Post-Traumatic Stress Disorder

WHAT IS POST-TRAUMATIC STRESS DISORDER?

Post-traumatic stress disorder (PTSD) is a problem that occurs after a person experiences a life-threatening event that makes him or her feel extremely frightened and vulnerable.¹ Such events include war, crime, rape, abuse, accidents, natural disasters like floods and earthquakes, and other potentially deadly and dangerous circumstances. However, the traumatic event doesn’t have to happen to the person directly for PTSD to develop. A person might develop the disorder after witnessing someone else in a life-threatening situation, or even after hearing about someone else’s tragedy.

Symptoms that begin immediately after a trauma or within the first month after a trauma are officially diagnosed as acute stress disorder.¹ If the symptoms persist for longer than one month, a diagnosis of PTSD would be made. Usually, symptoms of PTSD begin within three months of experiencing the trauma. However, it isn’t unusual to experience a delay of several months or even years before the symptoms begin.¹

The major symptoms of PTSD can be divided into three categories.¹ First, the traumatic event is reexperienced in some way after it has ended. This could mean that the person has vivid and frightening dreams about the event weeks or months after it takes place. Or throughout the day, the person may experience intrusive thoughts and memories about the event that he or she can’t get rid of or control. In severe cases, people might even feel as though they are once again reliving the event. Such experiences are called flashbacks. During a flashback, they might suddenly feel strange and unreal, like they are somewhere else. In addition, people might become extremely frightened or agitated when they’re in a situation similar to the traumatic event, or when they see or hear something that reminds them of the trauma. For example, if a woman experienced a traumatic event that involved gunshots, she might become frightened and have vivid memories of her trauma whenever she hears the sound of a car backfiring.

The second category of PTSD symptoms involves different kinds of avoidance behaviors caused by the trauma. For example, a person might stay away from the site where a traumatic event took place or avoid conversations and thoughts about the event. To friends and family members, it might even appear as if the person’s memory has blocked out all recall of the event. People struggling with PTSD might also find themselves avoiding objects, events, or people that made them happy before the traumatic event, or they might even experience a generalized numbing of their emotions.

The third category of PTSD symptoms includes various kinds of heightened anxiety. This could mean having trouble falling asleep, difficulty thinking and concentrating, a heightened sense of being on the alert for potential danger, or increased anger, agitation, and frustration. In addition, it’s also common for people with PTSD to think about death frequently, either their own death or other people’s deaths. For example, one client with PTSD remarked that she felt like she was living in “the land of the dead” more often than she felt alive.

ARE THERE OTHER PROBLEMS RELATED TO PTSD?

The 2005 U.S. National Comorbidity Survey Replication² observed that people with PTSD also struggle with other mental health problems, such as obsessive-compulsive disorder, depression, dysthymia, bipolar disorder, attention-deficit/hyperactivity disorder, and intermittent explosive disorder. In addition, the estimates of alcohol abuse among people with PTSD range from 16 to 68 percent.^3-5 This is much higher than the estimated rate of alcohol abuse in the general population, which is approximately 7 to 18 percent.⁶ In addition, men with PTSD are five times more likely than the general population to develop a drug abuse problem, and women with PTSD are almost two times more likely.⁷

Many people with PTSD frequently experience strong feelings of guilt, especially if they’ve survived a trauma in which someone else died.¹ In addition, people with PTSD sometimes experience chronic pain and poor physical health.^{8, 9}

WHO IS AFFECTED BY PTSD?

A 1996 report published by the World Health Organization and the Harvard School of Public Health¹⁰ stated that PTSD was the sixth most disabling mental health problem in the world, affecting approximately five million American adults every year.¹¹ It’s estimated that 70 percent of American adults will experience a severe traumatic event at some point in their lives,¹² and an estimated 14 to 25 percent of them will develop PTSD.¹³ For the overall population, this translates into approximately 4 percent of all adults developing PTSD every year,² and approximately 7 percent of all adults developing PTSD at some point in their lives.^{1, 14}

In general, women appear to develop the disorder twice as often as men.¹² However, according to the U.S. Department of Justice’s National Crime Victimization Survey,¹⁵ women are also more likely to be the victims of certain violent crimes. Women are ten times more likely than men to be the victims of rape and sexual assault, and six times more likely to have violence committed against them by a spouse or romantic partner.

