Download POST-TRAUMATIC STRESS DISORDER Yudi Artha1, I Gusti Ayu

POST-TRAUMATIC STRESS DISORDER
Yudi Artha1, I Gusti Ayu Indah Ardani2
1
Medical Education Study Program, Faculty of Medicine,
Udayana University, Denpasar, Bali, Indonesia
2
Department of Psychiatry, Faculty of Medicine, Udayana University/
Sanglah Hospital, Denpasar, Bali, Indonesia
ABSTRACT
Post-traumatic stress disorder (PTSD) is a mental disorder that occurred after the
exposure of traumatic event, which is characterized by re-experiencing, avoidance
and hyperarousal. The Lifetime incidence of PTSD is estimated around 13%, and the
lifetime prevalence rates ranges from 3%-78%. The exact pathophysiology of PTSD
is still unclear. However, there are a number of factors that must be considered in
interaction between environmental factor, personal response against stress, and
psychopathology. The management of PTSD includes the use of antidepressant, CBT,
and other psychotherapy.
Keywords : PTSD, re-experiencing, avoidance, hyperarousal.
PTSD often associated with psychiatric
INTRODUCTION
Post-traumatic
disorder
comorbidities and decreased quality of
(PTSD) is a chronic mental disorder
life, and the course usually chronic and
which is manifested as a feeling of fear
persist
of certain traumatic event, feeling of
properly.5 The patient that suffered from
being haunted, feeling as if the traumatic
PTSD seemed to have a lower quality of
events
life. There was a research reported that
is
experiencing
stress
still
ongoing
of
certain
and
re-
traumatic
PTSD
lifelong
patient
if
in
not
an
managed
emergency
events.1 However, the onset of such
admission was reported to had lower
traumatic event already has occurred
quality of life, compared with non-
many months or years ago. Another
PTSD patient.10
literature stated that PTSD is marked by
PTSD most commonly reported
development of symptom clusters after
to occur after the occurrence of certain
being exposure by traumatic life events.
traumatic events. Some literature stated
1
that the criteria for psychological trauma
traumatic event represent about 33%
to be able to elicit PTSD must have
overall the sample interviewed.2
characteristic of threatening or impacts a
The result of the research was
serious injury to the affected individual.
concluded that the tsunami produced
For example natural or man-made
posttraumatic stress reactions across a
disaster, punishment or torture, sexual or
wide
child abuse, rape, traffic accidents, or
Sumatra.2 The tsunami seemed to give
even after suffering from certain serious
bad impacts towards Aceh and North
illness, such as asthma, heart attack, or
Sumatra tsunami survivor. To solve such
myocardial infarction.1,11
problem, the local government along
region
of
Aceh
and
North
In Indonesia, by the end of year
with local public health center gave
of 2004, tsunami destroyed the Aceh and
counseling services to not only directly
North Sumatra region. Thousand people
affected people but also the people that
died in this natural disaster. The impact
lived near the impacted region.2
of Aceh tsunami was not only physical
In the view of travel medicine, it
but also affects the disaster survivor’s
is very important to understand the basic
mental status. There was a research
knowledge
conducted in 2005, which assessed the
prevention, management, and education
mental status of tsunami survivors in
for the patient. While a person is
Aceh and North Sumatra.
travelling to certain places, they might
The result was reported that post
of
PTSD
for
early
encounter stimulus that could elicit or
traumatic stress disorder was the most
activate
their
memory
common mental disorder among tsunami
traumatic event, and express PTSD
survivor in Aceh and North Sumatra.2
symptoms. In other word, one can
According to the data provided, the most
exacerbate
common traumatic events experienced,
travelling to certain places, and need to
which suggested PTSD symptom, by
be managed wisely, either by education
tsunami survivor was hearing of tsunami
such as pre-travel counseling, or in
wave and screams of other civilians
severe
during the tsunami occurrence, this
pharmacological intervention.
PTSD
cases
about
while
that
they
might
past
are
need
2
traumatic event to develop into PTSD in
the future.
EPIDEMIOLOGY
A
literature
stated
that
the
From
the
literature
it
was
lifetime incidence of PTSD is estimated
concluded that approximately 80-90%
to be around 13%, and the lifetime
people
prevalence rates ranges from 3%-78%.11
events would eventually able to adapt,
After the tsunami disaster at
which is not developed into PTSD.
