PTSD FAQ and PTSD Links

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Effects of Traumatic Experiences

A National Center for PTSD Fact Sheet
by Eve B. Carlson, Ph.D. and Josef Ruzek, Ph.D.


When people find themselves suddenly in danger, sometimes they are overcome with feelings of fear, helplessness, or horror. These events are called traumatic experiences. Some common traumatic experiences include being physically attacked, being in a serious accident, being in combat, being sexually assaulted, and being in a fire or a disaster like a hurricane or a tornado. After traumatic experiences, people may have problems that they didn't have before the event. If these problems are severe and the survivor does not get help for them, they can begin to cause problems in the survivor's family. This fact sheet explains how traumas can affect those who experience them. This fact sheet also describes family members' reactions to the traumatic event and to the trauma survivor's symptoms and behaviors. Finally, suggestions are made about what a survivor and his or her family can do to get help for PTSD.

How do traumatic experiences affect people?

People who go through traumatic experiences often have symptoms and problems afterward. How serious the symptoms and problems are depends on many things including a person's life experiences before the trauma, a person's own natural ability to cope with stress, how serious the trauma was, and what kind of help and support a person gets from family, friends, and professionals immediately following the trauma.
Because most trauma survivors are not familiar with how trauma affects people, they often have trouble understanding what is happening to them. They may think the trauma is their fault, that they are going crazy, or that there is something wrong with them because other people who experienced the trauma don't appear to have the same problems. Survivors may turn to drugs or alcohol to make themselves feel better. They may turn away from friends and family who don't seem to understand. They may not know what to do to get better.

What do trauma survivors need to know?

· Traumas happen to many competent, healthy, strong, good people. No one can completely protect him- or herself from traumatic experiences.

· Many people have long-lasting problems following exposure to trauma. Up to 8% of individuals will have PTSD at some time in their lives.

· People who react to traumas are not going crazy. They are experiencing symptoms and problems that are connected with having been in a traumatic situation.

· Having symptoms after a traumatic event is not a sign of personal weakness. Many psychologically well-adjusted and physically healthy people develop PTSD. Probably everyone would develop PTSD if they were exposed to a severe enough trauma.

· When a person understands trauma symptoms better, he or she can become less fearful of them and better able to manage them.

· By recognizing the effects of trauma and knowing more about symptoms, a person is better able to decide about getting treatment.

http://www.ncptsd.org/facts/general/fs_effects.html

PTSD: Parallel Responses


Characteristics In Veterans:


INTRUSIVE THOUGHTS AND FLASHBACKS:

Replaying military experiences in their minds, searching for alternative outcomes. Flashbacks triggered by everyday experiences: helicopters, the smell of urine, the smell of diesel fuel, the smell of mold, the smell of Asian food cooking, green tree lines, popcorn popping, rainy days, and refugees.

ISOLATION:

He has few friends. Isolates family emotionally and sometimes geographically. Fantasizes about being a hermit, moving away from his problems. Believes no one can understand and no one would listen if he tried to talk about his experiences. Isolates himself from his partner, family, and others with a "leave me alone" attitude. He needs no one.

EMOTIONAL NUMBING:

Cold, aloof, uncaring, detached. Constant fear of "losing control"... " I may never stop crying!"

DEPRESSION:

Sense of helplessness, worthlessness, and dejection. Lacks self esteem and suffers from great insecurity. Feels undeserving of good feelings. Seems unable to handle it when things are going well, and may appear to try to be sabotaging the situation.

ANGER:

Quiet, masked rage which is frightening to the veteran and to those around them. Sublimating the rage against inanimate objects. Unable to handle or identify frustrations. Unexplainable, inappropriate anger.

SUBSTANCE ABUSE:

Used primarily to numb the painful memories of past experiences. Heavy use of alcohol, nicotine, caffeine, and other drugs.

GUILT -SUICIDAL FEELINGS AND THOUGHTS:

Self-destructive behavior. Hopeless physical fights, single car accidents, compulsive blood donors. Self inflicted injuries to feel pain - many accidents with power tools. High suicide rate. Financial suicide. As soon as things are well off, doing something to lose it all, or walking away from it. Survivor's Guilt when others have died around them. "How is it that I survived when others more worthy than I did not?" (more so with medical personnel)

ANXIETY or NERVOUSNESS:

Uncomfortable when people walk close behind them or sit behind them. Conditioned suspicion, he trusts no one. Startled responses.

EMOTIONAL CONSTRICTION:

Unresponsive to self, therefore unresponsive to others. Unable to express or share feelings, cannot talk about personal emotions. Unable to achieve intimacy with family, partner, or friends.

DENIAL:

Unable to admit that he has any of the above symptoms or that he may have PTSD. May deny that his military experience could have anything to do with his attitude. In extreme cases, will deny that he was even in the military. Unwilling to seek help. Trusts no one.

Wives, Families, and Close Friends:


MEMORIES:

Preoccupation with the veteran. Constant tension and anxiety because she never "knows what he'll do next". Critical or self-righteous martyr attitude because of "what he has put me through". Continual manipulation of veteran and/or circumstances in order to be in control in a situation that is out of control.

ISOLATION:

May have few friends or be unable to relate to friends as she would like to because Vet has alienated them with his attitude and actions in the past. Vet has isolated family and/or is jealous of them. She has alienated friends because of her constant family hassles. The friends and family she does have tell her to get rid of him.

EMOTIONAL NUMBING:

Sexual problems. She feels that she cannot be truly intimate with the vet. Distrust of God, “how could he let this happen?" Low self esteem. Escapes into fantasy world, TV, thoughts of affairs, compulsive buying, etc. May lean on children, friends, or mother too heavily for emotional support.

DEPRESSION:

Sense of helplessness and hopelessness, "tired of trying.” Low self esteem, evidenced by poor appearance, dirty home, etc.

ANGER and OTHER RELATED EMOTIONS:

Resentment and bitterness developed over the years not only toward vet, but others. Withdrawal from vet and family emotionally. Constant fear and anxiety. May provoke or instigate fights or arguments with vet or take it out on the kids.

OVER RESPONSIBILITY: ("The "Enabler")

In an attempt to keep the family stable, may take over the financial and other responsibilities as well as the "wife" and "mother" roles leading to such traits as: think and feel responsible for others, perfectionism, feels-save when giving, nagging or silence, peace at any price, does things out of sense of duty, feelings of anxiety, pity, guilt, need to "help" husband and others, harried and pressured, constant time pressure, blame the husband or children for spot they are in, feelings of anger, victimization, unappreciation, and being used.

GUILT:

Guilt for having married a vet as well as guilt for thoughts of leaving him. Sorry for putting the children through trauma. Constant financial stress, never knowing how they will be able to pay mounting bills, how long he will work or fault, if I were a better wife, he would be different". Feels guilty about spending money on themselves or having a hard time just having fun. Feels guilty about just about everything. Fears rejection. Often comes from troubled, dysfunctional family.

STRESS:

Feels that if "one more thing happens, I'll loose my mind". Overcommitment leading to constant time pressure.

EMOTIONAL EXPLOSIONS OR PROJECTION:

Take out frustrations on the children. Children may become severely withdrawn or demanding, hyperactive, and agitated. Children may have less friends because of a negative home environment leading to their loss of self esteem. They may try to find fulfillment in other worthy causes, including getting overly involved in the church, children's activities, and other it worthy" organizations or projects.

DENIAL:

Denies that she or the children have problems... "after all, in spite of the circumstances, look how well I keep it together!" Denial that husband has problem or totally blames vet for ALL the problems. Denial that the Lord or others can help her husband or her family.

http://www.geocities.com/~pointmen/PMIMptsd.htm

General Symptoms of PTSD

Q: What are the usual symptoms of PTSD?

A: Symptoms of PTSD tend to fall into three general groups, as shown by the DSM-III-R Diagnostic Criteria for PTSD used by VA up to 11/7/96. In some cases, only one or two symptoms may be manifest for a short time. In other cases, clusters of the symptoms may persist for years.
Intrusive symptoms are frequent memories or images of the trauma that intrude into the lives of the individual, through which the traumatic event is re-experienced. This can take the form of repetitive thoughts, images, and dreams.

Typical symptoms may include:

Depression
Generalized anxiety
Intrusive recall -- different from normal memory in that it brings with it stress and anxiety
Sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociated [flashback] episodes, even those that occur upon waking or when intoxicated).
Recurrent and intrusive distressing recollections and/or of the event.
Intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma.
Survivor guilt

Avoidance symptoms, where sufferers persistently avoid stimuli associated with the trauma, withdraw from social interaction, or have difficulty responding emotionally to others. Because traumatic memories are very unpleasant, the individual tries to avoid situations, people or events which remind them of their stressors.

