In detail

PTSD Post Traumatic Stress Disorder: origin, symptoms and treatment

PTSD Post Traumatic Stress Disorder: origin, symptoms and treatment

Humans, throughout our history, have experienced numerous natural disasters, such as floods, hurricanes, earthquakes, etc., and also, unfortunately, we know the terror that we ourselves produce, such as war, terrorism, the violence of gender, crime, etc. These types of events, which we now call traumatic, have been permanently present throughout the history of mankind and in all cultures, to the point that some authors point out that the reaction to trauma, currently called Stress Disorder Post Traumatic (PTSD), is an abnormal reaction to relatively common events. In fact, it is estimated that every year there are more than 150 million people directly affected by a disaster. Authors such as Breslau, Kessler, Chilcoat, Schultz, Davis and Andreski recently point out that 90% of Americans would be exposed to a stressful event, as defined by the DSM-V.

Content

  • 1 Our response to traumatic situations
  • 2 Background of PTSD
  • 3 Signs and symptoms of PTSD
  • 4 Course and prevalence of PTSD
  • 5 Differential diagnosis and comorbidity
  • 6 Intervention and treatment

Our response to traumatic situations

However, the way to respond to these events is very varied. While in most people their negative effects are mitigated and even disappear over time (moreover, they may even have personal growth effects), others experience long-term sequelae, even for life, if they do not receive adequate treatment. . In a 2000 report, the Department of Health and Human Services from the US estimated that the 9% of people exposed to a stressful event would develop a PTSD.

So that, exposure to a traumatic event is a necessary but not sufficient requirement to develop significant pathological sequelae. 9% is a minority of people who have been exposed to a stressor. Therefore, it is not at all crazy to think that there can be natural recovery and healing mechanisms. In this sense, a premature or excessively aggressive intervention may even interfere with these natural mechanisms.

PTSD Background

Although, as we have just indicated, both the traumatic events and the pathological responses that can be triggered have been present throughout the history of mankind, however, the PTSD was recognized for the first time as a differentiated diagnostic entity in 1980, in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, APA, 1980). Since then, this disorder is included in the category of anxiety disorders, because its fundamental symptomatology is considered to consist of the presence of persistent anxiety, hypervigilance and phobic avoidance behaviors.

The inclusion of this disorder in the DSM was largely due to the pressure exerted by veterans of the Vietnam War. This group wanted to have a diagnostic category that reflected the psychological consequences of war and, in addition, that justified being able to receive the diagnosis of a "mental disorder", with its consequent medical and social benefits. Obviously, the disorder has been known since before 1980, and we can find descriptions in the poetry of Homer, Shakespeare or Goethe. In the psychopathological tradition it was known under very different labels, such as the "traumatic neurosis" of Oppenheim, the "war neurosis", the "Post-Vietnam syndrome", the "battle fatigue", the "bombing shock" shellshock), etc.

THE PTSD currently it is conceived as a disorder that appears in response to a highly stressful situation. This disorder is characterized by the presence of the following symptomatic manifestations related to exposure to that traumatic event.

Signs and symptoms of PTSD

Intrusive re-experimentation of the traumatic event

They are re-experimentations of the intrusive traumatic event, which they can cause the person a reaction of stress and anxiety very similar to those that occurred during the original trauma. Symptoms ranging from flashbacks, nightmares, etc. This re-experimentation can lead to a "re-traumatization", perpetuating the trauma, and "fixing" the person in an event to which he is continually being re-exposed.

Avoidance

Avoidance of trauma reminders is one of the most common symptoms of PTSD, and it can manifest itself in different ways. The person can present avoidance behaviors so as not to have to face any reminder of the traumatic experience. On the other hand, the affected person can avoid memories of trauma through dissociative mechanisms or symptoms of amnesia. Finally, it can show affective "detachment" through substance use, excessive dedication to work or other activities, etc.

Dullness

Emotional numbness or dullness can be expressed as depression, anhedonia, lack of motivation, but also as psychosomatic reactions, or dissociative states.

Regional hyperactivation

Subjects may present certain emotional and physical stimuli as if the threat still persists, although this autonomic activation no longer has the adaptive function of alerting the organism of danger. This hyperactivation is associated with sleep problems, they may be afraid of their nightmares, their sleep is interrupted as they wake up as soon as they begin to have a dream, for fear that it becomes a nightmare. The physiological hyperactivation experienced by these people also interferes with their ability to concentrate. These people often have trouble remembering everyday things. They may even return to previous stages of coping with stress, losing their ability to take care of themselves, showing excessive dependence, losing control of sphincters in children, etc.

