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Post-traumatic stress disorder

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Signs and Symptoms
What Causes It?
Who's Most At Risk?
What to Expect at Your Provider's Office
Treatment Options
Prognosis/Possible Complications
Supporting Research

Post-traumatic stress disorder (PTSD) is an anxiety disorder that is brought on by memories of an extremely stressful event or series of events that cause intense fear, particularly if feelings of helplessness accompanied the fear. That event may be war, physical or sexual assault or abuse, an accident (such as an airplane crash or a serious motor vehicle accident), or a mass disaster. You can develop PTSD if the event happened to you or even if you witnessed it. It's normal to feel stress when you experience a traumatic event. PTSD persists long after the event and is characterized by the intensity of the feelings, how long they last, how you react to these feelings, and the presence of particular symptoms. More than 5 million adults in the United States are affected by PTSD each year.

Signs and Symptoms

Symptoms of PTSD usually develop within the first 3 months after the event, but they may not surface until months or even years after the original traumatic event, Symptoms may include:

  • Intrusive thoughts recalling the traumatic event
  • Nightmares
  • Flashbacks
  • Efforts to avoid feelings and thoughts that either remind you of the traumatic event or that trigger similar feelings
  • Feeling detached or unable to connect with loved ones
  • Depression, hopelessness
  • Feelings of guilt (from the false belief that you were responsible for the traumatic incident)
  • Irritability or angry outbursts
  • Hypervigilance (being overly aware of possible danger)
  • Hypersensitivity, including at least two of the following reactions: trouble sleeping, being angry, having difficulty concentrating, startling easily, having a physical reaction (rapid heart rate or breathing, increase in blood pressure)

What Causes It?

Experts aren't entirely sure what causes some people to develop PTSD, but many think it happens when you are confronted with a traumatic event, and your mind isn't able to process all the thoughts and feelings as it usually does. Scientists studying the brain think there may be some differences in the brain structure or chemistry of those with PTSD. For example, certain areas of the brain involved with feeling fear may be hyperactive in people with PTSD. Other researchers have focused on the hippocampus, the area of the brain responsible for memory and for how we deal with stress, and are investigating whether changes in that area also appear in people with PTSD.

Who's Most At Risk?

How severe the traumatic event was and how long it lasted affect whether you are likely to develop PTSD. These factors also increase the risk:

  • A history of sexual or physical abuse
  • Working in a high-risk occupation, such as firefighting, military, or law enforcement
  • A history of depression or other psychological disorder
  • Abusing drugs or alcohol
  • Not having adequate social support
  • Women are twice as likely as men to show signs of PTSD
  • Veterans of war
  • Survivors of unexpected events, such as car wrecks, fires, or terrorist attacks.
  • Depression
  • Survivors of natural disasters 

What to Expect at Your Provider's Office

There are no laboratory tests to detect PTSD. In fact, PTSD is not diagnosed until at least 1 month has passed since the trauma. Your doctor will ask about your symptoms and ask you to describe the traumatic event. Your doctor will likely also use psychological assessment tools to confirm the diagnosis. Your doctor may refer you to a specialist (such as a psychologist or psychiatrist) for evaluation and treatment.

Treatment Options

Prevention

Early intervention immediately after a traumatic event -- through support groups, psychotherapy, and certain medications -- may help prevent PTSD. Rituals, such as prayer or healing ceremonies, may be helpful in relieving stress and other effects of the trauma.

Treatment Plan

The treatment for PTSD includes:

  • Cognitive behavior therapy -- With the help of a psychotherapist, you learn techniques to manage your thoughts and feelings when you are in situations that remind you of the traumatic event. You may gradually expose yourself to situations and thoughts that cause anxiety, as you build up a tolerance for them and your fear is lessened. Ultimately, the goal of cognitive therapy is to allow you to control your fear and anxiety.
  • Stress management therapy -- A therapist teaches you relaxation techniques to help you overcome fear and anxiety, and to break the cycle of negative thoughts.
  • Medication for depression or anxiety.

Drug Therapies

  • Antidepressants such as selective serotonin reuptake inhibitors (SSRIs), including sertraline (Zoloft), fluoxetine (Prozac), fluvoxamine (Luvox), or paroxetine (Paxil).
  • Benzodiazepines, a group of medications sometimes used for anxiety, including lorazepam (Ativan) and alprazolam (Xanax). These drugs have sedating properties and may cause drowsiness, constipation, or nausea. Do not take them if you have narrow angle glaucoma, a psychosis, or are pregnant. They also interact with other drugs, including some antidepressants (such as Luvox).
  • Dopamine-blocking agents, such as neuroleptics. There is some evidence of increased dopamine presence in children and adults with PTSD.