Typical symptoms may include:

Efforts to avoid thoughts or feelings associated with the trauma.
Efforts to avoid activities or situations that arouse recollections of the trauma.
Inability to recall an important aspect of the trauma (psychogenic amnesia).
Markedly diminished interest in significant activities.
Feeling of detachment or estrangement from others.
Restricted range of affect, e.g., unable to have love feelings.
Sense of a foreshortened future, e.g., does not expect to have a career, marriage, children, or a long life.
Substance abuse

Arousal symptoms arise because severe trauma can cause individuals to feel at risk of further traumatization, so they fell they must be constantly on guard and have trouble sleeping or show increased jumpiness, irritability and anger.

Typical symptoms may include:

Hypervigilance and scanning
Exaggerated startle response
Aggressive, controlling behavior (a high degree of insistence on getting their way)
Irritability, outbursts of anger, violent eruptions of rage
Difficulty falling or staying asleep, insomnia
Difficulty concentrating
Physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event.
Suicidal ideation

Q: What diagnostic criteria for PTSD does the VA use now?

A: Since 11/7/96, the VA has used the DSM-IV Diagnostic Criteria for PTSD. Since DSM-IV is a clinical protocol, we have not included details here (other than the GAF scale, below): however, searching for "DSM-IV" and "PTSD" in any major search engine will identify many sites with details.

Q: What is the GAF Scale?

A: "GAF" stands for "Global Assessment of Functioning" (DSM - IV Axis V). It is a clinical scale presented on page 32 of DSM-IV. A summarized version is shown below for information purposes only; it does not include all detail required for clinical use.

Code Description of Functioning


91 - 100 Person has no problems OR has superior functioning in several areas OR is admired and sought after by others due to positive qualities
81 - 90 Person has few or no symptoms. Good functioning in several areas. No more than "everyday" problems or concerns.
71 - 80 Person has symptoms/problems, but they are temporary, expectable reactions to stressors. There is no more than slight impairment in any area of psychological functioning.
61 - 70 Mild symptoms in one area OR difficulty in one of the following: social, occupational, or school functioning. BUT, the person is generally functioning pretty well and has some meaningful interpersonal relationships.
51 - 60 Moderate symptoms OR moderate difficulty in one of the following: social, occupational, or school functioning.
41 - 50 Serious symptoms OR serious impairment in one of the following: social, occupational, or school functioning.
31 - 40 Some impairment in reality testing OR impairment in speech and communication OR serious impairment in several of the following: occupational or school functioning, interpersonal relationships, judgment, thinking, or mood.
21 - 30 Presence of hallucinations or delusions which influence behavior OR serious impairment in ability to communicate with others OR serious impairment in judgment OR inability to function in almost all areas.
11 - 20 There is some danger of harm to self or others OR occasional failure to maintain personal hygiene OR the person is virtually unable to communicate with others due to being incoherent or mute.
1 - 10 Persistent danger of harming self or others OR persistent inability to maintain personal hygiene OR person has made a serious attempt at suicide.

PTSD and the Veterans Administration

Q: What period does the Veteran's Administration consider being the "Vietnam Era" for benefits?

A: The Vietnam War started, for U.S. veterans benefits, on Feb. 28, 1961 and with an ending date of May 7, 1975. These dates include what the Veteran's Department regards as being the "Vietnam Era."

Q: How can I contact the Veteran's Administration.

A: VA maintains a website at www.va.gov. They also have a 1 800 number for queries, which can be found by going to this site https://iris.va.gov/phonenbrs.asp. Check your local telephone directory for your local office.

Q: How does the VA establish service-related PTSD?

A: Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptoms and the claimed in-service stressor.

Q: What is required to apply for a PTSD disability from the Veterans Administration?

A: There are two basic steps (1) filing a claim with the VA for PTSD and (2) submitting a stressor letter.

Q: What must a claim establish?

A: A claimant must establish that he or she (1) was in the military and (2) was in combat. This process is intended to screen out phony combat veterans.

Q: How do I file a claim?

A: You can file a claim on your own, but there many veterans' organizations will represent you in a disability claim provided you provide them with a limited power of attorney to act in your behalf in the claim process. Contact them directly and they will provide you with full information about the claim process. Claims are forwarded to the VA Regional Office in your

Q. Which organizations can help me file a claim?

A: You have your choice. Look for local offices of national veterans organizations and contact them by mail, email, telephone or in person to see how they can help. Alternatively, you can visit their websites. Many Vietnam Unit Associations are also organized to help their members with claims. Finally, any VA Clinic or Vet Center should be able to put you in touch with a Veteran Service Officer (VSO) who can tell you more.

Some websites that may be helpful are shown below. Please note that this is not a complete list and that finding a suitable organization is your personal responsibility.


***** American Veterans (AMVETS) http://www.amvets.org/
***** Department of Veterans Affairs (VA) http://www.va.gov/
***** Disabled American Veterans (DAV) http://www.dav.org/
***** National Association of State Directors of Veterans Affairs (NASDVA) http://www.nasdva.com/
***** National Veterans Organization (NVOA) http://www.nvo.org/
***** Vietnam Veterans of America http://www.vva.org/


Q: What is a stressor letter?

A: A stressor letter is a written record of combat experiences which you felt were life threatening or have caused you to display symptoms of PTSD. The VA will request your stressor letter after your claim has been filed, usually within 30 to 60 days. The VA requires a stressor letter to support your claim. It is important to submit a thorough stressor letter, because it will largely help determine whether you are eligible for a disability rating and if so, what disability rating you will receive. If the initial stressor letter is rejected, the process to receive disability can be long and discouraging.

Q: What information should a stressor letter contain?

A: The VA will tell what details letter should include, but keep it focused on your actual combat experience where possible. You may find it useful to consider the following points when determining what to include in a stressor letter:
Name, rank, service number, dates in the war zone. Include your MOS, as well as any MOS you served in in Vietnam.
If you received a Purple Heart, include the date(s) wounded. If you were treated for malaria or other illnesses, include basic details.
If you were in actual combat and saw enemy killed, be as specific as possible about what you actually experienced. Write about you, not just about your unit.
If you lost close friends or saw any Americans killed or severely wounded, mention specific details and describe how it affected you. Remembering real names and approximate dates of KIAs will help your claim, as they are verifiable by VA.
Mention any civilian casualties that you saw.
If you handled the bodies of dead Americans, provide details.
Describe in detail times in combat where you lost hope or thought that you would not survive.
Details of combat incidents such as combat assaults, patrols, small arms fire, fire fights, mortar and rocket attacks, booby traps, mine fields, artillery fire, etc.
Names of field operations or missions to help verify your combat role.
How your life has changed because of the war.
Q: What else comes after the claim?

A: After you file for disability, either before or after you have submitted your stressor letter, you will receive a letter asking you to come to the nearest VA Hospital in your area for a Compensation Examination. This just means that you are going to speak to a VA psychiatrist. The psychiatrist will ask you many questions about your background (including your childhood and current social life) and your war service. The meeting with the doctor will probably last anywhere from 20 to 45 minutes. The VA will reimburse you with a small travel allowance for coming. You must show up for this comp exam. If you can't make it, call the VA and they will reschedule you. At the exam, relax and answer questions truthfully. The psychiatrist is not your enemy, he or she will try to determine whether you show symptoms of PTSD and send a report to the VA regional office.

It is the responsibility of the examiner to indicate the extreme traumatic stressor leading to PTSD, if he or she makes the diagnosis of PTSD. It is the responsibility of the rating specialist to confirm that the cited stressor occurred during active duty. A diagnosis of PTSD cannot be adequately documented or ruled out without obtaining a detailed military history and reviewing the claims folder. This means that initial examination to establish PTSD will often require more time than for examinations of other disorders. Ninety minutes to two hours on an initial exam is normal.

Links for PTSD Children and Family

General facts and information about PTSD
www.ncptsd.org/facts/index.html

PTSD Gazette: read the Gazette online or order a free copy - VERY useful for family
www.patiencepress.com/

Family teaching guide; look at Lesson III Effects and Lesson IV Tips, and Lesson V things veterans want their families to know. Be sure to read Handout X.
w3.uokhsc.edu/safeprogram/13.html

Sons & Daughters in Touch
www.sdit.org/

PTSD Links

DAV
www.dav.org
A source for current Veteran legislation


PTSD Manual - & Overview of Disability Process and Social Security claims
www.ptsdmanual.com/
Military Veterans PTSD Reference Manual
www.nasdva.com/

NATIONAL ASSOCIATION of STATE DIRECTORS of VETERANS AFFAIRS
Provides a VA directory for all states

www.va.gov/sta/guide/division.asp?divisionId=1
Department of Veterans Affairs Facility Directory


Info and chat areas:

www.hadit.com
You need a service officer from DAV (Disabled American Vets),
or another organization, or a good claims officer from the VA:
www.dav.org/veterans/claimshelp.html
Real helpful step by step guide online tells you what & how.

www.nasdva.com/
The Crow's Nest - Vet information
tmkc.netfirms.com/vetinfo.html
Appeals
VA Board of Appeals site - case decisions
www.va.gov/vbs/bva/
Claims Resources - BVA appeals

www.psychiatrictimes.com/p011158.html

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Re: VA options.../links for above

www.ptsdmanual.com/
State benefits offices:
www.nasdva.com/
VA Facilities Directory
www.va.gov/sta/guide/division.asp?divisionId=1