Refugees are also particularly at risk for developing PTSD. It’s estimated that between 5 and 35 percent of the world’s refugees have been tortured,¹⁶ and some studies have found the rate of PTSD in torture survivors to be as high as almost 74 percent.¹⁷

WHAT CAUSES PTSD?

PTSD arises after experiencing a life-threatening situation, either directly or indirectly. People who experienced traumas earlier in life are at a greater risk for developing PTSD if they experience traumas later in life.¹⁸ In fact, children whose parents have PTSD are even at a greater risk for developing the disorder themselves, perhaps due to the levels of stress hormones in both the parents and their children.^{19, 20}

Research on the disorder strongly suggests that trauma causes physical changes in the brain. These changes include shrinkage in the area of the brain associated with certain kinds of memories, increased activation in the area responsible for emotional processing, and decreased activation in the area responsible for language processing.²¹

Research published in the British medical journal The Lancet suggests that PTSD might be the unfortunate result of a natural survival process.²² When a person experiences a traumatic event, his or her body releases adrenaline, which helps the person survive the traumatic event. However, the release of adrenaline also reinforces the memory of the trauma, and in the case of PTSD, those memories are frequently reactivated. Reports such as this have prompted research using beta-adrenergic blockers (beta-blockers) to inhibit symptoms of PTSD, and, so far, this research has been promising.²³

Similarly, a theory of PTSD published in the journal Behavior Therapy suggests that a person’s fear response system is broadly expanded after suffering a trauma to help the person avoid being traumatized again, thus causing general avoidance of anything slightly resembling the event.²⁴

Yet another theory suggests that the intrusive memories, flashbacks, and dreams associated with PTSD result from an inability to integrate the traumatic experience into a person’s belief system about the world.²⁵ Many people wonder why the traumatic event happened to them or to someone they love. But it might be this constant wondering why that leads to an inability to forget the event.

WHAT TREATMENTS ARE EFFECTIVE FOR PTSD?

Despite the devastating effects that PTSD can have on a person’s life, the 2005 U.S. National Comorbidity Survey Replication²⁶ suggested that many people with the disorder wait as long as twelve years before seeking treatment. This is unfortunate, considering that there are three very effective cognitive behavioral treatments for PTSD that have been supported by research; stress inoculation, exposure therapy, and cognitive processing therapy.^{27, 28} On average, 67 percent of the people who complete one of these treatments recover from the disorder.²⁹

Stress inoculation training is an effective treatment designed to teach a variety of coping skills to help manage the fears associated with the trauma.^{30, 31} Exposure therapy also helps build coping skills, but in addition, it incorporates imaginative and real-life exposures to feared situations in a safe, step-by-step process.^32-34 Cognitive processing therapy utilizes writing exercises to neutralize thoughts, feelings, and memories about the traumatic event.^{35, 36}

Other treatments have also been shown to help relieve at least some of the symptoms associated with PTSD. In particular, eye-movement desensitization and reprocessing,^{31, 37} brief psychodynamic therapy,^{38, 39} hypnotherapy,³⁹ and acceptance and commitment therapy^{40, 41} have all demonstrated some effectiveness in small studies.

Because many people suffering with PTSD first seek treatment from their primary care physicians,⁴² medication is often prescribed as the initial treatment. Among the medications recommended for the treatment of PTSD are the antidepressants sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), fluvoxamine (Luvox), citalopram (Celexa), nefazodone (Serzone), and venlafaxine (Effexor).²⁸ The short-term use of certain antianxiety medications such as clonazepam (Klonopin) might also be prescribed for certain symptoms related to PTSD,²⁸ as might certain antipsychotic medications such as risperidone (Risperdal) and olanzapine (Zyprexa).⁴³ (Click here for information about the use of medications.)

