Posttraumatic Stress Disorder

Abstract
Posttraumatic stress disorder is a common and disabling disorder that develops as a consequence of traumatic events and is characterized by distressing re-experiencing portions of the trauma, avoidance of reminders, emotional numbing and hyper-arousal. In spite of the deleterious impact of PTSD within the U.S. military, our current understanding of the human pathophysiology governing the divergent paths associated with extreme stress response the remains unabated. Given the widespread phenomenon of ‘trauma’, it begs the question of whether or not preexisting features accompany some suffers who have developed PTSD and why others may or may not face the same effect. Much research has been conducted in this arena and it seems that no one researcher has a definitive cause, much less a standardized treatment approach for PTSD sufferers. Posttraumatic Stress Disorder Posttraumatic stress disorder (PTSD) develops as a consequence of traumatic events such as interpersonal violence, disaster, severe accidents, or other life-threatening experiences. The most common characteristics of PTSD are the re-experiencing of symptoms linked to a specific event. Patients involuntary re-experience aspects of the traumatic event in a very vivid and distressing way. This includes: flashbacks, in which the person acts or feels as if the event were recurring, nightmares, intrusive images or other sensory impressions from the event. For example, one soldier witnesses another, mortally wounded during a bombing. Consequently this survivor continues hearing the sound of the explosion and unwillingly relives the memories of the horrific encounter over and over.
Patients who suffer from PTSD display periods of both hyperarousal and numbing. Avoidance of situations, stimulus or reminders linked with the event is quite common. The patients’ emotional state can range from feelings of intense fear, anger, sadness or guilt, to shame and emotional numbness. Social and occupational functioning is often severely impaired with PTSD. These considerations present a significant burden not only to the individual but society at large (Bailey, 2013). If PTSD remains untreated, secondary problems such as depression, substance abuse, and social isolation may transpire.
Introduction
According to the DSM-IV-TR (APA, 2000), posttraumatic stress disorder is caused by situations in which a person “experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others” which provoked a response that “involved intense fear, helplessness or horror.” While anyone in the general population has the potential to have an experience that would qualify as traumatic, the likelihood of developing PTSD increases when the traumatic event involves danger or violence from other people. Events, such as those, are likely to occur during wartime experiences (Yehuda & LeDoux, 2007). Specific to the inherent dangers found on the battlefield, the development of PTSD is a momentous risk for combat veterans. Unprecedented when compared to the civilian population.
Incidence and Exposure Since 2001, over 1.6 million U.S. troops have served in the Afghanistan or Iraqi conflicts during both Operation Enduring Freedom and Operation Iraqi Freedom (Angkaw, 2013). As of November 17, 2011, 6,320 service members were killed in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) (Belasco, 2011). An estimated 50,000 to 100,000 service members were known to have experienced non mortal wounds and injuries during deployment in the theater of operations for OIF/OEF. The number of those injured during military service is staggering; with an unprecedented number of injured U.S. service members returning home in contrast to previous military actions (Gibson, 2012). Figures vary widely when attempting to establish an accurate illustration of the number of those affected by PTSD. Within the military population, the most agreed upon statistical findings reveal prevalence rates outside combat settings are 6 percent in males and 12 percent in females (Kessler, 2005). Kessler et al. examined the prevalence of PTSD related to combat and found that Vietnam era estimates were between 2 and 17 percent. Studies from OIF/OEF suggest combat-related PTSD has effected between 4 and 17 percent of veterans. While debate surrounds the figures for those, who have served multiple combat tours, it is believed that as many as 50% have PTSD or are likely to develop PTSD later in life. This drastic increase is proposed on the basis of prolonged exposure and the probability of encountering conditions that qualify as distressing or traumatic events that occur outside the realm of normal trauma.
