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Islamic University
Master of Community Mental Health Nursing Program
Post traumatic stress disorder (PTSD)
Jan-2010
Post traumatic stress disorder (PTSD)
Introduction:
Post-traumatic stress disorder or PTSD is an anxiety disorder that can be triggered by
witnessing or experiencing a traumatic event. PTSD is a medical diagnosis that
applies when someone has difficulty coping with the aftereffects of trauma to the
point where it disrupts their lives months or even years after the trauma occurred.
Symptoms often include reliving the event in your mind, as well as feeling
emotionally numb, difficulty sleeping, and feelings of isolation. The symptoms can
arise soon after the event occurs, or they may not appear until months or years later.
Examples of traumatic experiences that may cause PTSD include witnessing or
experiencing physical or emotional abuse, being a victim of violent crime, going to
war, or the death of a loved one. PTSD affects people of all ages including an
estimated five million American adults each year. An estimated 7 percent to 8 percent
of the population will experience PTSD at some point in their lives. There are
effective treatments for PTSD but it is important to seek treatment as soon as possible
to prevent the symptoms from getting worse.
Adult PTSD :
Anyone who has experienced an extremely traumatic event can suffer from PTSD.
Whether you’re a child who has been sexually abused, or a young adult involved in a
near-death car accident, or an elderly person who just came home from a war, you can
have PTSD. This anxiety condition is more usual in adults than in children although
its effects on children are less studied and harder to treat.
A child with PTSD grows up with this anxiety disorder if not treated immediately. As
an adult, the patient is haunted by the horrors from the past. Some adult patients
experienced the trauma in the later part of their lives. War veterans are the best
examples of this. In fact, the concept of PTSD was formulated during the Vietnam
War when numerous veteran soldiers suffered from an anxiety disorder and
experienced extreme fear, guilt, and helplessness after coming home from the war.
Some rescue workers also get this disorder after serving at a place with mass
casualties like the South Asian Tsunami in 2004 and the September 11 attacks in
2001. Other traumatic events than can trigger PTSD include elder abuse, rape, serious
illness, surgery, severe accidents like plane or car crashes, natural disasters, and
terrorist attacks.
PTSD is relatively common in elderly patients. It is more prevalent in patients with
cancer, people who’ve just had heart surgery, war veterans, and Holocaust survivors.
Symptoms of PTSD in adults are similar to that of children. These can be classified
into three cardinal symptom categories. The first category includes symptoms that
show that the patient is re-experiencing the traumatic event. These symptoms include
distressing recollections or flashbacks, and nightmares. The second category involves
avoidance or numbing. The patient avoids conversations, places, activities and people
that remind him or her of the trauma. He or she also gets a feeling of hopelessness.
Some patients develop selective amnesia. The last category involves increased
arousal. The symptoms in this category include irritability, hypervigilance, sleep
disorders, and exaggerated startled response. PTSD is a treatable condition. If left
untreated, PTSD is disabling in 50% of cases. The usual treatment employed is a
combination of medications like antidepressants and psychotherapy like cognitive
therapy, a form of interactive counseling.
Causes of PTSD :
Witnessing or experiencing a traumatic event is the trigger that can cause PTSD in
some people. Traumatic events that may trigger the development of PTSD in include:

combat or military exposure

childhood sexual or physical abuse

physical or emotional abuse as an adult

sexual assault or other violent crime

terrorist attacks

car accidents

plane crashes

natural disasters (e.g. fire, hurricane, earthquake)

life-threatening illness

death of loved one

loss….
While it is clear that these events can trigger PTSD, and witnessing or
experiencing such an event is required to develop the disorder, this does not
explain why some people who experience such events develop PTSD while others
do not. Psychologists believe that several factors probably interact to cause the
disorder. In addition to witnessing or experiencing a traumatic event, other factors
that determine whether a person develops PTSD likely include genetic factors,
previous life experiences, natural temperament and ability to cope with stress, and
levels of chemical signals in the brain called neurotransmitters. Researchers are
still trying to understand what role each of these factors plays in the development
Theory of PTSD :
There is no single theory which explains causality of PTSD. A wide range of both
psychological and biological non-mutually exclusive theoretical explanations
have been proposed. It is possible that theories significantly causal for an
individual might not be the same for another. Thus a summary of the various
psychological processes implicated has been provided herewith.
Biological

The amygdala is a key brain structure implicated in PTSD. Research has
shown that exposure to traumatic stimuli can lead to fear conditioning with
resultant activation of the amygdala and associated structures such as the
hypothalamus, locus ceruleus, periagueductal gray, and parabrachial
nucleus. The activation and the accompanying autonomic neurotransmitter
and endocrine activity produce many of the symptoms of PTSD.

