What is Post-Traumatic Stress Disorder?

According to some authors, Post-Traumatic Stress Disorder (PTSD) is a psychopathological condition that belongs to the category of anxiety disorders, which usually occurs in people that have been exposed to some traumatic experience 1.

On the other hand, in psychopathological manuals such as the Diagnostic and Statistical Manual of Mental Disorders in its last edition (DSM V), PTSD belongs to the category of Trauma and Stressor Related Disorders, which is pretty much related to anxiety disorders, sharing many of their symptoms and presenting high comorbidity between them. However, in this case, the main feature that allows differentiating PTSD from any anxiety disorder and others psychopathological categories has to do with the fact that the person at some point in his life went through a traumatic episode 3

So, in order to understand what PTSD is and is not, there is a term that we must define beforehand: trauma.

We can define trauma as “an unique individual experience of an event or enduring conditions, in which the individuals ability to integrate his/her emotional experience is overwhelmed” 2, this event often represents for the individual (in a subjectively or objectively way) “a threat to life, bodily integrity, or sanity” (Pearlman and Saakvitne, quoted by Giller, 1999).

Some of the most common traumatic events are usually natural disasters, accidents, wars, rape or in general those that have been a victim of any type of aggression.

What causes Post Traumatic Stress Disorder (PTSD)

The vast majority of people experience difficult situations during their life (as can be the loss of a loved one, for example), and as expected, these situations can generate a very intense emotional reaction that causes discomfort. However, it is not necessarily a “traumatic” situation according to the diagnostic criteria for a PTSD.

According to the DSM V, PTSD might occur in people who have been exposed to a traumatic event that would pose a potential danger of death, serious injury, or sexual violence in at least one of the following ways: (a) direct experience of the event; (b) to have witnessed how the event happened to other people; (c) the traumatic event happens to a family member or close friend in a violent or accidental way; (d) to have been exposed in a chronic way to details of traumatic events that might be aversive (e.g., police officers repeatedly exposed to cases of child sexual abuse) (this criterion does not apply to cases of exposure to television or graphic scenes, unless it is work related). 3

What are the symptoms of Post Traumatic Stress Disorder

Some of the symptoms and signs associated with the traumatic event  that must be present for the diagnosis of PTSD are: (a) recurring, involuntary and inevitable memories of the event; (b) recurrent dreams whose content or emotional response is related to the traumatic event; (c) dissociative reactions (flashbacks, for example) in which the person feels or acts as if the traumatic event is occurring (in some extreme cases the notion of the actual present may be completely lost); and (d) intense and / or prolonged psychological distress due to the presence of some of the signs that symbolize or are associated in some way with the traumatic event (eg, being in the presence of rain when the traumatic event was a flood). 3

In addition, the person has to avoid or try to avoid persistently and constantly any type of stimulation associated with the traumatic event that manifests itself in the following ways: (a) avoid or try to avoid the memories, thoughts or feelings associated with the traumatic event; (b) avoid or try to avoid any external signal that can activate memories, thoughts or feelings related to the traumatic event (places, people, conversations, situations, among others). 3

Similarly, people suffering from PTSD have cognitive and mood alterations associated with the traumatic event, which manifests itself in at least two of the following ways: (a) Inability to remember important aspects of the traumatic event usually as a consequence of dissociative amnesia, head injuries or substance use; (b) exaggeratedly negative beliefs or expectations about oneself, others, and the world. For example: “no one should be trusted” or “I am completely ruined”, among others; (c) beliefs or thoughts persistent and distorted with respect to the consequences or causes of the traumatic event that lead the person to blame themselves or others for what happened; (d) negative and persistent emotional state (eg, fear, anger, guilt, shame, among others); (e) decreased interest in participating or carrying out significant activities; (f) feelings of strangeness or detachment from others; and (g) persistent inability to experience positive emotions (happiness, satisfaction, love, among others). 3

Finally, there are marked alterations and reactivity in regard to the traumatic event, which may be evidenced in the following ways: (a) irritability and anger that occurs with little or no provocation, and which generally manifests itself as physical or verbal aggression towards persons or objects; (b) careless or self-destructive behavior; (c) Hypervigilance; (d) exaggerated startle response; (e) concentration problems; and (e) sleep disorders (like insomnia, nightmares, among others). 3

The list of symptoms that were presented previously, are those that must be necessarily present so that PTSD can be diagnosed. If we look at it correctly, we can see that the disorder manifests itself through emotional, behavioral, and cognitive symptoms, of which many of them also usually generate an important physiological discomfort.

Also, people suffering from PTSD may have other symptoms such as depersonalization (feeling that they are not themselves, that they are like external observers); derealization (experience of being alien to reality); hallucinations and pseudo hallucinations, difficulty in establishing interpersonal relationships, among others. It should be noted that these symptoms are common but their presence is not necessary to diagnose PTSD, which is why they were not included in previous paragraphs. 3

It is also important to take into account several aspects: first, for PTSD to be diagnosed, these symptoms can not be a consequence of the physiological effects of any substance or medication, nor of medical conditions or other mental disorder that may explain better the presence of these indicators. Second, the symptoms mentioned above must have appeared as a result of the traumatic event or have worsened after it happened, and its duration can not be less than one month (3).