Aceh in 2004, the prevalence of PTSD
However around 10-20% will fail to
seemed to be increased. This is proven
adapt, thus will develop PTSD later.1
by the research of adult people in Aceh
Another
and Nias Island, who survived from the
prevalence rates of PTSD in victim of
disaster. The result of that research was
traumatic event have been reported to
reported that most of people interviewed
approach nearly 100%.5 This percentage
suffered for high mental morbidity.
seems to be depend on the nature and
who
experienced
literature
stated
traumatic
that
the
The research also stated that the
degree of the traumatic event, also the
people who affected directly by the
personality trait and characteristic of the
tsunami were reported to have more
victim.
change in quality of life, than those who
did not. They were also reported to had
high rate of morbidity, such as symptom
RISK FACTOR
The
predisposing
factors
in
of panic disorder, affective disorders,
PTSD including: the presence of trauma,
anxiety disorder, and ultimately, PTSD.4
especially
However, not all people who
childhood
trauma,
the
presence of personality factor such as
experienced traumatic events would
personality
develop PTSD later, the probability of
borderline, and dependent personality),
the occurrence of PTSD after traumatic
social factor such as inadequate family,
events varies between individual. Some
recent stressful life changes, or lack of
literature
the
friend support, being a female, inherited
probability of people who experienced
genetic factor, excessive alcohol intake
provided
data
about
disorder
(antisocial,
and substance abuse.9,11
3
The
presence
childhood
stimulus (physical or mental reminders
trauma particularly has a high risk for
of the trauma, such as sight, smells, or
development
Other
sounds). Secondly, through instrumental
contributing factors such as trauma
learning, the conditioned stimuli elicit
timing, type of trauma, and its severity
the fear response independent of the
seem to modify genetic risk in PTSD.9
original unconditioned stimulus. The
of
of
PTSD.
person develop a pattern of avoiding
both the conditioned and unconditioned
PATHOPHYSIOLOGY
The exact pathophysiology of
stimulus.11
PTSD is still unclear. However, there
The development of PTSD also
are some contributing of factors that
related with the function of system
must
interaction
organ in human body. The system organ
between environmental factor, personal
involved such as endocrine system,
response
and
neurology, and neurochemical factors.
psychopathology.3 Some literature stated
From endocrine system view, abnormal
that in PTSD the affected person cannot
regulation of cortisol hormone and
process or rationalize the psychological
thyroid hormone may be related to the
trauma, thus precipitate the disorder.11
occurrence of PTSD. There was a study
be
considered
against
in
stress,
They keep re-experiencing such
in war veterans that demonstrated low
stress and trauma, thus they would
cortisol level in the blood and urine.3
attempt to avoid experiencing it again by
The researcher tried to found the
trying
stimulus,
correlation between hypocortisolism and
situation, or person that related or may
PTSD in war veterans. Hypocortisolism
remind
theoretically
to
avoid
them
to
certain
the
psychological
will
decrease
trauma, this defense mechanism is called
negative
avoidance technique.11
hypothalamus,
thus
Corticotropin
Releasing
There are two phases of PTSD
feedback
result
cortisol
towards
in
high
Hormone
development. Firstly, the trauma that
(CRH) level in the blood. High CRH
produces fear response is paired through
level was reported to be associated with
classic conditioning, with a conditioned
4
disorder on fear and stress processing in
subjective
PTSD patient.3
individuals with PTSD.3
The concentration of plasma
feeling
of
anxiety
in
Other factor that may be related
cortisol during trauma exacerbation
to
seems to have a predictive value of the
neurochemical factor. The core of
occurrence of PTSD in the future. There
neurochemical abnormalities that may
was
be
a
research
that
reported
pathophysiology
associated
with
of
PTSD
PTSD
is
include
administration of corticosteroid such as
abnormal regulation of catecholamine,
hydrocortisone
amino
psychological
shortly
or
peptide,
and
neurotransmitter such as serotonin and
development of PTSD in the future,
opioid, which is all of them are found in
although
the brain circuits that regulate and
exact
can
acid
prevent
the
trauma
after
percentage
of
successful prevention was not reported.3
Thyroid
hormone
also
integrate stress and fear responses.3
was
Catecholamine abnormalities in
reported to play a significant role in
PTSD patient include high level of
patient with PTSD, although there has
dopamine and high activity and level of
not been many literature supported that.