The orbitofrontal cortex exerts an inhibiting effect on this activation. The
hippocampus also may have a modulating effect on the amygdala.
However, in people who develop PTSD, orbitofrontal cortex appears less
capable of inhibiting this activation.
Fear Conditioning
Mowrer's two factor conditioning theory suggests that:
The intensity of the traumatic incident is such that stimuli that were present at the
time of the trauma (unconditioned stimulus) become associated with fear and arousal
symptoms - An example of classical (Pavlovian) conditioning. Henceforth similar
stimuli (now conditioned) trigger responses as if the trauma was recurring. Through
stimulus generalization, a wide variety of stimulus bearing the slightest or even no
resemblance to the actual traumatic stimuli become triggers of distress. Thus for
obvious reasons the person tries to avoid all the distressing stimuli in the immediate
and remote environment. Although it provides less distress, it is this avoidance
behavior that maintains and reinforces the deep seated fear, preventing extinction and
thus maintains the problem which we clinically elicit as PTSD.
Appraisals of the Traumatic Event
A similar traumatic experience might have different personal meanings for different
people. Some are able to see trauma as a time limited terrible experience that does not
necessarily have negative implications for the future. Unlike these people who are
likely to recover quickly, those with persistent PTSD are characterized by excessively
negative appraisals of the event. The nature of predominant emotional responses in
PTSD depend on the particular appraisals, for example, appraisals concerning:
danger lead to fear - no where is safe
others violating personal rules lead to anger - others have not treated me fairly
responsibility for the traumatic event lead to guilt or shame - it was my fault, I did
something despicable
loss leads to sadness - my life will never be the same again
In addition to appraisal of the traumatic event itself, negative appraisals of the initial
PTSD symptoms - I am going mad; as well as perceived negative responses from
other people - I have fallen down in their eyes; in the aftermath of trauma has often
been found to distinguish between traumatized individuals with or without PTSD.
Nature of Trauma Memories
It has been seen that PTSD patients have poor intentional recall of the traumatic
event. Narratives which were initially fragmented and disorganized become elaborate
and organized with successful treatment. This has led to the hypothesis that
insufficient elaboration of the event and its meaning leads to the re-experiencing
symptoms of PTSD. Ehlers and Clark thus proposed that the trauma memory is
inadequately linked to its context in time, place and other autobiographical memories,
hence even remotely similar stimuli can trigger of vivid memories and strong
emotional responses, as if the event was happening right then.
Maintaining Behaviors
The course of PTSD often depends on the presence or absence of certain maintaining
behaviors. Those with prolonged symptoms are seen to have either some or all of the
following:

Avoidance of reminders

Suppression of thoughts and memories connected to the event

Rumination

Safety behaviors

Dissociation

Use of alcohol or drugs
These behaviors and cognitive strategies maintain PTSD in three
ways:
Some behaviors directly lead to increase in symptoms e.g. thought suppression leads
to paradoxical increase in intrusion frequency. Other behaviors prevent changes in
the problematic appraisal e.g. safety behaviors like not going outdoors after being
assaulted might prevent change in the belief that one will be assaulted again if one
goes out of the house. Others prevent elaboration of the trauma memory e.g. after a
road traffic accident, avoiding thoughts about the same prevents the survivor from
incorporating the fact that he did not die, and thus he keeps re-experiencing the fear of
dying which he originally felt during the accident.
These are some of the psychological processes that have a causal and maintaining role
in PTSD symptoms. The enumeration is far from exhaustive. It must be borne in mind
that different combinations of theoretical models might be involved in different
individuals. As intervention needs to be individualized and often depends on the
precipitating and maintaining factors, care should be exercised in identification of the
same of PTSD.
Diagnosis of PTSD :
A doctor or mental health professional diagnoses PTSD based on the symptoms
described by the patient. Your doctor or mental health professional will perform a
thorough psychological evaluation, asking you to describe the symptoms you are
experiencing, when and how often they occur, and how intense they are. He or she
may also ask you about the traumatic event that triggered your symptoms. You may
also be given a physical examination to rule out other medical problems. In order to
be officially diagnosed with PTSD, you must meet certain criteria laid out in
Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the
American Psychiatric Association. The criteria for diagnosis with PTSD are:
You experienced or witnessed a traumatic event which involved death or serious
injury (or the threat of same), or a threat to the physical integrity of oneself
or others

Your response to the event involved intense fear, helplessness, or horror (or
in children: disorganized or agitated behavior).