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PTSD and Mental Health Links

www.ptsdmanual.com
veterans
www.psych-books.com
neuropsych is as good a place as any to start
(books are also on page 6 of trauma-pages below)
www.trauma-pages.com
You should be able to find just about anything & everything here or from here !


www.bein.com/trauma/
Welcome to trauma anonymous

www.iboww.org/home.htm
Bringing About Global Awareness of PTSD


PTSD and the Family

www.healthyplace.com/Communities/Abuse/Site/transcripts/ptsd.htm
Post-Traumatic Stress Disorder
PTSD DIAGNOSIS AND TREATMENT
online conference transcript

www.ncptsd.org/facts/treatment/fs_coping.html
Coping with PTSD


www.marijuana-anonymous.org/
Marijuana Anonymous is a fellowship of men and women….
recover from marijuana addiction.


www.violenceandsurvival.com

Neuro,psych & science info/urls



www.psychiatrictimes.com
www.neurotransmitter.net

Depakote
www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682412.html

Antidepressant Update by Dr Bob Hsuing
www.dr-bob.org/tips/antidepressants.html

Dr.Shay's medications for Combat PTSD
www.dr-bob.org/tips/ptsd.html

This message has been edited. Last edited by: CherryRead,

Jonathan Shay,M.D.on PTSD medications


A note to the reader: This article is applicable to anyone who seeks to understand the role of medication within the treatment framework of PTSD. Although it specifically addresses the veteran community, we have found the information given to be extremely valuable and well suited for any reader seeking information on this topic. Dr. Shay sincerely regrets that he is not available for consultation on psychopharmacology or questions you may have related to this article. If you would like further information in regards to medication and PTSD, please contact the PTSD specialist through the Sidran Foundation, at 410-825-8888, or e-mail attn. PTSD specialist at sidran@sidran.org.

About Medications For Combat PTSD By Jonathan Shay, M.D., Ph.D. Staff Psychiatrist, Boston VA Outpatient Clinic

A. Point of view

Everything I say here is my point of view, and carries no claim of special authority. Also, what I say here is no way complete. I have left out many important subjects, such as drug interactions, what medical conditions forbid the use of a given drug, overdoses and toxicity, and most specific side-effects. Also, many psychiatrists who also care about combat veterans will disagree with what I say here, particularly about the benzodiazepines like Ativan. Combat PTSD is moral, social, philosophical, and spiritual injury. The biological nature of human beings is to be moral, social, philosophical, and spiritual, so the injury also shows itself as MEDICAL disorders.

Healing is psychological, social, spiritual -- no medicine can cure combat PTSD. However, healing can never mean a return to 17-year old innocence. Healing means building a good human life with others -- a life that a veteran can embrace as his own.

Combat trauma brings about LONG-LASTING CHANGES IN BRAIN CHEMISTRY. We do not know whether these are permanent or can be reversed by psychological/social healing. A few existing medications can help some men with some symptoms of PTSD. We also do not know whether this changes the long-term outcome for the better, BUT THE HUMAN PAYOFF IN REDUCED SUFFERING IS UNMISTAKABLE.
B. A brief course in pharmacology Therapeutic effects (benefits) and side-effects Drugs are dumb chemicals -- they don't know what they are. They aren't born in a laboratory with a word spelled out across their foreheads "Anti-depressant!" or something like that. Most have been discovered by accident. Almost every drug known has multiple effects on the body. Which effect is a therapeutic (beneficial or main) effect and which is an unwanted side-effect is a human decision, not a chemical decision.
Illustrations: Think of the well-known drug Elavil (generic name: amitriptylene). What is it? An anti-depressant you say? Why is it used in the Intensive Care Unit to stabilize the heart beat of certain patients? Not because depression causes their irregular heart beat. Why is it used by neurologists to treat migraine? Not because depression causes migraine -- and the doses that work for migraine are usually too small to touch a depression. The point is, of course that a drug doesn't know what it is. Its successful human uses make it an anti-depressant, a migraine drug, an anti-arrhythmic.
What about side-effects? Again, this is a matter of the human purposes involved. Think of the anti-depressant trazodone (most common trade name: Desyrel). Its most prominent side-effect is drowsiness. I prescribe trazodone fairly often as a sleep medication to veterans who are on fluoxetine. It has the advantage that it doesn't lose its effect with repeated use (which also means there's little withdrawal syndrome when the veteran stops it), and it's almost useless as a pill to kill yourself with. So here the side-effect is the main effect and the anti-depressant effect is a side-effect. -- Is anybody confused yet?
Important to remember: When a drug has several different effects, each effect has its own way of unfolding in time. How long a drug takes to produce its different effects, is often different for each effect. The side-effects may hit immediately and the main effect only develop after several weeks! With another drug it's the opposite, with the main effect coming on immediately and the side effects happening later. An analogy: Think of a plant on your window sill. You've been away for the weekend and its gotten dry and droopy. You give it water and the leaves begin to respond almost as soon as the water goes on -- the plant responds as soon as the water reaches the roots. If the roots dry out, again the plant wilts again. This is like a pharmacokinetic effect. If you put some fertilizer in the water, on the other hand, this reaches the roots as fast as the water reaches them, but you may not see any result for days or weeks. This is because the plant has to build new parts in its own cells. This is like a pharmaco-dynamic effect.
Example: Most anti-depressants reach the brain quickly, but take several weeks to have an anti-depressant effect. This is probably because the changes that have to take place in the cells take that long to happen. However, some side-effects like a dry mouth or drowsiness happen quickly because they do not require cells to make anything new, but only to do what they're already doing faster or slower. Tolerance and withdrawal
I will use alcohol as the example, because most people have considerable knowledge about it. They just haven't realized that they can transfer this knowledge to other drugs. Pharmacologic tolerance is a critically important subject.
Consider a very heavy drinker, who drinks every day and more or less all day. Most of the time he is not drunk, in the sense of staggering or slurring or not thinking clearly. He may function quite well at his job with a blood alcohol level that would put a non-drinker almost in a coma. This is because the drinker has developed a tolerance to alcohol. His brain has adjusted to alcohol's presence and slowly adapted its machinery to get everything back to normal. This adjustment is called pharmacologic tolerance, and it takes a while to happen. The brain has developed a steady, compensating excitation to balance the steady sedating effect of chronic alcohol. When the two are exactly in balance, the drinker thinks and behaves more-or-less normally. If the alcohol is suddenly removed, the brain becomes dangerously over-excited, resulting in delirium tremens, DTs. The compensating excitation corrects itself much more slowly than the alcohol leaves the body. This whole set of events is called a withdrawal syndrome.
The same kind of DT-like withdrawal syndrome of dangerous over-excitement (seizures, hallucinations, etc.) happens after sudden withdrawal from high doses of other sedating drugs that people get tolerant to, such as barbiturates, benzodiazepines (such as Valium), etc. A good rule of thumb is that a patient who has become tolerant to a given drug effect will get a withdrawal syndrome if he or she stops it suddenly. Often, the withdrawal syndrome is the "mirror image" of the original effects of the drug.
Not all of the effects of a drug are detectable by the person taking it, so tolerance to these changes may not be subjectively felt, either. However, during cold-turkey withdrawal from the drug, a withdrawal syndrome may develop that is the mirror image of effects that the person was never aware of. An example of this is caffeine withdrawal headaches. Most people are unaware of the blood-vessel-narrowing effect of caffeine, but once tolerant to this effect, abrupt discontinuation of caffeine can cause headaches due to blood-vessel dilation.

The greatest tolerance and the most severe withdrawal reactions happen with long-term use. However, with some drugs, there can be a miniature version of the whole picture with a single dose. Again, alcohol gives a good example: A man who knocks many drinks back one after another and then stops is much more drunk when his blood alcohol level passes a given point on the way up, than later when his blood alcohol level passes the same point on the way down. This is called acute tolerance, because his body has already adjusted to the presence of the alcohol in the few hours since he started drinking. The next morning, during the hangover, he has a mini-withdrawal syndrome making his nervous system overly sensitive -- how loud every sound seems! -- is the mirror image of how much alcohol deadened sound when he was drunk.

An analogy: You are running a motor boat on a certain compass heading, say due north, on a windless day (no alcohol). Now a cross-wind begins to pick up (gradually increasing steady drinking) and you gradually adjust the rudder to keep on the same heading. Now you are still heading due north, despite the heavy cross-wind. Suppose the wind suddenly dies (suddenly stopping drinking, cold-turkey) and you keep the rudder where it was -- you start going in circles (withdrawal syndrome).
How much tolerance develops to each drug effect varies a lot from effect to effect and from person to person. A person may develop rapid tolerance to a nasty side-effect, such as dizziness. This means the dizziness actually goes away, not that the patient just gets used to it. So this person can bear with the drug and wait around for the therapeutic effect to kick in. Another person may never get tolerant to the dizziness side-effect and cannot make use of that particular drug. There's no iron-clad way to predict a given person's sensitivity to each of the effects of a given drug or how fast, if at all, he will become tolerant to each effect.

