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The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021
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Image from Flickr | Marines.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
Posttraumatic stress disorder (PTSD) occurs in survivors of natural disasters, crime victims, military personnel, mass shooting survivors, and other individuals who have experienced traumatic events in their lives. Military personnel returning from wars in Afghanistan and Iraq and other regions, as well as the series of mass shootings that occurred over the last two decades in the United States have particularly brought PTSD to the attention of the American people. Most people with exposure to such violent events experience symptoms of distress, such as sleep problems and jumpiness, but the majority recover in a few weeks or months. PTSD is currently the subject of many research studies that are funded by the National Institute of Mental Health (NIMH) at the National Institutes of Health (NIH).
Image from Wikipedia Commons | Yoshikia2001.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 updated version of the American Psychiatric Association's (APA) classification and diagnostic tool. In the United States, the DSM-5 serves as a universal authority for psychiatric diagnosis. The DSM-5 now includes the classification of "PTSD with Trauma- and Stressor-Related Disorders." This is a change from the DSM-IV, which addressed PTSD as an anxiety disorder.
Image courtesy of Sam Shlomo Spaeth.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
The diagnosis of PTSD, according to the DSM-5, is based on eight criteria. The first criterion identifies the trigger for PTSD as exposure to an actual or threatened death, serious injury, or sexual violation and must result from one or more of the following scenarios: (1) directly experiencing the traumatic event; (2) witnessing the traumatic event in person; (3) learning that the traumatic event occurred to a close family member or close friend; or (4) experiencing first-hand repeated or extreme exposure to aversive details of the traumatic event.[1] The second through fifth criteria concern symptoms such as re-experiencing the event, avoidance of stimuli associated with the event, having negative alterations in cognitions and mood associated with the event, and alterations in arousal and reactivity. The sixth criterion concerns the duration of symptoms; the seventh concerns functioning, such as social interactions or capacity to work; and the eighth classifies symptoms as not being attributable to a substance or co-occurring medical condition.[2]
Image from Wikimedia Commons/NIMH.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
Symptoms that accompany PTSD should be present for more than 1 month following the initial traumatic event. Re-experiencing covers spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks, or other intense or prolonged psychological distress. Avoidance refers to efforts to withdraw from distressing memories, thoughts, feelings, or external reminders of the event. Negative cognitions and mood represent myriad feelings, from a persistent and distorted sense of blame or negative belief of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event. Arousal and reactivity are marked by aggressive, reckless, or self-destructive behavior; sleep disturbances; hypervigilance; or related problems.
Image adapted from Tanielian T, Jaycox LH, and the Invisible Wounds Study Team.[4]MDD = major depressive disorder.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
The Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study reported a lifetime PTSD prevalence of 6.4% in a sample of over 34,000 US adults.[3] Lifetime PTSD prevalence was almost double in women (8.6%) than men (4.1%).[3]
A 2008 RAND Corporation study of US veterans who served in Iraq and Afghanistan found that nearly 14% suffered from PTSD (shown above).[4] A 2015 RAND survey reported that 9.4% (confidence interval [CI]: 8.4–10.5%) of service members across all branches reported probable depression, 14.2% (CI: 13.0.–15.5%) indicated probable GAD (generalized anxiety disorder), and 8.5% (CI: 7.4–9.5%) of service members indicated probable PTSD.[5]
In the context of coronavirus disease 2019 (COVID-19) stress, a recent epidemiologic survey by the Centers for Disease Control and Prevention (CDC) of more than 5000 adults reported a 29.3% prevalence of COVID-19 trauma and stressor-related symptoms.[6]
Image adapted from Wikimedia Commons | Sir dsn.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
The prevalence of post-disaster (including mass shootings) diagnoses (predominantly PTSD) ranges from 10% to 36%; however, subthreshold PTSD has been reported at percentages ranging from 50% to 90%.[7] In cases of community shootings (including school shootings), the rates of subsequent PTSD in the community appear to be reduced when the community members work together and take control of the situation. While survivors may benefit from individual counseling, this should be offered judiciously, as an indiscriminate offer of counseling in the immediate post-disaster period often engendered resentment.
