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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 REFERENCES of PTSD includes ensuring safe place, building Zohar J , Sonino R, E, Cohen secondary Weltzer AJ, Rachel S, Hamzany SC, Balaban H: New insight into prevention in post12 2. 3. 4. 5. 6. 7. 8. traumatic stress disorder. Dialogues in Clinical Neuroscience. 2011. 13:301-309 Frankenberg E, Jed F, Thomas G, Nicholas I, Robert , Iip UR, Bondan S, Alan S, Cecep S, Suriastini W, Duncan T. Mental Health in Sumatra After the Tsunami. American Journal of Public Health.2008. 98:1671-1677 Sherin JE, Nemeroff CB. Posttraumatic stress disorder: the neurobiological impact of psychological trauma. Dialogues in Clinical Neuroscience. 2011. 13: 263-278. 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