norepinephrine in the blood. The effect
Thyroid hormone is a hormone that
of high dopamine is interferes with fear
regulate body metabolism. Abnormal tri-
conditioning in mesolimbic system of
iodothyronine (T3) and thyroxine (T4)
PTSD patient.3 While the effect of high
ratio in the blood generally will increase
norepinephrine
human anxiety.3
hyperarousal, increased startle response,
activity
includes
Psychological trauma seemed to
affects the encoding of fear memories,
induce abnormality of thyroid gland
increases pulse rate, increases blood
activity. There was a study on Vietnam
pressure, and increases response to
War veterans with PTSD, who were
traumatic memories.3
found to have elevated baseline levels of
Noradrenergic system also plays
both T3 and T4 in the blood, furthermore,
an important role in development of
elevated T3 may relate increase of
PTSD symptoms. PTSD was reported to
affect
noradrenergic
system
by
5
increasing blood pressure and heart rate,
dissociation symptom were reported to
palpitation,
tremor.11 A
sweating,
flushing,
and
be associated with overactivation of
research
reported
that
prefrontal cortex and superior temporal
epinephrine level was increased in 24 -
cortex region of the brain.6
hour collected urine from war veteran
with PTSD.11 Other abnormalities such
CLINICAL FEATURE
as amino acid, and serotonin and opioid
The main clinical feature of
neurotransmitter was reported to have
PTSD is persistently re-experiencing
high anxiety effect in PTSD patient.3
traumatic
memory,
and
often
In the view of neurosurgery, the
accompanied by feeling as if the
occurrence of PTSD was reported to be
traumatic event were recurring or still
associated with some changes in the
ongoing
brain circuit. It was reported that the
flashback of traumatic event). This often
dorsal anterior cingulate cortex and
leads to intense psychological distress
insula appear to be hyperresponsive in
and
PTSD, as well as in other anxiety
exposure to internal or external cues that
disorders.6,8
also
resemble some setting in such traumatic
appears to function abnormally in
event.1 Some experts also defined PTSD
PTSD.8
as
The
The
hippocampus
characteristic
of
PTSD
(including
physiological
a
dissociative
reactivity
conglomeration
of
various
cognitive, behavioral, and physiological
symptoms could be associated with
disturbances
activation of certain region in the brain.
symptom
There was a research reported that
avoidance, and hyperarousal.5
symptom of hyperarousal in PTSD was
upon
characterized
clusters,
Diagnostic
ie,
and
by
three
intrusion,
Statistical
reported to be the result of over
Manual IV Text Revision (DSM IV-TR)
activation of amygdala and thalamus
stated that the main feature of PTSD is:
region of the brain, re-experiencing
Exposure of traumatic event makes the
symptom
over
affected person response it with fear,
activation of amygdala and insula
feeling of helplessness, or even agitated
region, while avoidance, numbing, and
in children case. Some time later the
is
associated
with
6
person will persistently feeling as if the
(thought, feeling, conversation, people,
traumatic
and place) that arouse recollection of the
event
followed
is
recurring
by psychological
and
distress.
Later the affected person will form such
trauma.
Two
studies
tested
the
defense mechanism, which is known as
hypothesis that a post-trauma processing
avoidance. They are usually trying to
advantage for trauma-related perceptual
avoid certain factor that may related or
stimuli (PAT) contributes to intrusive re-
may reminds them with such traumatic
experiencing
events, such as places, conversation
development of PTSD. The findings
related the trauma, or even the people
suggested that, compared to neutral
that seems to associated with the
stimuli, trauma survivors with post-
psychological
traumatic
trauma.
The
affected
and
thus
disorders
to
the
preferentially
person also pose bodily symptoms such
process stimuli that are reminiscent of
as hyperarousal, difficulty falling or
perceptual
staying asleep, irritability or anger,
trauma.7
impressions
during
the
difficulty in concentrating, exaggerated
The onset of symptom varies
startle response, dissociative disorder
between individual, because of different
and depression. Match for B, C, or D
characteristic and personality among
criteria for more than one month; B
individual.
criteria if while or after experiencing
develops shortly after trauma, however
trauma
of
there was a literature stated that it could
awareness of surrounding, derealization,
be delayed as short as 1 week or as long
depersonalization,
dissociative
as 30 years.11 The quality of symptoms
amnesia (inability to recall an important
are fluctuate over time and may be most
aspect of trauma) was developed; C
intense during period of stress.11
criteria
numbing,
if
the
decreased
or
usually
Those PTSD reactions are said to
persistently re-experienced in recurrent
be self-limited in most majority people,
images,
without
dreams,
event
symptoms
is
thought,
traumatic
The
illusion,
functional
impairment
or
flashback, and reliving experience; D
decrease in quality of life.3 If the
criteria if marked avoidance of stimuli
symptoms resolved within 3 months,
7
this is called acute stress disorder.
and
bodily
symptoms
However, for those who after exposed to
hyperarousal;
psychological trauma that profound to
functional impairment and decreased
threat usually will continue to have
quality of life which occur more than 1
longer-term mental disorder that has
month after exposure of traumatic event.
with
such
as
devastating
been defined as PTSD in the literature.