Complementary and Alternative Therapies

Conventional psychotherapy, such as cognitive behavior therapy, is the main treatment for PTSD. However, with instruction by licensed professionals, several mind-body techniques may be used as supportive treatments:

  • Eye Movement Desensitization and Reprocessing (EMDR), in which you move your eyes rapidly from side to side while recalling the traumatic event, seems to help reduce distress for many with PTSD. Doctors aren't sure how it works, or whether it is any better than standard treatment. It's also not clear how long PTSD symptoms are reduced using EMDR.
  • Biofeedback involves using a machine, at first, to see bodily functions that are normally unconscious and occur involuntarily (for example, heart rate and temperature). As you see how your body reacts to stress, you learn to control the reactions, and eventually you can perform the techniques to control the reactions without using a machine. Some studies suggest that biofeedback, among other forms of relaxation training, may be an effective treatment for some people with PTSD.
  • Hypnosis has long been used to treat war-related post-traumatic conditions. More recently it has been used in cases of sexual assault (including rape), anesthesia failure, Holocaust survival, and car accidents. Hypnosis induces a deep state of relaxation, which may help people with PTSD feel safer and less anxious, decrease intrusive thoughts, and become involved in daily activities again. Hypnosis is usually used in conjunction with psychotherapy and requires a trained, licensed hypnotherapist.
  • Emotional Freedom Technique (EFT), a process that combines tapping on acupuncture points while calling to mind traumatic events, has shown great promise in helping patients suffering with PTSD. More studies need to be done, but anecdotal evidence has been very encouraging.

Nutrition and Supplements

Although no studies have examined how nutrition can be used to treat PTSD, these general nutritional guidelines may be helpful:

  • Eliminate potential food allergens, including dairy, wheat (gluten), corn, soy, preservatives, and food additives. Your health care provider may want to test for food sensitivities.  
  • Avoid coffee and other stimulants, alcohol, and tobacco.
  • Exercise lightly, if possible, 5 days a week.

You may address nutritional deficiencies with the following supplements:

  • Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 - 2 tablespoonfuls oil daily, to help improve immunity and protect nervous system transmission. Omega-3 fatty acids can have a blood-thinning effect, and may increase the actions of blood-thinning medications, such as warfarin (Coumadin) and aspirin, among others. Speak with your physician.
  • A multivitamin daily, containing the antioxidant vitamins A, C, D, E, the B-vitamins, and trace minerals, such as magnesium, calcium, zinc, and selenium.
  • Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support. Coenzyme Q10 may interfere with warfarin (Coumadin), or other blood-thinning medications. Speak with your physician. 
  • L-theanine, 200 mg 1 - 3 times daily, for nervous system support. Theanine is often used for its calming effects. Speak with a physician before taking L-theanine, particuclarly if you're already taking medication for PTSD symptoms.
  • Melatonin, 1 - 6 mg before bed, for sleep and immune support.

Herbs

Herbs are generally available as standardized dried extracts (pills, capsules, or tablets), teas, or tinctures/liquid extracts (alcohol extraction, unless otherwise noted). Mix liquid extracts with favorite beverage. Dose for teas is 1 - 2 heaping teaspoonfuls/cup water steeped for 10 - 15 minutes (roots need longer). Herbs should be used only under the guidance of your physician, and you should keep all of your doctors and therapists informed about any herbal or CAM therapies you are using. Some herbal remedies can interfere with medications.

The following herbal remedies may provide relief from symptoms:

  • Kava kava (Piper methysticum) standardized extract, 100 - 250 mg 1 - 3 times a day as needed for symptoms of stress and anxiety. The Food and Drug Administration has issued a warning concerning kava kava's effect on the liver. In rare cases, severe liver damage has been reported. If you take kava, do not use it for more than a few days, and tell your doctor before taking it. Kava can interact with many different medications, including medications for Parkinson's disease. Kava may also aggravate symptoms of depression.
  • Green tea (Camellia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant and immune effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
  • Bacopa (Bacopa monniera) standardized extract, 50 - 100 mg 3 times a day, for symptoms of stress and anxiety. Bacopa can increase secretions in the GI tract, lungs, and bladder, and potentially increase the likelihood of ulcers or blockages in one of these systems.
  • Holy basil (Occimum sanctum) standardized extract, 400 mg daily, for stress and adrenal health. You can also prepare teas from the root. Holy basic can have a blood-thinning effect and may increase the effect of blood-thinning medications, such as warfarin (Coumadin) and aspirin.