C. Things that help Characteristics of good drugs for combat PTSD
Makes something better for the veteran Does not lead to tolerance Does not lead to abuse Cannot be used to commit suicide Does not require blood tests Does not cut a person off from the world or from himself Causes few, bearable side-effects
Some good drugs for combat PTSD
Serotonin reuptake inhibitors: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), etc.
The main effect of fluoxetine on combat vets with PTSD whom I've worked with is to allow them more time to think before they act, particularly in anger. It does this without sedation or cutting a man off from himself or the world. The duration of anger, once aroused, is also shorter. Greater self-mastery of anger leads to an increase in self-respect and relief from a sense of humiliation. Most men feel humiliated after they go off on people in situations they really would not have, if they had had the freedom to choose. In addition to this, fluoxetine may have a direct anti-depressant effect in combat PTSD. Fluoxetine effects on self-control and rage may take many weeks to kick in, although I've seen it as soon as a week.

Fluoxetine is practically useless as a drug to overdose on, if the goal is suicide. All anti-depressants have been known to give long-time depressed people the energy to kill themselves, and fluoxetine is no different. Many combat veterans go through brief periods of intense despair during the first few months that they are feeling generally better, more alive, and are coming out of their bunkers. Support from other veterans, family, therapists is especially important during those times -- nobody should try to go through it alone, or have to. Someone trying to go through it alone, might try to kill himself during one of these times of despair. Remember that this is no special risk with fluoxetine, but is a risk when anyone recovers from severe depression. Several vets I've treated have had bouts of despair like this, but none has ever tried to kill himself during one, because support and therapy are built into the program I'm a part of. The much publicized claim that Prozac has special powers make a previously non-suicidal person violently suicidal is without good foundation. Fluoxetine does have side effects, which not everyone can stand, and it doesn't work for everyone. A full discussion of side-effects, some of which depend on the dose and others not, would be too long for this summary.
Fluoxetine is the first drug of its type to be released for use. Other drugs in the same family have now come along, sertraline (Zoloft) and paroxetine (Paxil). They have been tried by many combat vets around the country, and from what I hear they are not a lot different than fluoxetine as far as main and side-effects. In the relatively limited number of men I have treated with paroxetine and sertraline, this has been what I have heard from them. Paroxetine has a 24 hour half-life and no active metabolites [what the body turns the parent drug into], so if the actions of the drug are otherwise identical to fluoxetine, it will be a superior drug from a safety point of view, because it doesn't hang around in the body so long. But on the down side, paroxetine may be expected to (and is reported to) have a withdrawal syndrome because it leaves the body so fast. Buspirone (Buspar) This anti-anxiety drug works differently from the benzodiazepines (like Valium). Like anti-depressants it takes a few weeks to kick in. It takes effect gradually, like the tide coming in. It usually has few side-effects and may help some people with intrusive thoughts and nightmares. Buspirone has no street value and is almost useless as a suicide pill. I am not aware of other drugs in this family coming along, but I hope there will be. I have recently read the report of a colleague who works with combat veterans that the best results with buspirone come at doses above 60mg/day. I do not yet have enough personal experience with patients who have tried this, to confirm or deny this report. Beta-blockers: propranolol (Inderal), nadolol (Corgard), atenolol (Tenormin), etc. This family of drugs breaks the mind-body-mind vicious cycle in rage reactions, by blocking the body effects of adrenalin. For example, if someone at work says something offensive about Vietnam vets, the words start the mind working into rage. The rage starts in the mind -- but within a second the body responds with adrenalin, which makes the gut burn, the heart pound, the muscles tense. These body changes send loud messages back up to the mind. For some veterans, the roar of the body drowns out all thought and shuts out everything else coming in. When adrenalin is roaring, it's impossible for most people to think clearly and to take in non-combat possibilities in the situation. This is the mind-body-mind vicious cycle that beta-blockers break up. By blocking the adrenalin effect on the body they prevent the roar of the body from drowning out all thought and choice about what you really want. "Is it really in my interests to rip this guy's lungs out? Is it really what I want to do?" When adrenalin is roaring these questions sometimes cannot be heard.

Some vets feel that these medications weaken them, because they associate being pumped up with adrenalin with their personal strength. When someone is over-medicated on these drugs (which started life as blood pressure meds) he is weaker because his blood pressure is too unstable, but this is usually not a problem with a correct dose. Tolerance does not develop to the anti-adrenalin effects of these drugs. Massive overdoses of a beta-blocker can be fatal, by dropping the blood pressure and slowing the heart to the point that the brain is not getting enough blood flow. Low-dose lithium Some respected practitioners of PTSD pharmacotherapy speak highly of lithium to help veterans maintain their self-control when they are angry. This means doses of about 600mg/day, far less than is usually need to treat bipolar affective disorder (manic-depressive disorder), and does not imply that the doctor recommending this thinks that the veteran is manic-depressive.
I agree that this can help some veterans, but I have found fluoxetine to be more reliable. It is also safer, in that lithium is readily fatal in a large overdose. For a veteran who cannot tolerate fluoxetine and whose life has been blighted by explosive violence, low-dose lithium may be a good thing to try. [no blood tests because of low dose] Other drugs for special circumstances
Trazodone (Desyrel) for sleep Trazodone is a non-toxic anti-depressant that has a useful side-effect: It causes drowsiness, and people don't get tolerant to this effect. Because fluoxetine slows the rate that the liver breaks down trazodone, much lower doses are needed for sleep by patients on fluoxetine than people who are not on fluoxetine. Quinine for nocturnal myoclonus This is the "sleep jerks." If quinine works, the veteran himself may not notice much but his wife has much better sleep. Low-dose antipsychotics for violent urges: thioridazine (Mellaril), mesoridazine (Serentil), etc. The key here is brief treatment on an as-needed basis, controlled by the veteran himself [for a limited time, when hospitalization is not possible]. The doses needed have been low, and I prefer the sedating anti-psychotics like thioridizine and mesoridizine, which appear to carry the least risk of dangerous (neuroleptic malignant syndrome) or possibly irreversible (tardive dyskinesia) complications. An unexpected additional use for these drugs also involves brief, low-dose treatment: to help someone who wants to get off marijuana get through the withdrawal syndrome. Future drugs Many combat veterans with PTSD feel dead inside. It is possible that this psychic numbing comes from the brain making its own opium-like substances, and that opiate blockers can give people back their feelings. It is not yet clear whether this works.
I hope the future will bring a drug like clonidine (trade name: Catapres) that people do not develop a tolerance to. In my experience, about one out of five combat veterans with PTSD experience major improvement of almost all of their PTSD symptoms on clonidine -- but the heartbreak has been that they grew tolerant to it in about a week. Any future drug in this family that does not induce tolerance to this effect will relieve much suffering. A new drug in this family, guanfacine (tradename, Tenex) has recently appeared, but I have no experience with it and have not heard any reports of usefulness to combat veterans with PTSD.
The most helpful drugs are likely to be ones that don't yet exist.

D. Things to avoid

One of the useful things I do for veterans I see is help them identify and get off of drugs that they use (whether prescribed by doctors of not) that are harming them. Some of what I say here is likely to be controversial. Benzodiazepines: diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), etc. Disinhibition: All the drugs in this class are similar to alcohol. Some people who "lose all their inhibitions" on either alcohol or benzos or both. This "dis-inhibition" can affect practically anything that a person thinks he might like to do -- but doesn't do -- when sober. It has included suicide and murder, but most often involves saying things that cumulatively do great damage to a veteran's life. A lot of family stress among veterans comes from things said to wives and children the veteran wishes he hadn't said, the moment it was out of his mouth. One of the inhibitions that benzos weakens is the inhibition about saying hurtful things to people we love. Memory loss: All of the benzos weaken the ability to remember what happened a short time ago, including things you yourself did or said. The more potent the benzo, the more it wipes out short-term memory -- this is probably why Halcion (generic name: triazolam) has been such a bad actor, it's one of the most potent. Here's a little scene that everyone has experienced one way or another:

"I'm going out for cigarettes -- want anything?""Quart of orange juice and a box of Pampers.""OK" Half hour later you're back -- with your cigarettes! No one is 100% on things like this, but people on benzos are sometimes close to zero.

Short-term memory is something that everyone needs to make relationships work, at home, at work, or anywhere. There's the additional stress that combat vets have when they find themselves forgetting -- they have been in real situations where people died because someone forgot. The tension and guilt that this creates in everyday life can be unbearable, and veterans often do not know that their benzodiazepines are responsible for memory lapses.

