Post Traumatic Stress Disorder PTSD

Post Traumatic Stress Disorder or PTSD for short (or previously shell shock or battle fatigue syndrome), is a 'disorder of extinction' (abilities) in response to an extremely terrifying traumatic event, either through experience or as a witness. The new DSM-5 classification of this disorder as one of extinction emphasizes the fact that sufferers are disordered in the normal extinction process of an understandable fear response. Sufferers are unlike the general population that usually recovers or 'extinguishes' normal fear response within 1 month. In short, a pivotal characteristic of this diagnosis is persistence or the inability to cause extinction. 

PTSD may also be considered as a group of symptoms that may occur as a result of the trauma. The US Diagnostic & Statistical Manual, 5th Edition (or, for short, DSM-5) of 2013 has recently re-classified PTSD (from among 'Anxiety Disorders') to  'Trauma & Stressor-Related Disorders'. (Read an article or see the video below for an introductory summary about this classification). This classification therefore reinforces the idea that the inability to extinguish fear relates specifically to some type of trauma.

This post will discuss the symptoms (the core ones of which include re-experiencing, avoidance, and hyperarousal) and conditions as set out by the DSM-5 that should be present in order for a diagnosis of PTSD. 

Criterion A: On of the following list of types of exposure to a traumatic event called a 'stressor' (at least one is required). Common traumatic events include the following. BTW, Interpersonal trauma are more likely to be a cause than other types. However, the other types are more likely for those with acute childhood trauma, especially if the person lacks social support systems. Example(s): war / combat; sexual violence, like rape or even THREATENED sexual violence; real OR threatened injury; violent muggings; accidents; natural disasters. 

  • direct exposure
  • witnessing the event
  • learning that someone close was exposed to the event
  • indirect exposure to details of the trauma, commonly in the course of professional duties, as in the case of first responders, and medics. 

 
Criterion B: At least one of the following symptoms of some type of INTRUSION (ie unwanted interference) aka re-experiencing. This criterion may be likened to a haunting by the ('ghost' of the) traumatic event. Essentially, although the event occurred in the past, it forces the sufferer to re-experience it. These intrusions can take several forms that include the following and are often triggered by something the sufferer perceives as similar to the initial traumatic event. Personal triggers are very personal and can include anything at all; from physical attributes (that resemble those of an attacker), tone of voice, a touch in a way that has some personal significance to the sufferer, certain type of behavior observed in others (like movements, mannerisms, speech, management style, etc), to objects and so on. In a sense, re-experiencing is like a mild form of dissociative identify disorder in that another fragmented part of your past self 'fronts' and as Dr Dawn Elise (aka on YouTube as Doc Snipes) said in her video while discussing C-PTSD, these fragments need to be fragmented.
  • Flashback re-experiences. Flashbacks can be very frightening. Unlike normal memories, a flashback is the sensation that the traumatic event is happening all over again, happening right now, replacing the present scene.
    • In severe cases, this may even cause dissociative states.
    • Video about somatoform symptoms, ie physical re-experiencing of past trauma: 'When Dissociation Gets Physical' by CTAD Clinic (Dr Mike Lloyd)
  • Frequently having unwanted, upsetting thoughts or memories about a traumatic event
  • Being physically responsive to reminders of the traumatic event (for example, feeling a surge in your heart rate, for starting to sweat)
  • Having very strong feelings of distress when reminded of the traumatic event
  • Nightmares
  • Distress (like emotional) after exposure to traumatic reminders
  • Physical reactivity after exposure to traumatic reminders

Criterion C: At least one of the following forms of AVOIDANCE. Avoidance is also a key component in the diagnosis of complex trauma and dissociative conditions. Avoidance is a natural and inevitable response to trauma. After a traumatic event, people generally try to avoid trauma-related stimuli / triggers, whether internal (like feelings) and or external (reminders). However, as discussed otherwise regarding anxiety phobic responses, avoidance becomes a diagnostic criterion when the sufferer's avoidance interferes with his or her ability to have a normal life. In the normal population, persons eventually overcome the  avoidant behavior and continue with their life as before. Unfortunately for those who can not do this, while avoidance offers short term relief (like a drug) to the sufferer, continuing to depend on it like one might an addiction can interfere with normal life over the long term. Too much avoidance eventually leads to simply engaging less in life. Essentially, the avoidance therefore creates a situation of loss of whatever the sufferer would have done in enjoyment of their life. Worse still, the actual phobia may remain unresolved over the long term. For instance, if you are fearful of driving again after a vehicular accident, the accident is still controlling you, even though you think that you are avoiding the reality of it. This is why treating trauma-related avoidant behavior is very important.
  • Trauma-related external reminders. Example(s):
    • avoiding the scene of an accident, taking smaller country roads versus major highways or being a passenger of a car after an accident
    • avoiding places like countries, homes of certain people, stores, neighborhoods, etc
    • avoiding situations like work places, employment characterized by bullying and other harmful behaviors.
    • avoiding contact with society by driving at only certain times of the day and avoiding public locations.
    • avoiding relationships (like sexual relationships) that are reminiscent of a toxic relationship (perhaps in which rape occurred).
  • Trauma-related thoughts or feelings / internal triggers. Example(s):
    • having dissociative amnesia or sinking into dissociative states push away emotional connection to traumatic events
    • forcing oneself to becoming emotionally numb (which avoids pain ... but also joy in life)
    • Addictions: substances (drugs, food, etc); gambling; escapist activities