COGNITIVE BEHAVIORAL THERAPY FOR POST-TRAUMATIC STRESS DISORDER

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

The CBT treatment for PTSD is often composed of six steps:⁴⁴

Conduct an assessment and provide education
Develop emotion-focused coping skills
Develop assimilation and rational-thinking skills
Engage in brief exposure exercises
Engage in prolonged exposure exercises
Prevent relapse

1. Conduct an Assessment and Provide Education

The first step in the cognitive behavioral treatment for PTSD is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with PTSD and not some other similar problem. Once people have been diagnosed with PTSD, it’s also important that they understand the basic nature and causes of the problem (as highlighted above), as well as the demands of the treatment for PTSD, particularly that CBT is an interactive treatment that requires them to do work outside of the therapy session. (Click here for more information about the nature of PTSD.)

2. Develop Emotion-Focused Coping Skills

The second step of the treatment is to teach the person specific skills to cope with overwhelming emotions that might arise during later stages of treatment. The two skills taught are an eye-movement technique and relaxation skills. The eye-movement technique involves imagining a moderately distressing memory and then moving one’s eyes from side to side, at the rate of about two back and forth movements per second, for twenty to thirty seconds. The eye movements can be done either with eyes open, following the therapist’s fingers from side to side, or it can be done with the eyes closed. The left to right eye movement has been shown to “break up” the memory and make it harder to remember, which also reduces the anxiety associated with the memory. (Click here for instructions on the eye-movement technique.)

Four different relaxation skills are also taught. All of these techniques include focusing on slow, rhythmic abdominal breathing, which often produces a feeling of calmness.

The first relaxation skill that’s taught is progressive muscle relaxation. It involves a seven-second tightening and releasing of specific muscle groups from head to toe, with emphasis on noticing the difference between the tense feeling and the relaxed feeling.

The second relaxation skill is learning how to release muscle tension without first tensing the muscles. This is done by focusing attention on the muscles and visualizing the tension being released.

The third skill is cue-controlled relaxation, in which a person is taught to relax his or her body by saying a relaxing word, such as “peace” or “relax,” with each slow exhalation.

And, finally, the fourth relaxation skill is special-place visualization. This skill teaches the person to envision a place of safety and comfort in his or her imagination. The person can go to this “mental safe place” during the PTSD treatment if he or she is overwhelmed by distressing feelings. (Click here for a full description of relaxation techniques.)

3. Develop Assimilation and Rational-Thinking Skills

The third step of the cognitive behavioral treatment for PTSD is to learn further coping skills that must be practiced before engaging in the exposure exercises. Part of the reason why traumatic events remain so haunting is because they often cause people to doubt the safety of the world, as well as their own actions at the time of the events. People with PTSD often think that their actions during the traumatic experience weren’t “right” or “correct” and therefore somehow caused the trauma or made it even worse. The assimilation process allows the person to differentiate between what was “right” and what was reasonable when the trauma took place. This is accomplished by recalling specific sensory and visual details of the trauma, as well as thoughts and worries, such as “It was my fault.” Then the person engages in a rational reframing of the situation by exploring whether another reasonable person would have behaved and reacted in a similar way. This allows people to stop blaming themselves for the trauma and recognize that they acted in much the same way as any other reasonable person would have. Typically, people in this stage create positive coping statements for themselves, such as “I did the best that I could in such a horrific situation.” Statements like these are very important in the next step of the treatment. (Click here for instructions on developing assimilation and rational-thinking skills.)

This step of the treatment might also include writing and journaling about the thoughts, feelings, and memories surrounding the traumatic event and applying the person’s rational thinking process to the story. (Click here for instructions on writing about PTSD.)