PTSD
is
often
accompanied
by
devastating functional impairment and
associated with lower quality of life.3
In order to diagnose PTSD, the
symptoms must last at least for one
month after the onset psychological
trauma.1 Acute PTSD is defined as the
symptoms of PTSD lasts more than one
month but less than 3 months, and if the
symptoms lasts more than 3 months it is
defined as chronic PTSD.1
Figure 1. Time course and post-traumatic
stress disorder (PTSD) subtypes.
Adopted from Zohar et al. New insights into
secondary prevention in post-traumatic
stress disorder.2011.p 302
If the
symptoms of PTSD occur within first
month after traumatic event, but the
DIFFERENTIAL DIAGNOSIS
Some literature stated that panic
symptom soon resolved or not exceeds
disorder
and
generalized
one month, it is defined as Acute Stress
disorder
are
quite
Disorder.1 While Delayed Onset of
differentiate with PTSD. The key to
PTSD defined as the occurrence of
differentiate
PTSD symptoms in 6 months after
carefully questioning the patient of their
traumatic events.1 (Figure 1).
family regarding the time course of
between
anxiety
difficult
them
is
to
by
In other words, PTSD is a cluster
symptoms.11 Furthermore, the classical
of symptoms that characterized by four
traits of PTSD are avoidance and re-
primary domains already mentioned
experiencing can be used to establish
before, which are trauma exposure,
diagnosis of PTSD, due to their absence
persistent re-experiencing, avoidance,
8
in
panic
or
generalized
anxiety
disorder.11
stress such as finding a secure place in
which the patient would feel comfort.
Secondly,
physiological
MANAGEMENT
Debriefing
to
was
one
restore
needs
by
patient’s
providing
of
adequate nutrition. Thirdly, to provide
psychological intervention that used to
some education and peer support system
solve the problem of PTSD; the method
such as family or friend, and helping to
is by the patient asked to focus on their
locate a source of support (family,
own memories the traumatic events.
friends, etc) with emphasizing the
Theoretically, by doing so, it would
expectation that the patient will be able
allow the patient to cope with the
resume its daily activity as soon as
memory, and solve it, thus it would lead
possible.
to spontaneous mental recovery of the
patient.1
Psychotherapy such as CBT,
cognitive
treatment,
and
hypnosis
However, there was a research
therapy may be helpful in the case of
reported that debriefing method could
PTSD.11 The current review suggests
bring harmful effects to PTSD patient, in
that CBT is effective for both acute and
which the PTSD symptoms might
chronic PTSD, with both short-term and
worsening. The statement was supported
long-term benefit.5 Despite of reports of
by data which reported that in a study of
efficacy in many studies, patient that
psychological debriefing on people after
failed to respond to CBT for PTSD can
traffic accidents with follow up for 4
be as high as 50%.5 This is contributed
months. The result of study reported that
to by various factors, including patient’s
after received debriefing intervention,
comorbidities and personality trait of the
the subject’s mental status became
people who experience PTSD.5
worse than before received debriefing
intervention.1
Currently
If after those intervention, the
symptom seems not improved after a
approved
non-
couple of months, then referral to
pharmacological management for PTSD
specific psychological intervention for
is firstly, reducing the exposure to the
9
Cognitive Behavioral Therapy (CBT)
PTSD. Also a β-adrenergic blocker like
are indicated.1
propanolol, theoretically will be useful
Pharmacological
treatment
of
in
reversing
the
effects
of
PTSD includes the use antidepressant
hyperreactivity of noradrenergic system,
agents, such as Selective Serotonin
such as palpitation, sweating, high blood
Reuptake Inhibitor (SSRI), Tricyclic
pressure, and high heart rate.11 For short
antidepressant (TCA), and Monoamine
term control of agitated or aggressive
Oxidase Inhibitor (MAOI).