Intense emotional reactions

Related to the above, there are difficulties in the regulation of affect. These people can respond to stimuli with intense and disproportionate reactions (anger, anxiety, panic, etc.), which can even intimidate others. But they can also be paralyzed.

Aggressive behavior towards others and towards themselves

Traumatized people they can manifest aggressive behavior towards others or towards themselves. For example, child abuse increases the likelihood of criminal and criminal behavior in adulthood.

PTSD course and prevalence

PTSD is one of the most common mental disorders. Regarding its global prevalence, it is believed that ranges from 1 to 14%. This great variability may be due to the fact that different studies have used variable diagnostic criteria and have studied different populations. For example, data in studies conducted on individuals at risk (war veterans, terrorist attacks, etc.) range from 3 to 58%. Regarding the prevalence throughout life, it is estimated that it ranges between 1.3% and 9% in the general population and at least 15% in the psychiatric population.

As regards its appearance, it can occur at any age, even during childhood. In addition, it usually appears abruptly, and although the symptomatology usually appears in the first 3 months after the trauma, it can also manifest itself after a temporary period of months, or even years.

The course can be very variable over time, and both the symptoms themselves, and the relative predominance of each, vary greatly throughout the course of the disorder. There are also important variations in the duration of symptoms. Approximately half of the cases usually recover spontaneously in the first 3 months. However, in the other half the symptoms may persist even beyond 12 months after the traumatic event and usually require therapeutic attention for recovery.

According to different studies, the two most important predictors are the history of previous traumas (those people who have been more exposed to previous traumas are more likely to develop a TPET) and the reaction in the moments after the fact (people who manifest reactions predominantly dissociatives have a worse prognosis).

With regard to other predictive variables, the most important factors are the intensity, duration and proximity of exposure to the traumatic event. Some studies have also indicated that the quality of social support, family history, experiences during childhood, personality traits and pre-existing mental disorders can influence the onset of this disorder, although PTSD may appear in individuals without any predisposing factor, especially when the event is extremely traumatic).

On the other hand, there are also important cultural differences, depending on the value given to human losses in different cultures. Other cultural and religious values ​​can also influence the response to stress. For example, it seems that Buddhist and Hindu philosophies manifest characteristics that can be considered as protective factors, such as the acceptance of pain and suffering, the understanding that the future will bring relief through rebirth, etc. These characteristics could maximize the recovery of traumatized people.

Finally, with regard to the characteristics of the traumatic event itself, it seems that certain stressors are more likely to trigger a PTSD than others. As we have already indicated, Traumatic events infringed by humans seem to be more likely to trigger a PTSD, especially when it comes to direct relatives or of people who should be trusted, or when they have suffered pressure to silence the event; repeated and repetitive events and those suffered at an earlier age are also more “traumatizing”.

Differential diagnosis and comorbidity

Many of the symptoms manifested by people diagnosed with PTSD can be confused with other psychological disorders, such as depressive disorder, somatization disorder, simulation, borderline personality disorder (BPD), antisocial, and even with some type of psychotic disorder In these cases it is necessary to assess the extent to which the symptoms are a response to a traumatic event and symptoms of the three groups indicated previously (re-experimentation, avoidance / dullness and hyperactivation) are manifested.

It should be borne in mind that although PTSD is a relatively easy diagnosis to be made when the existence of a traumatic event is known, or when the patient reports the relationship between their symptomatology and a highly stressful event, however, when the symptoms are of late onset, that relationship may not be as obvious, especially for the patient, so the clinician should assess the existence of such experiences, since the history of traumatic events is a key element for differential diagnosis.

As regards the comorbidity associated with PTSD, this is tremendously high. According to the literature, up to 80% of patients diagnosed with this disorder have at least one more psychopathological diagnosis, the most frequent being alcoholism or drug abuse (60-80%), affective disorders (26% -65%), anxiety disorders (30-60%), or personality disorders (40-60%).

As for the association with substance abuse, this is usually a frequent strategy to try to escape or hide the pain associated with the traumatic experience. Studies indicate that patients with both disorders show greater severity and worse response to treatment and tend to abuse "hard" drugs such as cocaine and opiates. In addition, the presence of both disorders is usually associated with other problems, such as begging, domestic violence, medical problems and difficulties in therapeutic involvement.

As for affective disorders, it is very common to observe subsequent depressive episodes, characterized by loss of interest, decreased self-esteem and even in the most serious cases, recurrent suicidal ideations (present in approximately 50% of rape victims) .

Finally, emphasizing the frequent presence of episodes of anger and aggressiveness, which although they are very common reactions among trauma victims, can in some cases reach disproportionate limits and significantly interfere with the daily functioning of patients.