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for PTSD based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. When being treated with homeopathic remedies, it is possible to experience a brief intensification of symptoms before your condition improves. In the case of PTSD, it is important to have a qualified support team in place to help you handle any worsening of symptoms. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

  • Aconitum -- for recurring panic following a traumatic experience. This remedy is most appropriate for individuals who have heart palpitations and shortness of breath which produce a tremendous fear of death. Aconitum is often the first remedy given for trauma, even if the trauma occurred years ago.
  • Arnica -- for chronic conditions (such as depression) that occur after a traumatic experience. This remedy is most appropriate for individuals who generally deny that anything is wrong.
  • Staphysagria -- for individuals who feel fearful, powerless, or unable to speak up or defend themselves.
  • Stramonium -- for anxiety disorders that occur after a shock or traumatic experience involving violence. The individual for whom this remedy is most appropriate tends to be generally fearful and have night terrors.

Acupuncture

Acupuncture may help with symptoms of PTSD, including insomnia, anxiety, and depression. In one case involving a Vietnam War veteran, acupuncture and relaxation with guided imagery reportedly reduced insomnia, nightmares, and panic attacks over a treatment period of 12 weeks. One study for anxiety (not PTSD-related) found that benefits lasted as long as 1 year after treatment. Acupuncturists treat people based on an individualized assessment of the excesses and deficiencies of qi located in various meridians in the body.

Prognosis/Possible Complications

If PTSD symptoms continue for longer than 3 months, the condition is considered to be chronic (ongoing). Chronic PTSD may become less severe even if it is not treated, or it may become severely disabling, interfering with many areas of life and causing physical complaints. Some research suggests that PTSD may be related to physical disorders, such as arthritis, but few studies have examined the relationship between PTSD and physical health.

Supporting Research

Auerbach. Wilderness Medicine, 6th ed. St. Louis, MO: Mosby, An Imprint of Elsevier: 2011.

Beers MH, Porter RS, et al. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2006:1678.

Brady K, Pearlstein T, Asnis GM, et al. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. JAMA. 2000;283(14):1837-1844.

Bryant RA. Acute stress disorder as a predictor of posttraumatic stress disorder: a systemic review. J Clin Psychiatry. 2011; 72(2):233-9.

Bryant RA, Moulds ML, Nixon RD, Mastrodomenico J, Felmingham K, Hopwood S. Hypnotherapy and cognitive behaviour therapy of acute stress disorder: a 3-year follow-up. Behav Res Ther. 2006 Sep;44(9):1331-5.

Cardena E. Hypnosis in the treatment of trauma: a promising, but not fully supported, efficacious intervention. Int J Clin Exp Hypn. 2000;48(2):225-238.

Cohen J, Bukstein O, Walter H, et al. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder. J of the Amer Acad of Child and Adoles Psychiatry. 2010;49(4).

Dunleavy K, Kubo Slowik A. Emergence of delayed posttraumatic stress disorder symptoms related to sexual trauma: patient centered and trauma-cognizant management by physical therapists. Phys Ther. 2012; 92(2):339-51.

Gros DF, Simms LJ, Acierno R. Specifity of posttraumatic stress disorder symptoms: an investigation of comorbidity between posttraumatic stress disorder symptoms and depression in treatement-seeking veterans. J Nerv Ment Dis. 2010; 198(12):885-90.

Qureshi SU, Pyne JM, Magruder KM, Schulz PE, Kunik ME. The link between post-traumatic stress disorder and physical comorbidities: a systematic review. Psychiatr Q. 2009;80(2):87-97.

Raboni MR, Tufik S, Suchecki D. Treatment of PTSD by eye movement desensitization reprocessing (EMDR) improves sleep quality, quality of life, and perception of stress. Ann N Y Acad Sci. 2006 Jul;1071:508-13.

Raphael KG, Widom CS. Post-traumatic stress disorder moderates the relation between documented childhood victimization and pain 30 years later. Pain. 2011; 152(1):163-9.

Seidler GH, Wagner FE. Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychol Med. 2006 Nov;36(11):1515-22.

Stapleton JA, Taylor S, Asmundson GJ. Effects of three PTSD treatments on anger and guilt: exposure therapy, eye movement desensitization and reprocessing, and relaxation training. J Trauma Stress. 2006 Feb;19(1):19-28.

Sullivan GM, Neria Y. Pharmacotherapy in post-traumatic stress disorder: evidence from randomized controlled trials. Curr Opin Investig Drugs. 2009;10(1):35-45.

Tarrier N, Humphreys L. Subjective improvement in PTSD patients with treatment by imaginal exposure or cognitive therapy: session by session changes. Br J Clin Psychol. 2000;39(pt 1):27-34.

Wessely S, Rose S, Bisson J. Brief psychological interventions ("debriefing") for trauma-related symptoms and the prevention of post traumatic stress disorder. Cochrane Database Syst Rev 2000;No. 2:CD000560.

Review Date: 12/28/2012
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.
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