Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder typically experienced after a traumatic event (such as rape or combat experiences), and the type of trauma experienced is considered by the American Psychiatric Association as less important than the severity of the trauma, and the individual reactions and vulnerabilities. For a diagnosis of PTSD, the traumatic event must have been threatening to the life or physical integrity of oneself or others, and the response to the event must involve intense fear, helplessness or horror. The three major characteristics of the disorder are: re-experiencing the event in some way (nightmares, flashbacks, intrusive thoughts); avoidance and feelings of numbness, and increased stress reactions which may be both physical and emotional. Onset of symptoms may immediately follow the traumatic event as in acute stress disorder, or may be delayed by several months as in chronic conditions.

The symptoms of nightmares and flashbacks may be triggered by any new event which is associated with the trauma. Nightmares are often exact replicas of the traumatic experience, and flashbacks - which may be described as 'waking nightmares' - may arouse such intense stress reactions that the individual becomes immobilised and may lose all sense of their immediate surroundings. The sufferer may not be aware of what has triggered a flashback, and this can increase the perception that their symptoms are both unpredictable and out of their control. Avoidance and numbing may occur as the sufferer attempts to protect themselves from distress, either consciously or unconsciously. For example, numbing may manifest in a rape victim losing all enjoyment in sex; avoidance may come into play by the victim refusing to leave their own home, which in turn can lead to agoraphobia. There may be an extreme fear of loss of control, and outbursts of anger are not uncommon. This can lead to further confusion, as the individual experiences new personality characteristics or behaviours that did not exist prior to the trauma.

Given the high incidence of sexual assault, it is probable that female victims make up the single largest group of those suffering from PTSD. It is estimated that over 50% of rape victims do develop PTSD at some point in their life. At present little is known about the prevalence of, and consequences for, male victims of sexual assault. Combat veterans represent another significantly large portion of the population who suffer from this condition. Social and occupational functioning may be impaired as a result of PTSD.

Symptoms & Criteria

Criteria for PTSD

The person has been exposed to a traumatic event in which:

  • the person has been exposed to an event which has involved actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others
  • the person's response involved intense fear, helplessness or horror

Re-Experiencing

Traumatic event is persistently re-experienced in at least one of the following ways:

  • recurring and intrusive distressing recollections of the event, including thoughts and images
  • recurring distressing dreams or nightmares of the event
  • acting or feeling as if the traumatic event were recurring (including flashbacks; hallucinations)
  • intense psychological and physical distress on exposure to occurrences that resemble an aspect of the traumatic event

Avoidance and Numbing

As indicated by at least three of the following:

  • avoiding activities, places or people that are reminders of the trauma
  • inability to recall an important aspect of the trauma
  • diminished interest in normal activities
  • feelings of detachment from others
  • less able to experience the normal range of feelings

Increased Arousal

As indicated by at least two of the following:

  • difficulty falling or staying asleep
  • irritability or outbursts of anger
  • difficulty concentrating
  • hyper-vigilance (heightened sense of watchfulness, or being on guard)
  • startles easily

The duration of the disturbance will be at least one month, and cause marked distress or impairment in social or occupational functioning.

Diagnosis & Assessment

Assessment has two main aims: that of making a diagnosis, and that of treatment planning for an individual. A third aim in the area of PTSD is that of determining other mental health disorders, as it is common for depression, anxiety disorders such as phobias, and substance abuse, to co-occur with PTSD. Suicide risk will also be assessed and monitored, as a small but significant number of sufferers either attempt, or contemplate, suicide at some point following their experience of trauma.

Medication Treatment

Different types of medication may be used to target different aspects of this mental health disorder. For example, minor tranquilizers and/or antidepressants may be used to help with emotional symptoms such as anxiety, depression and impulsive-aggressive behaviour. Lithium carbonate may be used to treat transient psychotic episodes. The effectiveness of medication with respect to symptom alleviation will be carefully monitored, and it is likely that it will be used in conjunction with psychological treatment.

The first important stage of assessment is to identify the traumatic event in the client's history, as the tendency to avoid trauma-related memories can mean victims fail to recognise that their mental health problems are associated with a specific event (such as being a victim of crime). This will usually be conducted by means of a supportive, non-judgemental interview. Symptoms will be assessed, for both severity and frequency, in the three major symptom areas: re-experiencing; avoidance and numbing, and hyper-arousal (please see symptom checklist in the above section). Changes in behaviour will also be focused upon. Assessment may be ongoing for a period of time, to determine the effectiveness of treatment.

Psychological Treatments

There are three main psychological treatment processes: Stress Inoculation Training; Prolonged Exposure, and Cognitive Processing Therapy. Stress inoculation training may be carried out with individuals or groups, and aims to give the client a sense of mastery over their fears and anxieties by teaching a range of coping skills. These include: muscle relaxation, breathing techniques, role playing and thought stopping.

Prolonged exposure is a cognitive-behavioural treatment which is conducted with individuals. Typically the client is asked to recall the assault (or other traumatic event) in as much detail as possible within the safety of the therapeutic session, so that they can then process the memory until it is no longer intensely painful. Exposures are usually graded, so that the least anxiety-provoking memories are elicited first, before approaching more painful memories later on. This will be done within a safe and supportive atmosphere.

Cognitive processing therapy is usually a 12 week structured programme in which clients are both encouraged to recall the traumatic event, as well as to challenge the associated thoughts, and break down any maladaptive fears and beliefs that have become established. New, corrective information will be presented that helps the client to re-evaluate themselves following the trauma; for example, an individual may be helped to move away from the experience of self-blame which is common for victims of crime such as rape.