4. Engage in Brief Exposure Exercises

The fourth step of the cognitive behavioral treatment for PTSD is using brief exposure exercises to lessen the distress of the traumatic memories. Exposure means confronting a memory or situation without avoiding it or running away from it. In the first type of exposure work, the person uses his or her imagination to recall traumatic memories while simultaneously using coping skills to reduce feelings of distress. The goals of this work are to help people challenge themselves without being overwhelmed and to practice applying the stress reduction and assimilation skills. Brief imaginal exposure begins with the person using relaxation skills before recalling details of the trauma. Then the person recalls the self-defeating thoughts associated with the trauma. And, finally, the person uses one of the previously learned coping strategies to lower his or her level of distress. Once people have mastered this process using imaginal exposure, they can safely begin exposing themselves to feared or avoided situations in real life, using the same coping skills. (Click here for instructions on brief exposure exercises.)

5. Engage in Prolonged Exposure Exercises

The fifth step of the cognitive behavioral treatment for PTSD is to engage in prolonged exposure exercises. The purpose of these extended exercises is to help people desensitize themselves to the emotions associated with the traumatic memories and triggering situations. Prolonged exposure is similar to brief exposure in that the person is instructed to imagine memories of the event, the associated self-defeating thoughts, and physical sensations of anxiety, raising the person’s distress level to a moderate range. However, instead of using the eye-movement technique and the other relaxation skills, during prolonged exposure the person only uses rational coping thoughts to deal with distress. And as in the previous stage of treatment, after the person has learned to cope with imaginal exposures, he or she can safely begin confronting feared or avoided situations in real life for a prolonged period of time using the same coping skills. (Click here for instructions on prolonged-exposure exercises.)

6. Prevent Relapse

Finally, the last step of the cognitive behavioral treatment for PTSD is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning PTSD, such as avoiding feared situations, in order to take steps to prevent relapse. (Click here for instructions on preventing relapse of PTSD.)

ACCEPTANCE AND COMMITMENT THERAPY FOR POST-TRAUMATIC STRESS DISORDER

Acceptance and commitment therapy (ACT) incorporates elements of behavior therapy, meditation and mindfulness practices, and scientific research on how humans think and learn.

ACT (pronounced “act”) is based on the principle that many psychological problems are caused by efforts to control, avoid, or get rid of emotions and thoughts that are undesirable. Often, people try to get rid of feelings and thoughts that make them sad or anxious, just as they get rid of other things they don’t want, such as old clothes. However, as ACT points out, feelings and thoughts can’t be controlled. A person can’t throw them out like an unwanted pair of shoes. In fact, the harder a person tries to control his or her thoughts and feelings, the more powerful they often become and the longer they stick around.

The ACT treatment for post-traumatic stress disorder generally includes eight steps:⁴⁵

Educate about PTSD, anxiety, and ACT
Develop creative hopelessness
Clarify values
Commit to taking action
Develop acceptance
Focus on contact with the present moment
Utilize cognitive defusion
Stay committed to values and actions

1. Educate About PTSD, Anxiety, and ACT

The initial step of the ACT treatment for post-traumatic stress disorder is to educate the person about trauma, PTSD, and the nature of anxiety. It’s especially important for the person to understand the nature of anxiety from an ACT point of view. According to this treatment, anxiety and fear themselves are not the causes of PTSD. Rather, it’s the person’s avoidance of anxious and fearful emotions and thoughts that make PTSD an overwhelming problem. Starting with the early stages of treatment, it’s also important for people to understand that ACT is an active, participatory treatment designed to help them live a more fulfilling life, not necessarily a “happier” one. (Click here for more information about acceptance and commitment therapy.)

2. Develop Creative Hopelessness

In order to develop what ACT calls “creative hopelessness,” a person must conduct a thorough evaluation of the strategies that he or she has already used to cope with fear and anxiety. After doing this, the person often recognizes that all of these strategies have been unsuccessful or actually made the problem worse. This is because these strategies are actually attempts to avoid and control feelings of fear and anxiety, which can never be successful. For example, a man who attempts to control his anxiety by drinking alcohol actually develops a worse problem, as does a woman who tries to avoid her anxious feelings by choosing not to talk to her loved ones about them. But rather than just being hopeless, this stage of treatment is also creative because it allows the person to begin exploring new, more successful ways of coping with fear and anxiety. (Click here for instructions on how to develop creative hopelessness.)

