Posttraumatic Stress Disorder, or PTSD, is characterized by individuals who have experienced or witnessed a terrifying or life-threatening experience, such as being kidnapped, raped, mugged, being in a natural disaster, experiencing combat, child abuse, plane crashes, first-responder duties or related experiences; however, though the experience has passed, they continue to experience overwhelming physiological stress reactions associated with the fight, flight, or freeze response. PTSD has been delineated into two categories, PTSD and PTSD for Children 6 and younger. With PTSD, the individual must have been directly exposed to a traumatic event, learn about a traumatic event happening to a close significant other or have chronic exposure to traumatic details (line of duty issues with first responders). Three clusters of symptoms constitute PTSD symptomology, including intrusion, avoidance, and arousal. Intrusion is characterized by symptoms of flashbacks (feeling as if is happening now, past is present), nightmares with content or emotion related to trauma, intrusive memories (“I close my eyes but the scene keeps replaying no matter what I do”), and physical and emotional reactions to triggers (reminders) of the events. Avoidance is characterized by efforts to abstain from thoughts, feelings, people, conversations, objects, memories, or anything that could serve as a reminder of the event. Avoidance also involves a lapse in memories surrounding the events, distorted cognitions, anhedonia, detachment, and disengaged from positive emotions. Arousal is characterized by irritability, anger outbursts, recklessness, hypervigilance, self-destructiveness, easily startled, being “on edge,” and insomnia. Symptoms must be present for a minimum of one month and cause functional impairment and distress in at least one significant area of functioning. Symptoms are not better explained by a substance or other condition. When coding, specify whether or not dissociative symptoms are present (depersonalization or derealization or both), recurrently or persistently. If onset of PTSD symptoms is not present for a minimum of 6 months beyond the event, specify “with delayed expression.” 

PTSD was first “discovered” and classified due to symptoms presented by Vietnam veterans. Similar patterns of symptoms were in the past called “shell shock”. People with this disorder often become emotionally numb and try to avoid anything that will trigger unwanted memories. People with posttraumatic stress disorder often have difficulty sleeping, aggressive behavior, and anxiety attacks. The theoretical approaches used in this disorder are psychoeducation, cognitive-behavioral, and psychodynamic. Symptoms of PTSD may be chronic (lasting many years resulting from unresolved childhood trauma) or may be much shorter in duration. Rapid treatment after a traumatic incident has been shown to prevent the more chronic symptoms. Some believe that Borderline Personality Disorder is related to early childhood trauma. PTSD in childhood may result in characterological defenses that become engrained in the adult personality. Further, individuals with a history of early trauma or disrupted attachment relationships may be more vulnerable to develop the maladaptive patterns of behavior associated with PTSD later in life.

With PTSD, you will need to conduct an assessment and establish a working relationship with the patient. You also should reduce isolation and provide some measure of immediate symptom relief. This can often be done by education and supportive empathic listening. A thorough clinical history of as well as a psychosocial will be needed. Family dynamics and emotional functioning are also very important to assess. A referral may be needed for a physician to see if there is a general medical condition (you will need to get a release). If your patient is in crisis then crisis intervention will be necessary. Finally, you will need to make an agreement with the patient in reference to treatment goals and refer to support groups as well as community resources.

Generally, exposure has been found to be the most effective treatment for PTSD. Exposure is repeated discussions of the traumatic situation. Validation of the individual’s trauma and the damage done is crucial. Often, reappraisal of the traumatic situation will be useful. For patients that were traumatized as children, looking at the situation through adult eyes and using the “inner adult” to protect the child is helpful. For a patient that was sexually abused as a child, reenacting the incident with more adaptive responses can empower them and shift the patient to a new perspective. (One example would be to have the patient imagine that he or she had a baseball bat with them at the time of the abuse. The clinician can explore possible responses in this scenario.) However, incest victims often blame themselves for the abuse. The clinician should be cautious to not add to the belief that the patient should have done something different to prevent the abuse. EMDR is a new therapy that has promise in treating PTSD. However, it is too early to tell how effective it really is. Stress reduction techniques have been found to be very effective in-patients with this disorder. Since the patient has learned to avoid recollecting the traumatic events, caution should be used in proceeding with treatment. Symptoms may exacerbate as the patient explores the events.

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