Confusion of pleasant side-effects with main effect: The pleasant, couple-of-drinks, or drowsy feeling that you get when you first take a benzo (especially the ones that are rapidly absorbed into the blood) is a side-effect that most (not all) people get tolerant to. Because it comes on at the same time as the anti-anxiety effect, it is natural for patients to think that this pleasant feeling is the anti-anxiety effect. One of the strengths of the benzos is that people do not get tolerant to the therapeutic anti-anxiety effect. A very common problem is that people feel the drug is quitting on them when they become tolerant to the pleasant side-effect, and become very afraid that their anxiety symptoms will return. Often out of fear of fear, they double up on their meds and pressure their doctors to increase their dose. This natural confusion of a gradually weakening, pleasant side-effect with the main effect is responsible for some addictive properties of the benzos.

Mini-withdrawal syndrome between doses: Benzos differ from each other mainly in their pharmacokinetics, that is, how fast they go into the body and how fast they leave. Mini-withdrawal reactions are particularly likely to happen with the benzos that leave the body quickly, such as Halcyon (generic name: triazolam). This is why people who take this drug for sleep often wake up in the middle of the night because they are in the withdrawal phase. Though Xanax does not leave the body quite as fast as Halcyon, it is particularly prone to giving mini-withdrawals between doses. My observation has been that many combat vets on Xanax have periods of anxiety and irritability during each day that do them great harm, and which, in my view are mostly mini-withdrawal reactions between doses.

Possible dangerous peculiarities of Xanax in PTSD during withdrawal: The staff of the in-patient PTSD unit at the American Lake VA in Washington State have published a paper reporting extreme violence by combat vets treated for long periods with Xanax and then taken off of it. This was apparently more frequent and more severe than what they found taking their patients off of other benzos, such as Valium. Several Vietnam combat veteran peer counselors whom I respect very highly, feel that Xanax has done a lot of harm. Xanax has some unique properties among its cousins in the benzodiazepine family. In lab tests Xanax acts the opposite at low blood levels of how it acts in the larger amounts actually used in medical practice. When you think about it, everybody passes through a low blood level twice when they take a pill -- once when the pill is just being absorbed in the body and once when the body is almost done getting rid of it (unless, of course, the person takes the same pill again, before the first one is completely gone). Whether this is what causes the problems with Xanax is not clear right now. Caffeine The pharmacology of caffeine is horribly complicated: it's not just one drug, it's really three, each of which can have a different effect on different people. The way it's three drugs is that it's the original caffeine, then the body converts it into theobromin, which the body then converts into theophyllin. The peak effects of these three successive drugs are roughly two hours for caffeine, four hours for theobromin and six hours for theophyllin. The good effects that any of these three drugs can have is feeling more awake, energetic, and optimistic. The bad psychological effects that any of these three drugs can have are anxiety and depression. A given person does not necessarily react to all three the same way. (I'm not talking here about the well-known effects of caffeine on sleep -- this is another important topic in itself. What many people are unaware of is that at very high doses -- like 15+ cups of coffee a day -- caffeine can reverse on you and it can be impossible to stay awake, unless the caffeine is stopped.)

Someone who reacts badly to caffeine itself has usually found that out long ago, because the anxiety and/or depression hits them soon after the big mug of coffee. These people know it's not for them. But there are literally millions of people who feel good after caffeine itself but have bad reactions to either theobromin or theophyllin (four or six hours after that big mug of coffee) and just think it's their life that's out of whack, not their brain chemistry. THERE IS NO WAY TO TELL WHETHER CAFFEINE AND ITS METABOLITES ARE RESPONSIBLE FOR YOUR ANXIETY AND/OR DEPRESSION UNLESS YOU TAKE YOURSELF OFF IT COMPLETELY FOR SEVERAL WEEKS. This means coffee, tea, Coke, Pepsi, Mountain Dew, Jolt, headache pills with caffeine. Some people are so sensitive to it that even the small amount of caffeine in decaffeinated coffee and in chocolate causes psychiatric symptoms. If you decide to take yourself off caffeine to see what your life is like, don't go cold turkey. Taper yourself off over a week or so, or you are likely to get severe withdrawal headaches. Yohimbine Yohimbine (brand names: Actibine, Aphrodyne, Yocon, Yohimex) is absolutely contraindicated in combat PTSD. It causes flashbacks and panic attacks. This drug is sometimes used to treat impotence. Any illegal drug The problems and appeals of specific illegal drugs in combat PTSD is a very big subject that can't be covered here, but all illegal drugs cause the following problems for combat vets with PTSD.Expense is the first problem -- I know there are Vietnam vets who have been very successful financially, but the men I know who have severe, chronic PTSD have a heroic struggle to make ends meet. I know it's stating the obvious, but the first problems of illegal drugs is the expense.

The second problem is much more subtle -- Getting illegal drugs involves you in relationships with and obligations to people you normally wouldn't let within a mile. Most of the combat vets I know have a very sharp eye for quality in human beings, and feel constantly tainted by the people they get involved with to support their habits.
The third problem is that situations of real danger and the presence of weapons gets in the way of healing from PTSD. In this country and time it's not possible to sustain a drug habit over a period of years without running into situations that rekindle PTSD because of their real combat elements.

The fourth problem is the worst -- using illegal drugs often puts veterans in situations where they bring down other vets. Calling for rescue is a very common way of bringing down other vets, even if the rescue is "successful." Users need to be rescued from the medical complications of their habits, from the pressure of debts to dealers, and so on. Vets who have been on rescue missions are put back into combat-mode and are wired for weeks after a rescue. Sometimes users bring down other vets by asking them for dangerous favors (e.g., "hold this for me till I come for it" where "this" is a parcel of drugs or drug-related weapons or money). And finally -- this is really obvious but it needs to be said -- if a fellow vet is trying to stay clean and you're using, this amounts to a standing invitation to break out.

All information on these pages© the Sidran Institute, 1995-2003

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Primary Care Treatment of Post-traumatic Stress Disorder


JENNIFER TRAVIS LANGE, CAPT, MC, USA, CHRISTOPHER L. LANGE, CAPT, MC, USA, and REX B.G. CABALTICA, M.D. Eisenhower Army Medical Center, Fort Gordon, Georgia A patient information handout on post-traumatic stress disorder, written by the authors of this article, is provided on page 1046. This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.

Post-traumatic stress disorder, a psychiatric disorder, arises following exposure to perceived life-threatening trauma. Its symptoms can mimic those of anxiety or depressive disorders, but with appropriate screening, the diagnosis is easily made. Current treatment strategies combine patient education; pharmacologic interventions, such as selective serotonin reuptake inhibitors, trazodone and clonidine; and psychotherapy. As soon after the trauma as possible, techniques to prevent the development of post-traumatic stress disorder, such as structured stress debriefings, should be administered. A high index of suspicion for post-traumatic stress disorder is needed in patients with a history of significant trauma. (Am Fam Physician 2000;62:1035-40,1046.)

Members of various medical faculties develop articles for "Practical Therapeutics." This article is one in a series coordinated by the Department of Family and Community Medicine at Eisenhower Army Medical Center, Fort Gordon, Ga. Guest editor of the series is Ted D. Epperly, COL, MC, USA.

Post-traumatic stress disorder (PTSD) can affect a wide range of patients in family practice, regardless of culture, age, sex or socioeconomic class. Busy clinicians need to be aware of its possible diagnosis to provide compassionate and effective care to affected patients or to initiate preventive interventions to those at risk.
The overall prevalence of this disease in the U.S. population is estimated to be between 1 and 12 percent.1 In populations at risk, it ranges from 0.2 percent in postpartum women to 18 percent in professional firefighters, 34 percent in adolescent survivors of motor vehicle crashes, 48 percent in female rape victims and 67 percent in prisoners of war.2-5
The clinical course is variable. Symptoms may emerge immediately and disappear after several months, or they may take longer than six months to appear and last indefinitely. In prevalence studies, one half of those suffering from PTSD have been estimated to still meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), after one year, and up to one third still have weekly symptoms 10 years after the trauma.1,6 This article provides strategies for primary care physicians to diagnose, treat and refer patients with PTSD.