Clinical Considerations PTSD related to any war throughout history has outstretched conventional wisdom and hindered effective treatment approaches. Regardless of advancements in neuropsychology pathology, behavioral psychology and any other mental health-related discipline, a visible gap remains between the evidence-based treatment methodologies and treatment approaches tailored for military personnel with adult-onset trauma, from an intersubjective perspective. One aspect hindering progress in this area is the ambiguity of the term “trauma” and idiosyncratic efforts to quantify an intangible subject. The fact remains, however, that something which enumerates as traumatic for one individual may not for another. Furthermore, in modern warfare it is impossible to determine or forecast who may or may not experience such trauma. Lastly, the magnitude of the traumatic event remains unseen. Hence, it remains unknown until the specific characteristics of the event translate into a traumatic moment for that person.
Psychological Dimensions
Supporting Boulanger and other similar views (Boulanger, 2007) adult-onset trauma must be explored inversely from the traditional psychoanalytic conceptualizations of childhood experiences. Providing distinction for adults, especially those personified by a military culture as being at a greater risk for co-morbid psychological and psychosocial conditions. These conditions can include: self-medicating in the form of alcohol or drug misuse, chronic depressive states and increasingly risky behaviors. This demographic portrays a complex picture of suffers, segregated by societal misunderstandings, with expressed guilt for surviving while their comrade did not - perishing on the battlefield. Also, there are mixed emotions that are unique to those who have perpetrated violent acts toward others, as they tend to struggle with balancing personal morality and moral authority (the concept of just cause.) Amidst these steep convolutions of the traumas met in a combat setting, many firmly contend that trauma is necessary. However, trauma, alone, is not sufficient cause for developing PTSD. Rather, it is a multifaceted play between nature and nurture, supported by evidence obtained from various twin studies (Kendler et al, 1993). Even Freud rejected, his, once personal proposition that suggested traumatic events, in itself, is not enough to cause significant emotional disturbances. Instead, Freud later suggests that persistent trauma reactions are a result of repressed internal conflicts (Jaycox & Foa, 1998).
When succeeding a psychodynamic perspective, one must consider the deeper constructs that underlie the meaning sufferers attribute to their event and the role they played in it. Prior to attending to this segment of society, it’s relevant to reiterate the uncertain psychological outcomes related to trauma, and how the psychosomatic nature of PTSD highlights this discrepancy between one’s internal information and the external environment. Further escalating the difficulty for the provider as they attempt to sort through the depths of traumatic encounters and identify the source propagating the internal debate and external indicators. Meanwhile continuing to recognize and address the condition in its entirety.
Disorder Cause and Effects
Normal, non-psychopathic people are reluctant to harm others and even though many soldiers are trained to accomplish military missions at any cost – the killing of enemy combatants – remains uncharacteristic of normal human behavior. To contest this dilemma the military has pioneered techniques to illicit desensitization and manipulate morality. Normal emotional response patterns consist of behaviors that deal with particular situations and the physiological responses (both autonomic and hormonal) associated to these events. To fully appreciate the intricate nature of combat stress, it is important to note: as the threat of imminent danger looms around the clock, so does the involuntary activation of the nervous system. The intensity and nature of this stimulus provokes a number of neurobiological systems. Most are mediated by simultaneous activation of the sympathetic nervous system and decreased function of the parasympathetic nervous system. Military personnel are exceedingly accomplished at developing psychological adaptations necessary to withstand, cope and function in any setting. When exposed to stress, soldiers undergo a coordinated series of psychological changes to prepare them for action. The manifestations of these changes include: increased heart rate, dilation of pupils, relaxation of lungs, increased blood sugar levels, and decreased propulsion within the digestive system. In time, individuals learn to adapt to particular stressors. Also known as stress resistance, the individual acquires an unconventional callousness to normal stressors and normal biological chain reaction stress responses. The degree of resistance is correlated to the individual’s personality and environmental factors.
Adaptation to extreme stressors is a dynamic process determined by the development of defensive strategies. Beginning the first day of military enlistment, each armed forces member is subjected to relentless training for this very reason. As units prepare for deployment, they forgo training with greater levels of stress aimed to pre-condition the body and mind. By now, behavior modification is explicitly designed to cause the individual to respond very methodical to conditioned stimulus. Normal psychological characteristics that would otherwise impair almost everyone have little effect on these elite groups. They carry out complex tasks in spite of the intense physiological response of the body. This habitation is a necessary evil. It’s necessary for survival. However, this adaptation is a short-term solution intended to distort the reality of a situation until the situation is no longer present. Prolonged exposure affords new challenges – unlearning one set of emotional response patterns and behaviors for another.