Studies show that post-disaster risk factors include individual factors (younger age, female sex, ethnic minority status, prior mental health issues, and poor psychosocial resources), contextual factors (developing vs developed countries), and the nature of the disaster (terrorism and shooting sprees have higher risk than natural disasters).[8] In 2020, under the stress of the COVID-19 pandemic, US adults reported significantly increased adverse mental health effects, including a sharp elevation in trauma and stressor-related disorders.[6]
Image from Wikimedia Commons | Sabar.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
Individual, manualized trauma-focused psychotherapy is recommended over other pharmacologic and nonpharmacologic approaches as the first-line intervention for PTSD.[9]
Pharmacotherapy is recommended when individual trauma-focused psychotherapy is not readily available or not preferred.[9] Three selective serotonin reuptake inhibitors (SSRIs)—sertraline, paroxetine, and fluoxetine—and one serotonin-norepinephrine reuptake inhibitor (SNRI)—venlafaxine—have a moderate level of evidence supporting their use in this setting. The most frequent adverse effects of these medications include sexual dysfunction, increased sweating, gastrointestinal discomfort, and drowsiness. In 2004, the US Food and Drug Administration (FDA) released a black box warning about increased risk for suicidality (suicidal thinking and behavior) in children, adolescents, and young adults taking these medications compared with placebo. While the suicidal risk is increased in patients younger than age 24, it is decreased in adults aged 65 or older.
The evidence suggests that second-generation (atypical) antipsychotics and benzodiazepines should not be used as monotherapy or augmentation therapy for PTSD.[9] However, these medications may be used as clinically indicated, to augment the effects of other antidepressants in patients with depression overlapping with PTSD. Second-generation (atypical) antipsychotics may cause unacceptable weight gain. Based on the level of evidence, there is no clear recommendation for or against the use of prazosin, an alpha-1 blocker blood pressure medication, for nightmares and propranolol, a beta-blocker, for PTSD-related anxiety.[9]
Molecular structure image of zolpidem (left) from Vaccinationist and trazodone (right) from Ben Mills, both via Wikimedia Commons. Image of pill bottle (left) from JCRules and pill package (right) from Troll Sockenpuppe, both via Wikimedia Commons.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
Insomnia is common in patients with PTSD. Improving sleep is critically important to recovery.[10] Except in cases of severe sleep deprivation, when immediate drug therapy is recommended to prevent harm, medications should not be routinely used for the treatment of PTSD-related insomnia. Instead, recommended first-line treatment is with sleep hygiene and Cognitive Behavioral Therapy for Insomnia (CBT-I), unless underlying medical or environmental factors are responsible for the sleep disorder.
The 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder reported insufficient evidence to recommend for or against the use of eszopiclone, trazodone, mirtazapine, hydroxyzine, cyproheptadine, zaleplon, or zolpidem as augmentation therapy for insomnia.[9] Avoid benzodiazepines and atypical antipsychotics, which have unclear benefits and well-known risks, among which are metabolic syndrome for the atypical antipsychotics and oversedation, abuse, and dependence for benzodiazepines.
Images from Jemasty (left) and Kyle Hunter (right), both via Wikimedia Commons.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
Complementary, alternative, and integrative therapies are anecdotally helpful, but there is not enough evidence for general recommendation of such treatments. Some studies have shown that acupuncture has provided sustained positive effects in patients with PTSD.[11] Stellate ganglion block is an anesthetic technique for pain that may also relieve some of the symptoms of PTSD. Other alternative treatment strategies include yoga, martial arts, meditation, and canine therapy.
See the series of articles on the use of complementary and alternative medicine in PTSD in Psychiatric Annals (January to July 2013).
Images courtesy of the NICoE Healing Arts Program/Melissa S. Walker, MA, ATR.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
In addition to the standard therapies for PTSD, the Department of Defense is working on innovative approaches, such as art therapy. At the National Intrepid Center of Excellence (NICoE), the masks shown above were created by soldiers during formal art therapy sessions facilitated by a credentialed art therapist. Creation of such masks provides soldiers with PTSD, other mental health issues, or traumatic brain injury (TBI) another means of expressing their feelings of trauma that may be difficult to verbalize.