Diagnostic Criteria

Four categories of criteria are needed to accurately diagnose PTSD (Table 1). First, a traumatic event occurred in which the person witnessed or experienced actual or threatened death or serious injury and responded with intense fear, horror or helplessness. Second, on exposure to memory cues, the person has reexperiencing symptoms, such as intrusive recollections, nightmares, flashbacks or psychologic distress. Third, the patient avoids trauma-related stimuli and feels emotionally numb. Fourth, the person has increased arousal, manifested by hypervigilance, irritability or difficulty sleeping. The symptoms persist for at least one month and significantly disturb the patient's social or occupational functioning (or both).6
TABLE 1 Diagnostic Criteria for Post-traumatic Stress Disorder --------------------------------------------------------------------------------

The person has been exposed to a traumatic event in which both of the following were present: The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person's response involved intense fear, helplessness or horror. note: In children, this may be expressed instead by disorganized or agitated behavior. The traumatic event is persistently reexperienced in one (or more) of the following ways: Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions. note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. Recurrent distressing dreams of the event. note: In children, there may be frightening dreams without recognizable content. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated). note: In young children, trauma-specific reenactment may occur.
Intense psychologic distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. Physiologic reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: Efforts to avoid thoughts, feelings or conversations associated with the trauma. Efforts to avoid activities, places or people that arouse recollections of the trauma. Inability to recall an important aspect of the trauma. Markedly diminished interest or participation in significant activities. Feeling of detachment or estrangement from others. Restricted range of affect (e.g., unable to have loving feelings). Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children or a normal life span).
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: Difficulty falling or staying asleep. Irritability or outbursts of anger. Difficulty concentrating. Hypervigilance. Exaggerated startle response. Duration of the disturbance (symptoms in Criteria B, C and D) is more than one month. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. Specify if: Acute: If duration of symptoms is less than three months. Chronic: If duration of symptoms is three months or more.
Specify if: With delayed onset: If onset of symptoms is at least six months after the stressor.
--------------------------------------------------------------------------------Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, D.C.: American Psychiatric Association, 1994:427-9. Copyright 1994.
Acute stress disorder (ASD), an anxiety disorder, is similar to PTSD in that it occurs after exposure to a traumatic event. Symptoms of ASD appear within four weeks of the trauma and last from two days to four weeks. As with PTSD, they include reexperiencing, avoidance and increased arousal. However, fewer symptoms are required in each category to make a diagnosis. ASD is distinguished from PTSD by having more dissociative symptoms; that is, patients describe feeling "as if in a daze" or have temporary amnesia about the trauma. ASD may progress to PTSD but is more responsive to treatment, emphasizing the need for early recognition and intervention.

Comorbidity

Up to 80 percent of patients with PTSD have a comorbid psychologic disorder.7 Having had a psychiatric diagnosis before a trauma increases a person's risk for developing PTSD. Also, having PTSD increases the risk of later developing psychiatric problems.8 The most common diseases that occur with PTSD are major depression, dysthymia, generalized anxiety disorder, substance abuse, somatization, panic disorder, bipolar disorder, phobias and dissociative disorders.7 Any coexisting psychiatric conditions should be treated simultaneously with PTSD because the particular psychologic issues cannot be separated.

Screening Techniques

Diagnosing PTSD in an office visit can be challenging. The diagnosis is frequently missed because patients do not typically volunteer information about the traumatic event or the stereotypic PTSD symptoms. Although direct questioning is necessary, making the diagnosis requires more than checking off a list of symptoms. It often requires a nonjudgmental approach and expressions of empathy and interest. Patients differ in their perception of trauma. Gently probing for symptoms facilitates the rapport patients need to be more forthcoming about their distress.
To ensure that the diagnosis is not missed, a brief trauma history should be included in all evaluations for anxiety or depression. Traumatic events of adulthood can be asked about directly: for example, "Have you ever been physically attacked or assaulted? Have you ever been in a severe accident? Have you ever been in a war or disaster?" A positive response should alert the examiner to inquire further about the relationship between the event and the current symptoms. Traumatic childhood experiences require reassuring statements of normality to put the patient at ease: "Many people continue to think about frightening aspects of their childhood. Do you?"9
TABLE 2DREAMS: A Mnemonic for Screening Patients for Post-traumatic Stress Disorder --------------------------------------------------------------------------------

Detachment

Reexperiencing the event
Event had emotional effects
Avoidance
Month in duration
Sympathetic hyperactivity or hypervigilance The mnemonic DREAMS can help elicit pertinent details after the trauma history has been obtained (Table 2). With each event, the examiner should determine if the patient appears emotionally Detached (called alexithymia), either from the event or in relationships with others. It may also manifest as a general numbing of emotional responsiveness. The patient Reexperiences the event in the form of nightmares, recollections or flashbacks. The Event involved substantial emotional distress, with threatened death or loss of physical integrity, and feelings of helplessness or disabling fear. The patient Avoids places, activities or people that remind the patient of the event. The symptoms have been present longer than one Month, and the patient experiences Sympathetic hyperactivity or hypervigilance, which may include insomnia, irritability and difficulty concentrating. As with all psychiatric interviews, assessing imminent danger of the patient to self or others is essential.

Treatment

The diagnosis and treatment of PTSD are complicated. The wide range of symptoms and intricate psychobiologic features make therapy difficult. The three arms of treatment are patient education, pharmacotherapy and psychotherapy. Nearly every patient can benefit from education, which is started at the time of diagnosis. Families may also welcome education about PTSD. The National Alliance for the Mentally Ill (NAMI) has excellent resources and lists of local support groups for patients with PTSD (as well as other mental illness). They can be contacted by calling 800-950-NAMI or on the Internet at www.NAMI.org. State affiliates of NAMI list local support groups at www.apollonian.com/namilocals/default.asp.
If symptoms are severe enough to prevent effective trauma-focused therapy, pharmacotherapy is warranted as a next step. Pharmacotherapy and psychotherapy have been shown to alleviate the three clusters of PTSD symptoms: reexperiencing, avoidance and hypervigilance.10
Up to 80 percent of patients with post-traumatic stress disorder have a comorbid disorder, such as depression, anxiety disorder, substance abuse, somatization or panic disorder. Serotonergic Agents Studies have consistently shown that serotonergic dysregulation can create avoidance, hypervigilance and other associated symptoms.11 Selective serotinin reuptake inhibitors (SSRIs) have the broadest range of efficacy--being able to reduce all three clusters of PTSD symptoms.11 In addition, these agents are used to treat many diseases that often coexist with PTSD. Patients taking sertraline (Zoloft) have reduced alcohol consumption, and those taking fluvoxamine (Luvox) have had a reduction in obsessional thoughts and the elimination of insomnia.11,12
Trazodone (Desyrel) at doses of 50 to 200 mg has SSRI properties and serotonin blockade action. It reverses the SSRI-induced insomnia; augments the antidepressant effects of SSRIs; promotes sleep through its sedative properties; and suppresses rapid eye movement sleep, thus reducing the nightmares associated with PTSD.10
Tricyclic Antidepressants The effectiveness of tricyclic antidepressants in relieving symptoms of PTSD has been mixed. In several studies, their use resulted in modest lessening of the symptoms of reexperiencing and minimal or no effect on avoidance or arousal symptoms. Patients treated with tricyclic antidepressants have not shown greater improvement than those treated with SSRIs, so the newer agents have replaced the antidepressants in pharmacotherapy for PTSD.13
Monoamine Oxidase Inhibitors Monoamine oxidase (MAO) inhibitors irreversibly inhibit monoamine oxidase, the enzyme responsible for the degradation of serotonin and related molecules. They have been used primarily as an effective antidepressant for refractory depression, but their use has been curtailed because of the dangerous side effect of hypertensive crisis in patients whose diets contain tyramine. Patients with PTSD who have received phenelzine (Nardil) have shown moderate to good improvement in reexperiencing and avoidance symptoms, but the drug has had little effect on the symptoms of hyperarousal. Insomnia ceases to be a problem in these patients, and they have a modest reduction in the frequency of nightmares.14 However, there are substantial risks with the use of these agents because patients with PTSD frequently ingest alcohol and other contraindicated or illegal substances.
Selective serotonin reuptake inhibitors have the broadest range of efficacy in the treatment of post-traumatic stress disorder. Antiadrenergic Agents Because autonomic hyperactivity may be a problem in patients with PTSD, antiadrenergic agents may be effective pharmacotherapy. Three agents in particular--clonidine (Catapres), propanolol (Inderal) and guanfacine (Tenex), have successfully reduced nightmares, hypervigilance, startle reactions and outbursts of rage. Most patients respond to treatment with clonidine, 0.2 mg three times a day, titrated from 0.1 mg at bedtime. Patients' blood pressures should be checked periodically when this agent is used for long-term therapy.9
Benzodiazepines Historically, benzodiazepines were the primary agent in PTSD treatment. Alprazolam (Xanax) and clonazepam (Klonopin) have been used extensively, but the efficacy of benzodiazepines against the major PTSD symptoms has not been proven in controlled studies.10 These agents are effective against anxiety, insomnia and irritability, but they should be used with great caution because of the high frequency of comorbid substance dependence in patients with PTSD. Patients should be fully informed of the risks and benefits of these medications, including the risks of dependency and of withdrawal after abrupt discontinuation.

Psychotherapy

Medications are used to relieve the most distressing symptoms, allowing the patient to concentrate on psychotherapy.10 Any medication regimen should be part of a psychotherapeutic process. Attention to a range of issues, including the effects on the family, education about the disease and treatment options, is paramount.
The goal of therapy is to break the pattern of self-defeat by reexamining the traumatic event and the patient's response to it. Education about the disease and recognition of cues or situations that trigger symptoms are invaluable. Improving the patient's coping mechanisms, such as relaxation techniques, can also foster the patient's relationships with others.