    Criterion D: At least 2 forms of NEGATIVE ALTERATIONS IN COGNITION AND MOOD.
    Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):
    • Inability to recall key features of the trauma. / altered sense of reality of one's surroundings or oneself
      • This is a dissociative state.
    • Overly negative thoughts and assumptions about oneself or the world
      • Feeling ashamed of one's own trauma response symptoms
      • Living, stuck in a constant state of fear.
    • Exaggerated blame of self or others for causing the trauma
    • Negative affect
      • Persistent inability to experience positive emotions like happiness, satisfaction or loving feelings.
    • Decreased interest in activities
    • Feeling isolated
      • Detachment from others.
    • Difficulty experiencing positive affect


    Criterion E: Sufferers may have alterations in arousal and reactivity. (This is not a required criterion). Hyperarousal refers to an abnormally heightened state of anxiety. This may make sufferers more sensitive and overly responsive to stimuli and events in the world around Signs and symptoms include the following.
    • Chronic anxiety
    • Panic attacks
    • Difficulty falling or staying asleep. This is very common. Note that many people with PTSD have comorbidity with major depression disorder (MDD), which has sleep disruption as one key feature.
      • Some people try to avoid nightmares (one form of intrusion), thereby disrupting their sleep cycle.
      • Night time is very scary by virtue of being dark with unknown sounds that can trigger fear.
    • Being constantly on guard for threats (hypervigilance)
    • Heightened startle reaction. Being easily startled (excessive startle reflex)
    • Sufferers often can no longer walk through life with the same level of pre-trauma calm. 
    • Difficulty concentrating
    • Anger and angry outbursts
    • Irritability or aggression
    • Risky or destructive behavior.
      • Reckless behaviors are common among sufferers like 
        • reckless driving among war veterans 
        • reckless sexual behavior among sexually assaulted children. 

    Criterion F: The symptoms are required to last for AT LEAST 1 MONTH for the diagnosis. This is noteworthy because anyone in the population is likely to demonstrate the symptoms of PTSD after a traumatic event. However, the difference between someone who can be diagnosed as having the condition is the persistence of the disorder beyond what occurs normally in the population (which is 1 month). In other words, under normal circumstances (for the majority of cases), people recover and 'extinguish the fear', ie stop having the symptoms over time. In contrast, someone suffering with PTSD does not get better. In fact, this disordered way of dealing with fear, ie the inability to overcome the fear as normal is the reason for the classification of this disorder. (This criterion is key for differentiating PTSD from acute stress disorder or ASD that can occur to anyone in the general population but not beyond roughly 1 month.)

    Criterion G: Significant functional impairment (social, occupational, etc) is required.

    Criterion H: Exclusions are conditions that should not be related to the symptoms. If they are, the sufferer can not be considered to suffer from PTSD.
    • the effect of substances
      • drugs (pharmaceutical or otherwise) and alcohol 
    • another medical condition 
      • mild brain injuries


    Correlations (biological factors)

    Correlations include the following. 

    • dysfunctions in hypothalamic-pituitary-adrenal axis (or HPA axis). The HPA axis relates to the interaction among the 3 and, by extension how the body responds to stress.
    • Deficits in the sleep and arousal regulatory systems. In other words, the person is likely to have challenges maintaining a healthy sleep cycle, likely due to insomnia. Their body and mind's responses are prone to anxiety disorders as they are unlikely to handle stressful situations with feelings of anxiety that are at normal levels for the general population, especially as they relate to circumstances that are similar or reminiscent of the original trauma. 
    • dysfunction in the endogenous opioid system. This system naturally creates and releases opioids throughout the body in ways that can promote pain relief, sedation, slowed breathing and euphoria. It therefore helps in managing mood, stress responses and pain. Its arsenal involves the central and peripheral nervous systems. 

    Considerations (Family History)

    PTSD is also correlated with a family history of mood and anxiety disorders.


    Treatment(s) for PTSD

    • Exposure therapy has proven very effective.
    • Group therapy
    • Medication 
      • anti-depressants like Selective Serotonin Reuptake Ibhibitora /  SSRIs
      • anti-anxiety medications that decrease psychological arousal like Clonazepam 
    • Sleep aids
    • Self medication, ie the use of alcohol and other substances. Unfortunately, when abused, these substances can worsen symptoms.


    CONTENT RELATED TO POST TRAUMATIC STRESS DISORDER (PTSD)
            
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    Challenges with mental health and fatigue from masking neurodivergence are clues that helps in recognizing neurodivergence, especially for boomers and generation Xers. 

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