PTSD can be developed at any age after the first year of life (however, for children under six years of age some of the diagnostic criteria change). Similarly, in some cases the symptoms appear up to three months after experiencing the event, a phenomenon called “delayed expression”.3

 

How is Post Traumatic Stress Disorder normally treated?

As with other psychopathological diagnoses, the most common PTSD treatment involves medication and psychotherapy.

As for medication, the prescription of antidepressants is common in order to reduce some of the symptoms, while the strategies or therapeutic approaches that have proven to be effective are exposure therapy and the cognitive-behavioral approach,1 (the latter being the most used by specialists for being the one with the most empirical support in terms of effectiveness).

The first one, exposes the person (as his name indicates) in a safe and progressive way, to the stimulation associated with the traumatic event, as can be certain memories, people, places, etcetera; with the aim that the discomfort that these stimuli generate also be reduced progressively. On the other hand, cognitive-behavioral therapies have as the main objective that the person can identify the signs related to the trauma, and modify the negative cognitions (thoughts, beliefs, expectations) that they produce. Similarly, the person is taught how to use anxiety management strategies that help reduce PTSD symptoms, such as breathing or relaxation techniques, for example.1

Like other psychopathological disorders, when the discomfort produced by PTSD is too intense, it can be accompanied by suicidal ideation, which in many cases is transformed into suicidal attempts or gestures. That said, the exploration and intervention of this aspect becomes one of the main therapeutic goals in order to preserve the life of the patient, regardless of the psychotherapeutic approach.

Some of the other therapeutic goals involve (a) establishing social support networks; (B) promote the development of resources (psychological, social, emotional) for the person to adapt to their environment, and to be functional in some of the most important areas of their life, as is usually the work area, one of the most commonly affected by PTSD.

How does addiction affect Post Traumatic Stress Disorder?

In the same way that substance use increases the probability of experiencing a traumatic event,  it is also common for people who have experienced it,  to seek relief from alcohol and drug use 1,5, 6; using them as a strategy to evade the symptoms and discomfort that these experiences generate. However, in the long run, it is common for PTSD symptoms to worsen and people become addicted to the substances consumed 1. This since the symptoms (and therefore, the disorder) do not really disappear, they are only relieved temporarily. In turn, the need to constantly avoid the discomfort produced, can lead to increase the frequency and dose of consumption.

Special considerations for people with PTSD in Addiction treatment

There are authors who suggest a combination of treatment for both conditions, since not necessarily the treatment for PTSD will also work to treat addictions. 1 Therefore, and given the high probability of co-occurrence between PTSD and addictions, some researchers have decided to adapt and modify certain aspects of cognitive behavioral therapy applied to PTSD cases, incorporating strategies also useful for the treatment of addictions. These therapeutic adaptations have proven to be effective and well tolerated by the patients, becoming a useful tool for the treatment of both disorders simultaneously.4

Likewise, the need to intervene in both disorders, not only in one of them, increases when considering that having been exposed to traumatic experiences (especially if PTSD has been developed) not only increases the probability of consumption but also a relapse 5 The effectiveness of treating both disorders together has been scientifically demonstrated, with significant relief of symptoms associated with trauma less than one month after cessation of use. 7

However, and taking into account the above mentioned, in both cases the use of medications, exposure therapy and / or cognitive behavioral therapy could be beneficial if the necessary therapeutic adaptations are made. In the same way, many of the psychotherapeutic objectives are maintained for both disorders.

 

 

1. Hazelden Foundation (2008). Post- traumatic Stress Disorder.
2. Giller, E. (1999). What Is Psychological Trauma?. Annual Conference of the Maryland Mental Hygiene Administration “Passages to Prevention: Prevention across Life’s Spectrum”.
3. AMERICAN PSYCHIATRIC ASSOCIATION (APA). (2013). Diagnostic and Statistical Manual of Mental Disorders. Washington, USA.
4. McGovern, M., Lambert-Harris, C., Acquilano, S., Xie, H., Alterman, A., Weiss, R. (2009). A cognitive behavioral therapy for co- occurring substance use and posttraumatic stress disorders. Addictive Behaviors, 34 (10), 892-897.
5. Norman, S.; Tate, S., Anderson, K., Brown, S. (2007). Do trauma history and PTSD symptoms influence addiction relapse context?. Drug and Alcohol Dependence, 90, 89-96.
6. Reynolds, M., Mezey, G., Chapman, M., Wheeler, M., Drummond, C., Balcacchino, A. (2005). Co-morbid post-traumatic stress disorder in a substance misusing clinical population. Drug and Alcohol Dependence. 77(3), 251-258
7. Coffey, S. Schumacher, J., Brady, K., Dansky, B. (2007). Changes in PTSD symptomatology during acute protracted alcohol and cocaine abstinence. Drug and Alcohol Dependence, 87 (2), 241-248.