3. Clarify Values

ACT acknowledges that life is often lived on autopilot, without much sense of what a person really cares about. Clarifying and establishing what a person values can often help that person live a more fulfilling life, despite having occasional feelings of anxiety or fear. Values are the elements of life that give it meaning and importance, like “maintaining a loving relationship with my spouse or partner” or “being an active member of my community.” These values are like compass headings that guide a person through life. They are not destinations at which a person can ever arrive. A person can never stop maintaining a loving relationship and still have a loving relationship. Values are concepts that point a person in the direction of a fulfilling life, and ACT uses many types of values clarification tools to help people identify their values. (Click here for instructions on how to clarify and establish values.)

4. Commit to Taking Action

After a person has determined his or her values, it’s important to establish goals that support those values and then commit to taking actions that fulfill those goals. For example, if a person’s value is to be an active member of her community, she might list a number of different goals to fulfill that value, such as “attend community meetings twice a month.” This is something that can be completed and thereby create a sense of valued living. The ACT treatment for post-traumatic stress disorder includes development of skills and goals that lead to taking committed action. (Click here for instructions on how to commit to taking action.)

5. Develop Acceptance

In ACT, learning to accept feared situations and anxious emotions is the alternative to trying to control or avoid them. Acceptance can be hard, but it’s often the only way people can reclaim control of their lives. Many situations cannot be altered, no matter how much a person wishes them to be changed. Accepting this fact is often the first step in reengaging with life. Accepting what cannot be changed frees a person from struggling against it and allows that person to start taking actions based on what he or she values in life.

In order to cultivate acceptance, people are encouraged to experience the anxious emotions that they have been avoiding, to cease fighting things that cannot be altered, and to engage in situations that have been evaded. (Click here for instructions on how to develop acceptance skills.)

6. Focus on Contact with the Present Moment

Focusing on what’s happening in the present moment can help people develop more flexible coping strategies for handling fear and anxiety. When people dwell on the past, they often become sad, and when they anticipate the future, they often become anxious. In both cases, they miss what’s happening at the present time. Paying attention to what’s happening in the moment gives people more control over the decisions they’re making and allows them to see more possibilities in life. This skill is often developed with present-focused mindfulness skills, such as focusing on the rising and falling of the breath or on physical sensations in the body. (Click here for instructions on how to develop present-focused mindfulness skills.)

7. Utilize Cognitive Defusion

Cognitive defusion is a mindfulness technique that helps people observe their anxious and fearful thoughts without becoming attached to them. “Defuse” is an invented word that means to unstick or to unfuse one’s self from the words that arise in thoughts. The goal of this stage of treatment is to allow people with PTSD to function more freely without judging themselves, their feelings, or their thoughts. Thoughts and emotions often arise haphazardly, so it’s easy to see that PTSD could worsen over time if a person were to follow or believe every thought and emotion that arose.

Cognitive defusion is often accomplished using meditation or mindfulness techniques, such as imagining thoughts floating by on a cloud, repeating the words of a thought over and over until they lose meaning, or imagining a thought as something outside of oneself. By observing the process of thinking and feeling, the goal is to create space between the person and his or her experience. This gives the person more control over decisions made based on those thoughts and feelings. (Click here for instructions on how to develop cognitive defusion skills.)

8. Stay Committed to Values and Actions

In order to create a fulfilling life, it’s crucial for people to continue making decisions based on what they value in life, rather than based on the thoughts and feelings they have tried to avoid in the past. (Click here for instructions on how to stay committed to values and actions.)

REFERENCES FOR POST-TRAUMATIC STRESS DISORDER

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