You persistently re-experience the event in one of the following ways:

recurrent distressing thoughts, perceptions, or images of the event

recurrent distressing dreams of the event

Feeling as if the event were happening again through hallucinations or
dissociate episodes (flashbacks)

Intense psychological distress or physical stress reaction upon exposure
to things that remind you of the event

You attempt to avoid situations, people, or things that remind you of the
traumatic event or feel a sense of emotional numbness

You have persistent symptoms of increased arousal (not present before the
trauma), such as feeling “on edge” or hyper-vigilant for signs of danger,
which may cause difficulty sleeping, irritability, or problems concentrating.

Your symptoms last longer than one month

Your symptoms cause significant distress or impairment in social situations,
work, or other important areas of functioning.
Sign and Symptoms :
In most cases, the first symptoms of PTSD occur in the first three months after a
traumatic event, but in a small number of cases symptoms may not arise until years
later. Common symptoms experienced by those with PTSD include:

flashbacks, or reliving the traumatic event

nightmares about the event

uncontrollable scary thoughts

avoidance of things that remind you of the event

feelings of worry, sadness, or isolation

feeling shame or guilt about the event

difficulty sleeping

trouble with concentration or memory

feeling “on edge”

irritability or angry outbursts

thoughts of hurting yourself or others

problems with relationships

self-destructive behavior, such as drinking too much

feeling emotionally numb

feelings of hopelessness about the future

being easily startled or frightened
The symptoms may be constant or they may tend to come and go. Symptoms are often
intensified during periods of life stress or when something reminds you of the
traumatic event.
Risky people :
While any traumatic event can cause PTSD, certain events are more likely to cause
the disorder in those who experience them. PTSD is especially common among those
who have served in combat, where is it sometimes called “shell shock.” Other events
with a high potential for causing PTSD include seeing someone killed or seriously
injured, living through a major natural disaster, and experiencing a life
threatening accident. While there are several factors that determine if a person will
develop PTSD, some of which are yet to be elucidated, certain factors can increase the
likelihood that you will develop PTSD subsequent to experiencing a traumatic event.
Factors Impacting the Development of PTSD
PRE-EVENT FACTORS

Previous exposure to severe trauma or early childhood victimization

Family Instability

history of psychiatric disorder, numerous childhood separations, economic
problems, family violence

Early Depression or Anxiety

Early Substance Abuse

Absence of social support during difficult times

Ineffective Coping

Gender: women twice as likely than men to develop PTSD

Age: adults under age of 25 are twice as likely to develop PTSD

Genetics: some families less able to withstand trauma than others
EVENT FACTORS

Geographical closeness to the event

Amount of exposure to the event/trauma

Duration of the trauma

The event’s meaning to the victim

The existence of a continuous threat that the trauma will continue (i.e. war)

Age: victim being young at the time of event
POST-EVENT FACTORS

Absence of good social support

Not being able to do something about what happened

Indulging in self-pity while neglecting one’s own self-care

Inability to find some meaning in the suffering

Developing Acute Stress Disorder

Experiencing immediate reaction shortly after the traumatic event:

physiological arousal, avoidant or numbing symptoms.
Factors Impacting Ability to Cope with Trauma

High extroversion (seek out others)

Openness

Conscientious in working toward goals

Agreeableness (ability to get along with others)

Motivation

Optimism

Successful resolution of other crises

Internal Locus of Control

Belief that control of what happens lies within you, not with sources outside of
you

