veteran and other traumatized populations.

It is important to note that at the present time, existing research is not able to determine conclusively that PTSD causes poor health. Thus, caution is warranted in making a causal interpretation of what is presented here. It may be the case that something associated with PTSD is actually the cause of greater health problems. For example, it could be that a factor associated with PTSD, such as smoking, is the actual cause of the increased health problems. This is not likely, however, given that we know that PTSD is associated with poor physical health even when behavioral factors such as smoking are controlled.

What Specific Health Problems Are Related to PTSD?

At this point we do not have a lot of information about what specific health problems, or bodily systems, are associated with PTSD. Many studies have not looked at specific health problems, but instead report only number of health problems overall. Although studies that did examine specific health problems have been based primarily on self-report, there is some evidence to indicate PTSD is related to cardiovascular, gastrointestinal, and musculoskeletal disorders. The one study that examined physician diagnosed disorders and PTSD in relation to specific bodily systems also found similar results.

A number of studies have found an association between PTSD and poor cardiovascular health. These studies found that either self-report of circulatory disorders or cardiovascular symptoms were associated with PTSD in veteran populations, civilian men and women, and male firefighters. Among studies that have examined cardiovascular illness in relation to PTSD via physician diagnosis or laboratory findings, PTSD has been consistently associated with greater likelihood of cardiovascular morbidity. In a recent study, Vietnam veterans were examined in regard to cardiovascular function by comparing veterans with and without PTSD on electrocardiogram (ECG) findings. While controlling for risk factors such as alcohol consumption, weight, current substance abuse, and smoking, in addition to current medication use, PTSD was found to be associated with having a nonspecific ECG abnormality, atrioventricular conduction defects, and infarctions. Caution is warranted in interpreting this study insofar as the PTSD group included only those veterans with severe PTSD. It is therefore unknown at this point whether men with less severe PTSD would show the same ECG abnormalities. In addition, there have been no studies of cardiovascular morbidity and PTSD in women.

Other bodily systems that have been shown to be associated with PTSD include the gastrointestinal and musculoskeletal systems. Studies using self-report and physician diagnosis have found PTSD related to illness in these systems, but neither has been as extensively researched in relation to PTSD as the cardiovascular system. The majority of the available studies have been with veterans, but a similar finding was found among civilian young men and women for GI symptoms, and among male firefighters for musculoskeletal symptoms. Additional research is needed to learn more about these and other bodily systems that may be related to PTSD.

How is PTSD Related to Physical Health?

PTSD may promote poor health through a complex interaction between biological and psychological mechanisms. Study of these mechanisms is in progress at the National Center for PTSD and at other laboratories around the world. Current thinking is that the experience of trauma brings about neurochemical changes in the brain. These changes may have biological, as well as psychological and behavioral effects, on health. Biologically, there may be a vulnerability to hypertension and atherosclerotic heart disease that would explain in part the association with cardiovascular disorders. Research also shows that there may be abnormalities in thyroid and other hormone functions, in addition to increased susceptibility to infections and immunologic disorders, associated with PTSD.

The psychological and behavioral effects of PTSD on health may be accounted for in part by co morbid depressive and anxiety disorders. Many people with PTSD also experience depressive disorders or other anxiety disorders. Depressed individuals report more physical symptoms and use more medical treatment than do no depressed individuals. Depression also has been linked to cardiovascular disease in previously health populations and to additional illness and mortality among patients with serious medical illness. PTSD also may be related to poor health through symptoms of co morbid anxiety or panic. The evidence linking anxiety to cardiovascular morbidity and mortality is quite strong, but the mechanisms are largely unknown.

Hostility, or anger, is another possible mediator of the relationship between PTSD and physical health. It is commonly associated with PTSD and decades of research on the health risks associated with the Type A behavior pattern have isolated hostility as a crucial factor in cardiovascular disease. PTSD and poor health also may be mediated in part by behavioral risk factors for disease such as smoking, substance abuse, diet, and lack of exercise.

Little is known about how coping and social support relate to health in PTSD, but it is likely that both play important roles. Further research is needed to better understand these potential protective factors.

What Is the Agenda for Clinical Practice?

An agenda for clinical practice is to increase collaboration with primary and specialty medical care professionals in order to better address this relationship between PTSD and health problems. Greater awareness is needed among medical personnel of the potential harmful effects of trauma and PTSD on health. Increased attention should be paid to the role of screening for PTSD in medical settings. Studies of patients seeking physical health care show that many have been exposed to trauma and experience post-traumatic stress, but have not received appropriate mental health care. Efforts to integrate PTSD treatment services with medical care services may be warranted.

All information contained on these pages is in the public domain unless explicit notice is given to the contrary, and may be copied and distributed without restriction.

Information taken from this site; http://www.ncptsd.org/facts/index.html

FACTS PAGE

HOME PAGE