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
According to a number of studies, military personnel returning from tours of combat in Iraq and Afghanistan are at high risk for PTSD, traumatic brain disorder, and pain. This triad puts military personnel at high risk for alcohol and substance abuse. The 2008 Department of Defense Health Behavior Survey reported increases in prescription drug abuse and heavy alcohol use. In fact, prescription drug abuse doubled among US military personnel from 2002 to 2005 and almost tripled between 2005 and 2008.[12] Almost one in 10 veterans referred for first-time care via the Veterans Affairs (VA) system met diagnostic criteria for a substance use disorder.[13]
Table data from Czeisler ME, Lane RI, Petrosky E, et al. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049-57.[6]
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
PTSD and COVID-19
The global epidemic of COVID-19 increased the risk of PTSD. For patients with a prior history of traumatic experiences, the pandemic-driven social isolation and decreased social support and access to services heightened the risk of PTSD exacerbation.
PTSD rates of up to 17% have been reported for healthcare workers who are involved in the treatment of patients with COVID-19 and who have been exposed to traumatic or stressful situations, including increased deaths among their patients, lack of personal protective equipment, and life-and-death decisions made on the basis of limited supplies.[14] Extremely high rates of PTSD have been reported among patients with COVID-19 who have been separated from their families and isolated and who fear for their survival.[15]
A large survey of the US general population showed that the increased stress associated with the pandemic resulted in an overall rise in mental health issues. Although PTSD cannot be diagnosed without direct trauma exposure, 26% of the respondents reported trauma- and stressor-related disorder symptoms (shown in the table above).[6]
Image from Flickr | US Army Sgt. Matthew C. Moeller.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
There is insufficient evidence about the benefits of immediate intervention, with medication or psychotherapy/counseling, following acute exposure to trauma, as long as no indication of acute stress disorder (ASD) is present. However, for individuals with ASD, individual trauma-focused psychotherapy is an effective intervention for preventing PTSD. The principal methods used to combat acute stress reactions are reflected in the acronym PIES (proximity, immediacy, expectancy, and simplicity). In the military, preventing the cycle of PTSD is possible by promoting unit cohesion and morale; ensuring that individuals know their jobs; inducing stress during training to teach coping skills; providing realistic information and expectations about combat; and holding group debriefings immediately after any traumatic event.[16]
In addition, results from a retrospective study suggest that important differences between the sexes exist in the prevalence of positive screenings for military sexual trauma (MST), depression, obesity, and PTSD. Clinicians, researchers, and senior leaders need to ensure that female veterans receive the health services they need within the VA system.[17]
Image from US Navy | Lt. Michelle Tucker.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
Individual, manualized, trauma-focused psychotherapies, in which clinicians use a predetermined treatment protocol, are effective for PTSD and recommended over other pharmacologic or nonpharmacologic treatments as the primary intervention for PTSD. These therapies are based on exposure and/or cognitive restructuring, and they include prolonged exposure (PE), cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), specific cognitive behavioral therapies for PTSD, brief eclectic psychotherapy (BEP), narrative exposure therapy (NET), and written narrative exposure. They are usually delivered by psychologists and social workers, and most are available in military and VA settings.
Virtual reality programs are a variation of PE that may be self-administered. "Virtual Iraq" is a well-known program in which clinicians control various stimuli and tactical situations experienced by a patient through a head-mounted display.
Image from Wikimedia Commons/David Shankbone.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
Substance abuse, depression, physical injuries with associated pain, unemployment, and homelessness are all associated with PTSD. This is especially relevant in the context of increased PTSD in veterans and also for civilians, in the United States and abroad, who have experienced or witnessed mass shootings or terrorist attacks. Preventive efforts focus on health care, employment, housing, education, and the criminal justice system.