PTSD can have devastating effects on the family, and family therapy may be warranted. Cognitive-behavioral therapy, group therapy and stress-inoculation training (systematic desensitization) are helpful against reexperiencing and avoidance symptoms. Substance abuse programs, if needed, are vital before a patient engages in therapy.
Formal psychotherapy is difficult in a brief office visit. Because psychotherapy is frequently required to resolve PTSD, referral to a mental health professional should be considered if symptoms are not quickly relieved with medication.

Initial Management

A prudent approach tailors each treatment plan to the needs of the patient. A good first-line treatment plan is thorough education about the disorder and enrollment of the patient into a local PTSD group. If the physician has time constraints or other difficulties providing supportive therapy, referral to a mental health professional should be considered. Any substance abuse issues should be addressed as an adjunct to therapy. Some PTSD symptoms are difficult for patients to tolerate, and rapid pharmacologic treatment may be helpful. More than one class of medications may be needed to control the diverse symptoms.

SSRIs are efficacious against the broadest range of symptoms, and the number of agents available helps to target patients' symptoms. Although a therapeutic response is usually evident in two to four weeks, any SSRI should be given a minimum of six to eight weeks at therapeutic dosages before it is declared a treatment failure.10
If insomnia continues to be a predominant complaint, trazodone augmentation is a useful and safe alternative to hypnotic agents. Persistent insomnia accompanied by significant hyperarousal and reexperiencing symptoms should be treated with clonidine. The major symptoms of PTSD can be alleviated with the combination of an SSRI, trazodone and clonidine.10 If symptoms persist despite these initial interventions, psychiatric consultation should be obtained before sedative or hypnotic agents are given.

Prevention

The primary prevention of PTSD is vital and should include support and advocacy of community and national efforts to prevent violence and curb its sequelae. Gun control and educational efforts to prevent rape, child abuse and domestic violence are primary preventive strategies that may reduce the incidence of PTSD.
Although secondary prevention has not been well studied, one technique, Foa's brief prevention program, has shown promise in reducing PTSD when started within 14 days of the trauma.15 Victims are educated about common responses to assault and taught breathing and muscle relaxation techniques. They are asked to confront their fear by reliving the assault, and their irrational beliefs about the trauma are challenged. Two months after the treatment, PTSD symptom severity in a treated group was one half that in a group whose symptoms were not treated. Ten percent of the treated subjects met criteria for PTSD, whereas 70 percent of untreated subjects still met the diagnostic criteria, demonstrating that early interventions substantially reduce the morbidity of PTSD. 15

Debriefing on the stress of the critical incident is a prevention method being used with more frequency for groups such as military personnel and victims of natural disasters. A group of participants discusses the key elements of a traumatic incident soon after it is over, verbalizing their emotions and examining their reactions to the witnessed events. Although long-term studies have not proven the efficacy of these stress debriefings in preventing PTSD, in the short term they have decreased anxiety and enhanced feelings of empowerment.
16
Family physicians are likely already caring for patients with PTSD. There are simple strategies to screen and manage those at risk for the disorder. Interventions should be undertaken as soon after the traumatic event as possible with empathic communication and confrontation of irrational beliefs, as needed. The DREAMS mnemonic can help make the diagnosis when it is being considered. Because of the wide range of populations at risk and the many possible approaches to therapy, no one therapeutic approach has been proven the most effective for those who suffer from PTSD. Therefore, prevention and treatment must be tailored to the patient and the available community resources. Although primary care physicians can adequately care for these patients, a multidisciplinary approach will enhance their efforts.
The opinions expressed in this article reflect the views of the authors and do not reflect the opinion of the Department of the Army, the Department of Defense or the United States Government. --------------------------------------------------------------------------------
The Authors
JENNIFER TRAVIS LANGE, CAPT, MC, USA, is currently a fourth-year combined family practice and psychiatry resident at Malcom Grow Medical Center of Andrews Air Force Base, Maryland. Dr. Lange completed two years of a combined family practice and psychiatry residency at Eisenhower Army Medical Center after receiving her medical degree from Georgetown University School of Medicine, Washington, D.C.
CHRISTOPHER L. LANGE, CAPT, MC, USA, is currently a fellow in child and adolescent psychiatry at Walter Reed Army Medical Center, Washington, D.C. He graduated from the Uniformed Services University for the Health Sciences, Bethesda, Md., and served a residency in psychiatry at Eisenhower Army Medical Center, Fort Gordon, Ga.
REX B.G. CABALTICA, M.D., is currently a staff family physician at Worldlink Medical Centers in Shanghai, China. He received his medical degree from Harvard Medical School, Boston, and completed his residency in family practice at Eisenhower Army Medical Center, Fort Gordon, Ga.
Address correspondence to Jennifer Travis Lange, CAPT, MC, USA, 89th MDG, Mental Health Clinic, Andrews Air Force Base, MD 20762 (jennifer.lange@mgmc.af.mil). Reprints are not available from the authors.
REFERENCES
Solomon SD, Davidson JR. Trauma: prevalence, impairment, service use, and cost. J Clin Psychiatry 1997;58(suppl 9):5-11. Reynolds JL. Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth. CMAJ 1997;156:831-5. Wagner D, Heinrichs M, Ehlert U. Prevalence of symptoms of posttraumatic stress disorder in German professional firefighters. Am J Psychiatry 1998;155:1727-32. Stallard P, Velleman R, Baldwin S. Prospective study of post-traumatic stress disorder in children involved in road traffic accidents. BMJ 1998; 317:1619-23. Kluznik JC, Speed N, Van Valkenburg C, Magraw R. Forty-year follow-up of United States prisoners of war. Am J Psychiatry 1986;143:1443-6. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994:424-9. Brady KT. Posttraumatic stress disorder and comorbidity: recognizing the many faces of PTSD. J Clin Psychiatry 1997;58(suppl 9):12-5. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-60. Blank AS Jr. Clinical detection, diagnosis, and differential diagnosis of post-traumatic stress disorder. Psychiatr Clin North Am 1994;17:351-83. Friedman MJ. Current and future drug treatment for posttraumatic stress disorder patients. Psychiatr Ann 1998;28:461-8. Brady KT, Sonne SC, Roberts JM. Sertraline treatment of comorbid posttraumatic stress disorder and alcohol dependence. J Clin Psychiatry 1995;56:502-5. Marmar CR, Schoenfeld F, Weiss DS, Metzler T, Zatzick D, Wu R, et al. Open trial of fluvoxamine treatment for combat-related posttraumatic stress disorder. J Clin Psychiatry 1996;57(suppl 8):66-72. Davidson J, Kudler H, Smith R, Mahorney SL, Lipper S, Hammett E, et al. Treatment of posttraumatic stress disorder with amitriptyline and placebo. Arch Gen Psychiatry 1990;47:259-66. DeMartino R, Mollica RF, Wilk V. Monoamine oxidase inhibitors in posttraumatic stress disorder. J Nerv Ment Dis 1995;183:510-5. Foa EB, Heast-Ikeda D, Perry KJ. Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. J Consult Clin Psychol 1995;63:948-55. Shalev AY, Peri T, Rogel-Fuchs Y, Ursano RJ, Marlowe D. Historical group debriefing after combat exposure. Mil Med 1998;163:494-8.
Copyright © 2000 by the American Academy of Family Physicians.

Article: Recovery Your Mental Health - A Self Help Guide

The information in this booklet is from studies designed to find out how people who experience psychiatric symptoms deal with these symptoms and help themselves feel better. The researcher and the study participants are people who have been told that they have a psychiatric or mental illness. Not all of these ideas work for everyone--use the ones that feel right to you. If something doesn't sound right to you, skip over it. However, try not to dismiss anything before you have considered it.
Have you been told that you have a psychiatric or mental illness like depression, bipolar disorder or manic depression, schizophrenia, borderline personality disorder, obsessive-compulsive disorder, dissociative disorder, post traumatic stress disorder or an anxiety disorder? ___ yes ___ no
feeling like your life is hopeless and you are worthless
wanting to end your life
thinking you are so great that you are world famous, or that you can do supernatural things
feeling anxious
being afraid of common things like going outdoors or indoors, or being seen in certain places
feeling like something bad is going to happen and being afraid of everything
being very "shaky", nervous, continually upset and irritable
having a hard time controlling your behavior
being unable to sit still
doing things over and over again--finding it very hard to stop doing things like washing your hands, counting everything or collecting things you don't need
doing unusual things like wearing winter clothes in the summer and summer clothes in the winter
believing things like the television or radio are talking to you or that the smoke alarms or digital clocks in public buildings are taking pictures of you
saying things over and over that don't make any sense
hearing voices in your head
seeing things you know aren't really there
feeling like everyone is against you or out to get you
feeling out of touch with the world
periods of time go by when you don't know what has happened or how the time has passed--you don't remember being there but others say you were
feeling unconnected to your body
having a hard time keeping your mind on what you are doing
a sudden or gradual decrease or increase in your ability to think, focus, make decisions and understand things
feeling like cutting or hurting your body
feeling like you are a "fake" ___ yes ___ no
If you answered yes to either or both of these questions, this booklet is filled with helpful information and things you can do to feel better.
First , remember, you are not alone. Most people experience feelings or experiences like these at some time in their life. Some of them get help and treatment from health care providers. Other people try to get through it on their own. Some people don't tell anyone what they are experiencing because they are afraid others will not understand and will blame them or treat them badly. Other people share what they are experiencing with friends, family members or co-workers. Sometimes these feelings and experiences are so severe that others know you have are having them even though you have not told them. No matter what your situation is, these feelings and experiences are very hard to live with. They keep you from doing what you want to do with your life, doing things you have to do for yourself and others, and doing things that are rewarding and enjoyable.
As you begin to work on helping yourself to feel better, there are some important things to keep in mind.