Treatment
Existing assessment methods are becoming more effective in the areas of identifying the severity of symptoms and variations of PTSD categories. While discriminating from other psychiatric disorders, clinicians should note each sign or symptom, possible causes, and formulate a working diagnosis. Available working diagnosis include: normal stress responses, acute stress responses, uncomplicated PTSD, PTSD with comorbid disorder and posttraumatic identity disorder (complex PTSD). Effective treatment hinges on an accurate assessment and diagnosis. Several pharmacological and psychological-based approaches are available; offering patients and therapists a collection of management options (Wisco, 2012). U.S.-based guidelines for PTSD recommend a combined tactic of trauma-focused cognitive approaches, including: cognitive behavioral therapy (CBT); exposure therapy, eye movement desensitization and reprocessing (EMDR), as first-line measures.
Medications are available considerations; however not as a substitution for focused therapy. Implementation of medications may be indicated if the patient does not respond to psychological treatments or lives under serious current threat of further trauma. Medications recommended for adults with PTSD include: selective serotonin reuptake inhibitors (SSRIs) or selective noradrenaline (norepinephrine) reuptake inhibitors (SNRIs); among many others.
One research effort yielded favorable outcomes by using a form of exposure therapy through the use of virtual reality (VR). Previous VR has been used to facilitate treatment of specific phobias and recently has emerged as treatment for PTSD (Mclay, 2011). This author theorized VR exposure would have greater improvements in anxiety levels than treatment with imaginal exposure alone.
Treatment Challenges Many veterans seeking treatment for PTSD have coinciding medical conditions; specifically debilitating physical injuries and chronic pain. As a result, management of both PTSD and medical conditions such as chronic pain has been challenging for both primary care providers and psychiatrists. Management of such patients truly requires a multidisciplinary approach because of the higher rates of morbidity and premature mortality compared to the general population. Significant challenges present to psychiatrists while treating patients with comorbid medical conditions. Psychiatrists have the greatest level of responsibility for medical conditions that may be the result of an action taken by the psychiatrist, such as the development of diabetes in a patient who is receiving antipsychotic medications. Therefore, the psychiatrist is obligated to be aware of the medical risks of psychiatric drugs. Likewise, psychiatrists are responsible and must be aware of any treatments that may potentially exacerbate the psychiatric condition they are treating, and they have a duty to ensure that these medical conditions are being addressed properly.
Other challenges providers face is tied to the stigma associated with PTSD as a “mental illness.” Active duty personnel may be concerned that a PTSD diagnosis will interfere with their work or result in a medical discharge from the military. Veterans may also be concerned about their ability to return to service in the future. Such service members may not seek treatment or may be motivated to conceal or minimize the severity of their symptoms to clinicians. Factors associated with perceived stigma include: negative beliefs about mental health treatment and lower levels of perceived [military] unit support (Wisco, 2012).
Conclusion
The effect of war on the physical and emotional health of return service members has been personally witnessed by family members and health care providers. Much has been learned about PTSD over the years from the generations of war veterans. Those involved in the treatment of PTSD and other associated conditions are constantly challenged to come up with new innovated approaches that enhance the overall well-being of those they care for. Today, health care professionals are more versed in the considerable burdens that PTSD and other medical conditions placed on veterans. It is well understood that individuals with untreated PTSD and other mental health problems will unnecessarily suffer and struggle in their everyday life. In summary, several well validated approaches regarding PTSD screening and diagnostic measures now exist. Evidence based treatments that have proven effective in the areas of pharmacological and psychological treatments for PTSD are available. Despite these promising advances, a good number of veterans or active duty members are still not receiving these evidence-based assessments and treatment approaches. Moving forward, efforts should focus on effective dissemination of these proven methods into the hands of as many clinicians as possible so they can deliver them effectively to the military population they may find themselves treating.

References
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