Self-Efficacy

Sense of confidence in one’s own coping ability

Coherence

Recognizing that even significant traumatic events are understandable,
manageable, meaningful
Sociocultural effect of PTSD
If you think that emotional damages to a person can’t do anything alarming, you’re
wrong. Post-traumatic stress disorder may seem to be a petty emotional problem but
it’s not. It is definitely more than that. It is more dangerous than that. In fact, it can be
fatal.
Emotions are complex. These are caused by many processes in the body and are
triggered by what happens around us. Every emotion has a corresponding
physiological manifestation. Every emotion is powerful. Every emotion can be potent
enough to lead to many destructive and harmful behaviors.
People suffering from PTSD find themselves overpowered by their emotions. They
find it difficult to cope with the environment and deal with the problem. Moving on is
a very distant thing almost impossible to reach. The disorder’s symptoms are enough
to disrupt the normal healthy life of the patient. These symptoms include physical,
mental, social, behavioral and emotional changes. One of these emotions is intense
fear.
Fear may be just an emotion. However, when intense fear is accompanied by sadness,
guilt, helplessness, hopelessness, and anger, the human mind tends to resort to things
that common people find irrational and useless. For people with PTSD, alcohol abuse
is one of the most usual approaches in coping with the condition. The feelings of
desolation, sadness, guilt, hopelessness make them want to just drown the trauma with
alcohol. It is one of the easiest ways to forget about the event temporarily. Alcohol
abuse in itself can lead to major health damages and problems with the patient’s
relationships with the people around him or her.
Some PTSD patients resort to drug abuse. Obviously, illegal drugs come with a
variety of adverse effects to the body. However, drug abuse is seen by some patients
as one easy way to forget. Drug addiction is not an easy thing to go through. It can
harm several organ systems in the body. It also affects the people close to the patient.
In some cases, eating disorders emerge. Depression is also considered both an effect
and a symptom of the disorder. But the most alarming effect of PTSD is having
suicidal thoughts and actions. The patient has lost control of his or her life to the
haunting trauma. To a patient, ending his or her life seems reasonable because he or
she cannot see any sense in living since the trauma has taken control of his or her life
Treatment:
Treatment for PTSD includes medications, psychotherapy, or a combination of the
two. Combined treatment can help improve symptoms and improve your ability to
cope with your intrusive thoughts and feelings about the traumatic event. Several
types of medications can help improve the symptoms of PTSD. These include:
Antidepressants: Two classes of antidepressants can be helpful for people with
PTSD, selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac)
and sertraline (Zoloft) and tricylic antidepressants such as amitriptyline (Elavil).
These medications can help symptoms of depression and some symptoms of
anxiety. They may also help sleep problems and improve your concentration.
Anti-anxiety Medications: These medications may also be able to relieve
some of the feelings of anxiety and stress that can occur with PTSD. Anti-anxiety
medications include the class of drugs called benzodiazepines such as diazepam
(Valium) and alprazolam (Xanax) as well as other drugs such as buspirone
(Buspar). These are usually used for short term treatment since they have an
addictive potential.
Beta-blockers: These drugs are used mainly to reduce the physical symptoms of
anxiety such as heart palpitations, sweating, and trembling. They work by lowering
blood pressure and slowing the heartbeat.
Other Drugs: Some other drugs that may help the symptoms of PTSD include
mood-stabilizers such as lithium carbonate and carbemazepine. The anti-psychotic
drug risperidone may help with dissociation (flashbacks) and aggression.
Psychotherapy is a very effective way to help improve the symptoms of PTSD. It can
help you learn ways to cope with the scary feelings that arise and help you explore the
reasons that underlie those feelings. Psychotherapy can take several forms but all of
them involve talking about your fears and emotions with a trained therapist. The form
that is best for you depends on your symptoms and situation. Another option is group
therapy, which can offer a way to connect to others going through similar
experiences. Some of the main types of therapy used to treat PTSD include:
Cognitive Therapy: This type of therapy helps you understand and change
how you think about your trauma and its aftermath. Your therapist can help you
learn to replace the scary thoughts with more realistic, less distressing thoughts and
can help you learn ways to cope with your fears.
Eye movement desensitization and reprocessing (EMDR): This type
of treatment can help change how you react to memories of your trauma. It
involves talking about your distressing memories while at the same time following
the finger of your therapist with your eyes. While the reasons are still unknown,
this technique appears to help decrease the symptoms of PTSD.
Exposure Therapy: This type of therapy is based on the premise that fear is a
learned association, which explains why things that remind you of the trauma also
recall feelings of fear like you experienced during the event. By talking about your
trauma repeatedly with a therapist you can learn to associate thoughts about the
trauma with other things besides fear, eventually allowing you to stop being afraid
of your memories.
Brief psychodynamic psychotherapy: This type of therapy helps you learn
ways of dealing with emotional conflicts caused by your trauma. Your therapist
helps you become more aware of your thoughts and feelings, so you can change
your reactions to them.
Many people who develop PTSD get better, but about one third of people with PTSD
may continue to have some symptoms for long periods. However, even if you
continue to have symptoms, treatment can help you cope with those symptoms and
make them less intrusive.
Prevention of PTSD :
Avoiding traumatic experiences is a sure-fire way to prevent PTSD. However, since
there is no reliable way to avoid trauma in your life, the best way to prevent PTSD is
to deal with a trauma when and if it does occur. A common reaction to experiencing
trauma is to bottle it up and not talk about it with anyone. However, the best way to
avoid PTSD or limit its effects is to reach out for help. This may mean relying on
family and friends for their support or it may mean seeking out a mental health
professional for therapy or even for a brief chat. You can also talk with other trusted
people in your life such as clergy or a sobriety sponsor. Whoever you chose to talk
with, research shows that talking about your experience can help prevent your
feelings from spiraling out of control and becoming PTSD. Getting support may also
help prevent you from turning to unhealthy coping methods, such as a drug abuse.
NURSING PRIORITIES
1. Provide safety for client/others.
2. Assist client to enhance self-esteem and regain
sense of control over
feelings/actions.
3. Encourage development of assertive, not aggressive, behaviors.
4. Promote understanding that the outcome of the present situation can be
significantly affected by own
actions.
5. Assist client/family to learn healthy ways to deal with/realistically adapt to
changes and events that have occurred.
Patient-Family Education
When a family member is diagnosed with PTSD, the entire family may be effected.
Members may experience shock, fear, anger, and pain because of their concern for the
victim. Living with family members who have PTSD does not cause PTSD. Yet, it
can cause similar symptoms such as feelings of alienation from and anger towards the
victim. Other family members may find it hard to communicate with a person with
PTSD. Sleep disturbances and abuse (physical and substance) may occur among
family members.
What clients with PTSD Need to Know