PTSD patient, especially in emergency
SSRI such as sertraline and
paroxetine are considered as first-line
department setting, antipsychotic such as
haloperidol is indicated.11
treatment for PTSD.11 They was reported
The newest and controversial
to decrease symptoms from all PTSD
psychotherapy
technique
is
Eye
symptom cluster and were effective in
Movement
improving symptoms not only those
Reprocessing (EMDR). The method is
unique to PTSD, but also those that
patient asked to relax and focused on
similar with depression or other anxiety
physician finger movement. At the same
disorder.11
time patient is asked to maintain mental
Desensitization
and
TCA such as imipramine and
image of their traumatic events. It was
amitriptyline were reported in some
said that it would allows patient to work
research had some negative effects.
on their traumatic events in a state of
However, there was some research
deep relaxation, thus it would relieves
reported that TCA was more effective
PTSD symptoms.11
for treating anxiety, depression, and
The
administration
of
hyperarousal; than in treating avoidance,
corticosteroids shortly after trauma may
denial, and emotional numbing in
prevents the occurrence of PTSD in the
PTSD.11
future. There was some research studied
Other drugs like MAOI such as
about
the
effect
of
corticosteroid
phenelzine and trazodone may be useful
injection shortly after exposure to
in PTSD, although there has not been
traumatic
literature that reviews their role in
Quervain et al, the administration of
event.
According
to
De
10
corticosteroid
immediately
after
In untreated PTSD patient, only
psychological trauma can prevent the
around 30% will recover completely,
development of PTSD.3 This finding
40% continue to have mild symptoms,
probably associated with the role of the
20%
hypothalamic-pituitary-adrenal axis in
symptoms, and 10% unchanged or
pathophysiology of PTSD.
become worse.11 If followed for one
continue
to
have
moderate
Studies in animal also reported
year, around 50% of PTSD patient will
about the effectiveness of corticosteroid
recover spontaneously.11 The factors that
administration immediately after trauma
determine a good prognosis of PTSD is
exposure for prevention of PTSD. A
measured
study in mice reported that after
disorder course, which consist of : rapid
hydrocortisone injection after 1 hour
onset of symptoms, short duration of
exposed
was
symptoms (< 6 months), strong family
associated with less anxiety behavior of
and peer support, the absence of other
the mice.1 It was also reported that
psychiatric,
timing of corticosteroid greatly affects
related disorder.11
with
predator
smell,
by
the
characteristic
medical,
or
of
substance-
the outcome. Another research was done
with the same method; however, the
CONCLUSION
corticosteroid was given 14 days after
Post-traumatic
stress
disorder
psychological trauma. The result was
(PTSD) is a chronic mental disorder
completely different compared with
which is manifested as a feeling of fear
those animals, which were received
of certain traumatic event, feeling of
corticosteroid one hour after trauma.1 In
being haunted, feeling as if the traumatic
other word, there is golden hour in order
events
to administer corticosteroid regarding
experiencing of certain traumatic events,
prevention of PTSD, which is around
which occurred months or years ago.
one hour after psychological trauma
PTSD most commonly reported to occur
exposure.
after the occurrence of traumatic events,
is
still
ongoing
and
re-
such as natural or man-made disaster,
PROGNOSIS
punishment or torture, sexual or child
11
abuse, rape, traffic accidents, or even
strong family and peer support, restoring
after suffering from certain serious
patient’s physiological needs, CBT, and
illness, such as asthma, heart attack, or
in severe cases the use of antidepressant
myocardial infarction.
and
After the tsunami disaster at
β-adrenergic
Corticosteroid
blockers.
administration
around
Aceh in 2004, the prevalence of PTSD
one hour after trauma exposure may be
seemed to be increased. It was reported
useful to prevent development of PTSD
that posttraumatic stress disorder was
in the future.
the most common mental disorder
The factors that determine a
among tsunami survivor in Aceh and
good prognosis of PTSD is measured by
North Sumatra.
the characteristic of disorder course,
The lifetime incidence of PTSD
which
consist
of:
rapid
onset
of
is estimated to be around 13%, and the
symptoms, short duration of symptoms
lifetime prevalence rates ranges from
(< 6 months), strong family and peer
3%-78%.
support, the absence of other psychiatric,
The exact pathophysiology of
medical, or substance-related disorder.
PTSD is still unclear. However, there
are some contributing of factors that
must
be
considered
in
ACKNOWLEDGMENT
interaction
The author thanks to Dr. I Gusti
between environmental factor, personal
Ayu
response
Department
against
stress,
and
Indah
Ardani,
of
from
Psychiatry
Sanglah
Medical
Faculty
psychopathology. The main feature of
Public
PTSD is history of exposure from
Udayana University, Denpasar, Bali,
traumatic
Indonesia for her supports in this journal
events,
re-experiencing,
avoidance, bodily symptom such as
Hospital,
Sp.KJ
composing.
hyperarousal, which must lasts at least
for
one
month
after
the
onset
1.
psychological trauma.
The
management
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