Suicide rates among active-duty US Army personnel had been increasing since 2004, surpassing comparable civilian rates in 2008, but there has been a recent drop, likely because fewer forces are deployed in military combat. Among soldiers, rates of attempted suicide are higher in those with a diagnosis of PTSD or depression, those who were never or previously deployed (vs currently deployed), those in the early stages of army service, and those who are female, younger, non-Hispanic white, and less educated.[18,19] According to one report, suicide rates among US army personnel increased 80% from 2004 to 2008. It is estimated that between 2007 and 2008, 17% of the soldiers who committed suicide had a diagnosis of mental illness.[20]
Image adapted from Tanielian T, Jaycox LH, and the Invisible Wounds Study Team.[4]
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
The economic cost of the recurrent mass shootings that have occurred in the United States over the last two decades is not known but, historically, soldiers involved in war have consistently had high rates of PTSD, representing a significant and costly illness to veterans, their families, and society as a whole. The image shows estimated 2-year cost components for 50,000 veterans of the Iraq and Afghanistan wars with PTSD and MDD at age 25 years and with 5-7 years of military service; these and other data were compiled by the RAND Corporation and presented in their monograph Invisible Wounds of War.[4]
Further research is needed to advance our understanding of PTSD prevalence, as well as associated information on its course, phenomenology, protective factors, treatment, and economic costs. The National Center for PTSD provides some excellent information on coping with the effects of war.
Image courtesy of NICoE.
The Persistence of Trauma: PTSD
COL (Ret) Elspeth Cameron Ritchie, MD; Mark P. Brady, PA-C | January 5, 2021 | Contributor Information
One of the most important changes for patients with PTSD is the lessening of the stigma associated with it and with other mental health disorders. In the past, soldiers were concerned that seeking help for PTSD or other mental illness would damage their careers or shade the way their commanders perceived them. However, as researchers have come to better understand PTSD, more soldiers are now seeking help, spurred in some cases by leaders who have shared their own struggles with PTSD. But there are still too many service members reluctant to participate in treatment.
From the COVID-19 pandemic to the emergence of antimicrobial-resistant disorders, community-acquired infections have gained increasing focus in the healthcare community and in the media.Medscape Reference Slideshows, Dec, 2020
Posttraumatic stress disorder (PTSD) is defined as a pathological anxiety that usually occurs after an individual experiences or witnesses severe trauma that constitutes a threat to the physical integrity or life of the individual or of another person.Medscape Reference Slideshows, Nov 2018
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Contributor Information
Authors
COL (Ret) Elspeth Cameron Ritchie, MD
Chief Medical Officer
District of Columbia Department of Behavioral Health
Washington, DC
Disclosure: COL (Ret) Elspeth Cameron Ritchie, MD, has disclosed no relevant financial relationships.
Mark P. Brady, PA-C
Dept. of Emergency Medicine
Cambridge Health Alliance
Cambridge, MA
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Reviewer
Adrian Preda, MD
Professor of Clinical Psychiatry and Human Behavior
University of California, Irvine, School of Medicine
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Boehringer Ingelheim, GLG, Guidepoint
Received research grant from: Acadia, Takeda.
Editors
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
John Heinegg, RN
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: John Heinegg, RN, has disclosed no relevant financial relationships.
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References
Gore TA, Lucas JZ, Lubit RH. Posttraumatic stress disorder. Medscape Drugs & Diseases from WebMD. Updated November 14, 2018. Available at: https://emedicine.medscape.com/article/288154-overview. Accessed December 18, 2020.
Pietrzak RH, Goldstein RB, Southwick SM, Grant BF. Prevalence and axis I comorbidity of full and partial posttraumatic stress disorder in the United States: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. J Anxiety Disord. Apr 2011;25(3):456-65. PMID: 21168991
Tanielian T, Jaycox LH, and the Invisible Wounds Study Team. Stop loss: a nation weighs the tangible consequences of invisible combat wounds. Summer 2008. Available at: https://www.rand.org/pubs/corporate_pubs/CP22-2008-08.html. Accessed December 18, 2020.
Meadows SO, Engel CC, Collins RL, et al. 2015 Health Related Behaviors Survey: Mental and Emotional Health Among U.S. Active-Duty Service Members. Santa Monica, CA: RAND Corporation, 2018. Available at: https://www.rand.org/pubs/research_briefs/RB9955z3.html. Accessed December 18, 2020.
Czeisler ME, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1049-57. PMID: 32790653
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