Important to emphasize that she/he is having these symptoms because of what
happened to her and Not because of anything about her

PTSD symptoms are normal, common human reactions to extreme stress after
experiencing a highly traumatic event

Trauma associated w/PTSD does not cause or produce serious mental illness

PTSD is treatable

PTSD is learned.
PTSD is acquired according to psychological learning
principles. It is not a disease.

Since PTSD is learned, it can be unlearned. Although we cannot change what
happened to you, we may be able to change the way you interpret what
happened to you.
PTSD Summary

After a person experiences a traumatic event that involves an actual or
perceived threat of death or injury, they may develop Post Traumatic Stress
Disorder (PTSD).
PTSD is the most common mental health disability
affecting troops who have served in combat.
Symptoms of PTSD include:

re-experiencing of the traumatic event, often through flashbacks or
nightmares;

avoidance of anything associated with the trauma and numbing of emotions;
and

difficulty sleeping and concentrating, and irritability.

PTSD can develop at any time after exposure to a traumatic event.
For
veterans, it often emerges several months after return to civilian life.
Prevalence

Because neither the Department of Defense nor the VA adequately diagnose
or effectively track PTSD in veterans, precise statistics on the prevalence of
PTSD in OEF/OIF veterans are not available.
However, current studies
estimate that the prevalence of PTSD among returning veterans ranges from
15% to 50%.

Because PTSD can take months or years to manifest, and because many troops
are subjected to multiple deployments and the worsening violence in Iraq and
Afghanistan, rates of PTSD will continue to rise.
Consequences

PTSD is a serious and specific diagnosis, but it can vary greatly in its severity.
In severe cases, it can lead to addiction, anti-social behavior or suicide.

Troops who have served in Iraq and Afghanistan are killing themselves at
higher percentages than in any other war where such figures have been
tracked.

Many factors can impact the extent of the reaction to a traumatic event. These
include the amount of death and devastation witnessed, and the degree of
responsibility felt for not preventing the event. Other factors include gender,
age and race.
Treatment

Types of treatment include: individual psychotherapy, behavioral or cognitive
behavioral therapy (CBT), eye movement desensitization and reprocessing
(EMDR), group therapy, and medication.

Early treatment is more likely to be effective, and can help avoid a decline into
alcoholism or other destructive behavior.
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