Posttraumatic Stress Disorder (PTSD)

Posttraumatic stress disorder (PTSD) is an anxiety disorder that occurs as a result of exposure to an extreme traumatic stressor involving the threat of death or serious injury. The threat may be experienced directly or may involve witnessing others at risk for death or injury. Some examples of traumatic events are sexual and physical assault, war experiences, imprisonment, car accidents, and natural disasters. Not everyone who experiences such an event develops PTSD, nor is PTSD the only possible reaction to stressful events. In the overall population, approximately 8% will have PTSD at some point in their lives. It is estimated that about 25% of those exposed to trauma go on to develop PTSD. The severity of the trauma is an important risk factor, as is having a previous history of traumatic events or other anxiety problems. For those who do develop PTSD subsequent to a stressor, symptoms manifest in three areas: re-experiencing the event, attempts at avoiding reminders of the event, and hyper-arousal of the nervous system.

Re-experiencing symptoms can include recurrent thoughts and images, dreams or nightmares, or “flashbacks” where one feels as if they are reliving the event. The person may become apprehensive or even try to avoid sleep because of the fear of having nightmares. Stimuli in the environment such as smells, sights or sounds that resemble some part of the trauma can “trigger” a re-experiencing of the trauma. This re-experiencing is different than a normal memory of some event in that it is much more vivid and intense, “as if” the person was back in the original trauma. Therefore, these re-living experiences are extremely distressing and the person may feel paralyzed and emotionally overwhelmed when they occur. This overwhelming feeling can lead to ongoing efforts at avoiding any reminders of the event.

Avoidance symptoms may manifest in not talking about what happened, not going near where the event happened or even near situations that are similar in some way to the trauma. Often, the person withdraws from others and can become very isolated and secluded in contrast with previous behavior. Those close to the person, like family members or friends are often confused and distressed by these severe changes in the person's behavior that seem to occur for no reason. Another aspect of avoidance is emotional numbing, where the person experiences numbness or emotional detachment in situations where they would normally have some emotional reaction. The PTSD sufferer can fluctuate between feeling detached, unemotional and numbed out at times, to being flooded with feelings and thus being very overwhelmed at other times.

Hyper-arousal symptoms may involve sleep difficulties, bouts of irritability, problems with attention and concentration, hyper-vigilance, and an increased startle response. In PTSD, the nervous system seems to be overwhelmed and over-aroused by trauma and so relaxation becomes very difficult. This hyper-arousal is often accompanied by scanning for signs of threat and becoming very vigilant to potential dangers in the outer world. Another aspect of the hyper-arousal is that the person becomes very sensitive to loud sounds or bright colors, essentially experiencing “stimulus overload” when there is too much going on at one time.

PTSD is considered when the symptoms have persisted for at least one month following the traumatic event. If someone experiences significant anxiety symptoms in the month immediately following the trauma they may be suffering from Acute Stress Disorder.

Acute Stress Disorder (ASD)

Acute Stress Disorder involves the more immediate response to a trauma and has both anxiety and dissociative symptoms. The person may experience emotional numbing, detachment, being in a daze, depersonalization, derealization, and/or amnesia for parts or all of the traumatic incident. Depersonalization involves a feeling of being unreal and detached or disconnected from one's self. In some cases this may manifest as an “out of body” experience. Derealization involves experiencing the outer world as somehow unreal or different. Anxiety and hyper-arousal symptoms may occur in sleep difficulties, irritability, impaired concentration, hyper-vigilance, increased startle response, or restlessness. If the symptoms persist beyond a month the possibility of PTSD needs to be considered.

Treatment of PTSD and ASD

Fortunately, PTSD and ASD are treatable with therapy. Early diagnosis is important and treatment is often briefer when the person is provided with help early on. If not given help, the person with PTSD can also develop other difficulties such as depression, substance abuse, or relationship difficulties. Medications can be helpful in alleviating some of the hyper-arousal and may be necessary if the person also has other difficulties like depression or panic disorder.

Treatment for PTSD has three phases where the hyper-arousal, re-experiencing symptoms, and avoidance behaviors are targeted sequentially with cognitive-behavioral therapy techniques. Relaxation training, Eye Movement Desensitization and Reprocessing (EMDR), and hypnotherapy can be useful therapies depending on the needs of the individual in the various stages of treatment.

Related Sites

National Centre for PTSD
http://www.ncptsd.va.gov

The International Society for Traumatic Stress Studies
http://www.istss.org

European Society for Traumatic Stress Studies
http://www.estss.org

PTSD Rating Scale for Therapists (AFRAID Scale)

Download the AFRAID Scale (pdf)

Fraser's “AFRAID” Scale Acronym for Posttraumatic Stress Disorder
Dr. George A. Fraser, FRCP(C), Ottawa Anxiety & Trauma Clinic

This is an acronym that is based on the DSM-IV (American Psychiatric Association, 1994) criteria for Posttraumatic Stress Disorder (PTSD).  The DSM-IV designates the six diagnostic categories required for the PTSD diagnosis by the letters A through F.   However only the A and F of the AFRAID acronym are used to correspond to the DSM-IV lettering.  The AFRAID acronym is an easy way for therapists to remember the six categories that must all be present in order to make the diagnosis of PTSD. Symptoms in DSM-IV are divided into three “Symptom Clusters”. The AFRAID Scale includes a Subject Units of Distress Scale (SUDS) from zero to 10 where 10 is severe distress and zero is no distress). This provides a measure of intensity of PTSD symptoms and can be used as a measure of response to therapy upon retesting.

The following explains what each letter of the acronym stands for:

A	The “A criterion” (DSM-IV) is the presence of a traumatic event and the accompanying fear, horror and helplessness. One can also think A as in 'Assault' or 'Accident' (i.e. A traumatic event).
F	Functioning.   There must be impairment in the person's current functioning as a result of the trauma. Coincidently, this is also the F criterion of PTSD in DSM-IV.
R	This refers to the Reexperiencing Symptom Cluster. There must be at least one symptom from this cluster.
A	This A stands for Avoidance/Numbing Symptom Cluster. There must be at least three symptoms from this cluster.
I	This stands for the Increased Arousal Symptom Cluster (Hyperarousal). There must be at least two symptoms from this cluster.
D	This stands for the Duration of symptoms. There must be four weeks of symptoms before the PTSD diagnosis can be applied. The D can also be a reminder of the less common onset of PTSD that may only be considered if symptoms begin six months or more after the traumatic event, i.e. Delayed onset PTSD.

A	A criterion (DSM-V) (assault, trauma, feeling helpless / terror
F	Functional impairment
R	Re-experiencing symptom cluster
A	Avoidance / Numbing symptom cluster
I	Increased Arousal symptom cluster
D	Duration (at least 30 days of symptoms)