Intervention and treatment

The first thing to emphasize, and in what most authors agree, is that the experience of trauma itself is not a sufficient justification for treatment, but other psychopathological manifestations related to that event, such as those listed in the PTSD or other diagnosis (depression, anxiety disorders, etc.) must be present.

The psychological processes that are considered responsible for the development and maintenance of PTSD is avoidance, both the active avoidance of trauma reminders, and the emotional dullness, which is considered as an emotional escape when active avoidance is unsuccessful. Therefore, it is not surprising that a common element of many therapeutic approaches has been precisely the exposure and processing of internal and external evidence related to trauma.

The main approaches to the treatment of PTSD are.

Pharmacotherapy

The use of psychoactive drugs is generally recommended in people whose anxiety, insomnia, etc. problems. they can be very disabling, also those that do not want or may be involved in a psychological treatment focused on trauma. It is also recommended for those who are under the threat of subsequent trauma (eg, domestic violence), or are benefiting little or no from psychological treatment focused on trauma, etc.

Psychodynamic psychotherapy

There are quite a few differences in the therapeutic approaches arising from the psychodynamic approaches. The process" (debriefing) constitutes the basic strategy to address the acute catastrophic stress reaction, together with the techniques of “abreaction”, support and self-cohesion.

Hypnotherapy or clinical hypnosis

The use of hypnosis for the treatment of trauma has a long history, dating back to Freud's work. There are a number of reasons to use hypnosis and related techniques in the treatment of post-traumatic disorders: First, hypnotic techniques can be easily integrated into various therapeutic approaches, such as psychodynamic, cognitive-behavioral and pharmacological therapy. Second, patients with PTSD tend to have a greater response to hypnotic suggestions than other clinical and 'normal' groups. Third, a high percentage of patients with PTSD suffer from dissociative symptoms and hypnosis can help patients modulate and control the involuntary occurrence of these phenomena and remember forgotten traumatic information.

Thus, hypnosis can have several uses in the treatment of PTSD (support suggestions, work with traumatic memories, cognitive reinterpretation of traumatic events) and can be used in different stages (establishment of the therapeutic relationship, decrease in symptoms, psychological reintegration , labor and social of the patient).

EMDR: eye movements, desensitization and reprocessing

The Eye Movement Desensitization and Reprocessing (EMDR) It consists of a form of exposure, accompanied by saccadic eye movements. In this technique, the patient focuses on a disturbing image or memory, while following the movements of one of the therapist's fingers. After each sequence, the patient indicates their subjective level of anxiety and their degree of belief in positive thoughts.

Cognitive Behavioral Treatments (CBT)

In general, treatments derived from the cognitive-behavioral approach have produced the largest number of controlled studies and the most rigorous studies. These types of treatments usually include various procedures and strategies, such as psychoeducation, exposure, cognitive restructuring, and anxiety management techniques. It seems that both prolonged exposure procedures and stress inoculation training are the most effective tactics for reducing PTSD symptoms.

Acceptance and commitment therapy (ACT)

Acceptance and Commitment Therapy (ACT) attempts to promote people's abilities to make and maintain commitments to change their behavior. In this way, patients are encouraged to identify goals in their lives and to engage in actions that are consistent with those values.

References

Breslau, N., Davis, G.C., and Andreski, P. (1991). Traumatic events and post traumatic stress disorder in an urban population of young adults. Archives of General Psvchiatrv. 48, 216-222.

Breslau, N., Kessler, R., Chilcoat, H., Schultz, L., Davis, G., and Andreski, P. (1998). Trauma and posttraumatic stress disorder in the community. Archives of General Psychiatry, 55, 626-633

Echeburúa, E. (2004): Overcome trauma treating victims of violent events. Madrid: Pyramid

Foa, E. B., Keane, T. M., and Friedman, M. J. (2000). Practice guidelines from the international society for traumatic stress studies: Effective treatments for PTSD. New York: The Guilford Press.

Heltzer, J.E., Robins, L.N., and McEvoy, L. (1987). Post-traumatic stress disorder in the general population. New England Journal of Medicine, 317 (26), 1630-1634.

Horowitz, M.J., Wilner, N., Alvarez, W. (1979). Impact of Event Scale: a measure of subjective distress. Psychosomatic Medicine, 41:207-18

Marmar and D. Bremmer (Eds.), Trauma, memory and dissociation (pp. 57-106). Washington, DC A.P.A.

Spiegel, D. (1989). Hypnosis in the treatment of victims of sexual abuse. Psychiatric Clinics of North America, 12, 295-305.

Spiegel, D., and Cardeña, E. (1990). New uses of hypnosis in the treatment of posttraumatic stress disorder. Journal of Clinical Psychiatry, 51, 39-43.

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