September 16, 2014
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Post-traumatic stress disorder

Janet had been off work for 2 months by the time I saw her. Her family and co-workers said she had changed. She had become distracted and forgetful, she stopped looking after her appearance and now she avoided all the social activities she once loved. She used to laugh and cry. She would stage elaborate practical jokes or sometimes get outrageously angry - at least for a little while. But not anymore - now she's like a zombie.

During the assessment it came out that she was having problems with sleep; horrible nightmares awakened her. She preferred to stay home, finding that many situations provoked fear. She now felt few emotions beyond her free-floating anxiety. Events that once caused her to experience strong feelings - such as the birth of a baby or death of a friend, left her feeling numb. It wasn't until late in the diagnostic assessment that the source of Janet's problem was revealed.

Post-traumatic stress disorder (PTSD) is a disabling condition due to changes in chemistry and function of certain parts of the brain, triggered by a life-threatening event. Not everyone is equally prone to develop PTSD. About 30% of soldiers returning from active combat experience symptoms. At any time it is estimated that 4% of North Americans suffer from this disorder. Since the horrors of September 11, the prevalence of PTSD is likely much higher, especially in New York. The condition might onset immediately but usually it's after a period of weeks to months and it can last for years. There is effective treatment.

Diagnostic Symptoms

Like many popular diagnoses, such as ADHD or fibromyalgia, critics have stated PTSD is overdiagnosed; used as an excuse by some, looking for compensation, or a way to build clientele for some therapists. When this condition truly exists it is dramatic and disabling. In order to make the diagnosis the following criteria must have been present for at least a month and be serious enough to interfere with one's daily life.

The sufferer:

  • experienced or witnessed a life threatening event that caused them at the time to feel intense fear, helplessness or horror
  • re-experiences the event as distressing memories, dreams or flashbacks in which the event is relived and situations that remind them of the event trigger emotional distress and/or physical symptoms
  • avoids reminders of the event, such as conversations, thoughts, situations
  • detaches from feelings or becomes numb, forgetting parts of the event, losing interest in significant parts of life, experiencing a decreased range of emotions, feeling detached from other people. They no longer plan for or have expectations about the future.
  • experiences sleep problems, outbursts of irritability and anger, an exaggerated startle response, has difficulty concentrating, feels hypervigilant or always on guard.

Brain Changes

Brain research has shown there are lesions in several areas of the brain with PTSD. The amygdala, responsible for extreme emotions such as rage and intense fear shows altered function. The hippocampus, active in learning and memory, is altered and the locus ceruleus and NMDA receptors, responsible for adrenaline-like responses of anxiety, startle, and fight-flight - become overly active. The endorphin system becomes impaired and the serotonergic systems that regulate sleep, avoid depression and modulate appetite are also altered.

PTSD is a condition that is biological: with significant brain changes, psychological: caused by and resulting in changes in thinking and feeling, and social: resulting in isolation and avoidance to relieve acute symptoms yet perpetuating the condition. Not surprisingly, the most effective treatments combine biological or pharmacological treatment with psychological and social therapies.

Treatment

For many people PTSD eventually goes away by itself as they intuitively learn ways to deal with their symptoms. There is good evidence, however, that certain medications and forms of psychotherapy will significantly shorten the course of the illness. Based upon clinical trials using the antidepressant, sertraline, it appears that selective serotonin reuptake inhibitors (SSRI's), such as Prozac® (fluoxetine), Paxil® (paroxetine), Zoloft® (sertraline), and Celexa® (citalopram) are twice as effective as placebo in reducing symptoms and increasing function in people with PTSD. Cognitive behavioural therapy, in which the psychotherapist helps the sufferer correct distorted and disturbing thoughts, has been proven to be effective. The other proven treatment is called exposure therapy, in which the sufferer gradually experiences situations more and more like the triggering event, much like the process of building immunity with allergy shots, so that the power to trigger negative emotional reactions is removed from these stimuli.

There are also more controversial treatments with less convincing evidence. These include critical incident debriefing, where counselors interview disaster survivors and encourage them to talk about their experience, validate their feelings and help them cope with it. Although people who talk about the experience are shown less likely to suffer PTSD, it is less clear that this type of therapy reduces future incidence of the disorder. EMDR is a technique in which the client initiates active eye movements while being encouraged to think and speak about certain things related to the event. Like many other psychological treatments, it is difficult to separate the effects of one part of the therapy from others. Repeatedly research has shown that for many psychiatric conditions, the type of therapy used is unimportant; psychiatric disorders respond better to any type of counselling than to no therapy at all. For EMDR the evidence is equivocal and the jury is still out.

Other helpful therapies for the person recovering from PTSD include instruction and practice at relaxation, breathing and meditation.

So, back to Janet. A tear slid down her cheek as she reluctantly described the rape. While it was happening she thought she was going to be killed. But since then, it was as if part of her had died.

That was two years ago. Now Janet is pretty much back to her old self. She still goes to her support group, as much to support the newcomers as to reinforce her new skills. If you asked her if she's cured she'd probably say something like, "I'll never be the same person I was, but with the skills I've learned and the growth I've experienced, in some ways I'm better".

I love my job.



Dr. Ray Baker is Assistant Clinical Professor in the Faculty of Medicine at the University of British Columbia. He has been awarded fellowships in both Family Medicine and Addiction Medicine. He has been a practicing physician for over 23 years. From 1993 to 1997 he represented Canada on the Board of Directors of the American Society of Addiction Medicine, North America's credentialing body in this specialized area of medicine. His area of special clinical expertise is in assessment and treatment planning of the worker disabled by one of the "invisible disabilities", stress, depression, chronic pain syndrome or substance use disorder.

Dr. Ray Baker, BSc (Hon), MD FCFP, FASAM

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