You will feel better. You will feel happy again. The disturbing experiences and feelings you've had or are having are temporary. This may be hard to believe but it's true. No one knows how long these symptoms will last. But there are lots of things you can do to relieve them and make them go away. You will want help from others including health care providers, family members and friends in relieving your symptoms, and for on-going help in staying well.
The best time to address these feelings and experiences is now, before they get any worse.
These feelings and experiences are not your fault.
When you have these kinds of feelings and experiences, it is hard to think clearly and make good decisions. If possible, don't make any major decisions--like whether to get a job or change jobs, move, or leave a partner or friend--until you feel better.
These feelings and experiences do not mean that you are not smart or are less important or valuable than other people.
Sometimes people who have these kinds of feelings and experiences are treated badly by people who don't understand. If that happens to you, talk to your friends about it (if you don't have any friends, or only have a few, read the section of this booklet on making new friends. Try to stay away from people who treat you badly. Spend time with upbeat, positive people, people who are nice to you, and who like you just the way you are.
Listen to the concerns and feedback from your friends, family members and health care providers who are trying to be helpful.
These feelings and experiences do not take away your basic personal rights, like your right to:
ask for what you want, to say yes or no, and to change your mind.
make mistakes.
follow your own values, standards and spiritual beliefs.
express all of your feelings, both positive or negative, and to be afraid.
determine what is important to you and to make your own decisions based on what you want and need.
have the friends and interests of your choice.
be uniquely yourself and to allow yourself to change and grow.
your own need for personal space and time
be safe.
be playful and frivolous.
be treated with dignity, compassion and respect at all times.
know the side effects of recommended medications.
to refuse medications and treatments that are unacceptable to you for any reason. You may be told that the following things are not normal. They are normal. These kinds of things happen to everyone and are part of being human.
getting angry when you are provoked
expressing emotion when you are happy, sad or excited
forgetting things
feeling tired and discouraged sometimes
wanting to make your own decisions about your treatment and life.
It's up to you to take responsibility for your behavior and for getting better. You are the only one who can help yourself feel better. However, you can reach out for help from others. What to do if these feelings and experiences feel overwhelming--If any of the following apply to you, or your feelings and experiences feel overwhelming, do some things to help yourself right away.

You feel absolutely hopeless and/or worthless.
You feel like life is not worth living anymore.
You think a lot about dying, have thoughts of suicide or have planned how you will kill yourself.

You are taking lots of risks that are endangering your life and/or the lives of others.
You feel like hurting yourself, hurting others, destroying property or committing a crime . Things you need to do:

Arrange an appointment with your doctor, a health care worker or a mental health agency. If your symptoms make you a danger to yourself or someone else, insist on immediate care and treatment--a family member or friend may need to do this for you if your symptoms are too severe. If you are taking medicines and you think it would be helpful, ask for a medicine check.
Ask a friend or family member to stay with you until you feel better -- talk, play cards, watch a funny video together, listen to music, etc..
Call someone you really like and talk to them about how you are feeling.
Do something simple that you really enjoy, like "getting lost" in a good book, staring at a beautiful picture, playing with your pet or brushing your hair.
Write anything you want to in a notebook or on scraps of paper. You will find other ideas in the next section, Things you can do right away to help yourself feel better. As you learn what helps you to feel better, and take action quickly, you will find that you will spend more and more time feeling well and less time feeling badly.
Sometimes when you feel this bad, you may feel like doing things that are dangerous, frightening to others, or things that will be embarrassing to you or others. Keep in mind that no matter how bad you feel, you are still responsible for your own behavior.
If you possibly can, see a physician or a health care worker you like and trust. These feelings and experiences can be caused or worsened by medical illnesses that you don't know you have--like thyroid problems or diabetes. The sooner you get help, the sooner you will feel better. Insist on help with figuring out what to do about any feelings or experiences that are making you uncomfortable or keeping you from doing the things you want or need to do. If you feel it is necessary, ask to be sent to someone else who knows more about treating these kinds of issues.
Doctors and health care workers can tell you about possible things they can do for you or you can do for yourself that will help you feel better. When you go to see them, take a complete listing of all medicines and anything else you may be using to help yourself feel better, and a list of unusual, uncomfortable or painful physical or emotional symptoms--even if they don't seem important to you. Also describe any difficult issues in your life--both things that are going on now and things that have happened in the past--that may be affecting the way you feel. This will help the doctor give you the best possible advice on what you can do to help yourself. It's always easier to go to the doctor if you take along a good friend. This person can help you remember what the doctor suggests, and could take notes if you want them to.
Your doctor or health care worker is providing you with a service, just like the person who installs your telephone or fixes your car. The only difference is they have experience and expertise in dealing with health issues. Your doctor or health care worker should:

listen carefully to everything you say and answer your questions.
be hopeful and encouraging.
plan your treatment based on what you want and need.
teach you how to help yourself.
know about and be willing to try new or different ways of helping you feel better.
be willing to talk with other health care professionals, your family members and friends about your problems and what can be done about them, if want them to. Your health care rights include the right to:
decide for yourself treatments that are acceptable to you and those that are not.
a second opinion without being penalized.
change health care workers--this right may be limited by some health care plans.
have the person or people of your choice be with you when you are seeing your doctor or other health care worker. Your health care worker may suggest that one or several medicines would help you feel better. Find the answers to the following questions to help you decide whether or not you want to take this medicine, and so that you have important information about the medicine. You can get this information by asking your health care worker or pharmacist, looking it up in a book on medications in the library, or by searching for it on the internet.

What is the common name, product name, product category and suggested dosage level of this medicine?
How does the medicine work?
What does the physician expect it to do? How long will it take to do that?
How well has this medicine worked for other people?
What are the possible dangers of taking this medicine?
What are the possible long and short term side effects of taking this medicine? Is there any way to reduce the risk of experiencing these side effects?
Are there any dietary or life restrictions (such as no driving) when using this medicine?
How are medicine levels in my blood checked? What tests will be needed before taking this medicine and while taking the medicine?
How would I know if the dose should be changed or the medicine stopped?
How much does it cost? Are there any programs that would help me cover some or all of the costs of this medications? Is there a less expensive medication that I could use instead? If your symptoms are so bad that you can't understand this information, ask a family member or friend to learn about the medication and to discuss with you whether or not this is a good medicine for you to take.
If you decide to use medicine or medicines, they must be managed very carefully to get the best possible results and to avoid serious problems. To do this:

use these medicines exactly as the doctor and pharmacist has suggested.
report any side effects to your doctor.
tell your doctor about any times that you have not been able to take your medicine for any reason so the doctor can tell you what to do--do not double the next dose unless the doctor tells you to.
avoid the use of alcohol or illegal drugs (if you are addicted to them, ask your doctor for help).
pay close attention to lifestyle issues that cannot be corrected by medications, such as stress, chaos, poor diet (including excessive use of sugar, salt and caffeine), lack of exercise, light, rest, and smoking.

Things you can do right away to help yourself feel better

Tell a good friend or family member how you feel. Telling someone else who has had the same or similar experiences or feelings is very helpful because they can best understand how you are feeling. Ask them if they have some time to listen to you. Tell them not to interrupt with any advice, criticism or judgments. Tell them that after you get done talking you can discuss what to do about the situation, but that first, just talking with no interruptions will help you feel better.

If you have a counselor you feel comfortable with, tell her or him how you are feeling and ask for their advice and support. If you don't have a counselor and would like to see someone professionally, contact your local mental health agency (The phone number can be found in the yellow pages of your phone book under Mental Health Services.) Sliding scale fees and free services are often available.

In order to deal most effectively with the way you feel and to decide what you are going to do about it, learn about what you are experiencing. This will allow you to make good decisions about all parts of your life like: your treatment; how and where you are going to live; who you are going to live with; how you will get and spend money; your close relationships; and parenting issues. To do this, read pamphlets you may find in your doctor's office or health care facility; review related books, articles, video and audio tapes (the library is often a good source of these resources); talk to others who have had similar experiences and to health care professionals; search the Internet; and attend support groups, workshops or lectures. If you are having such a hard time that you cannot do this, ask a family member or friend to do it with you or for you.

Get some exercise. Any movement, even slow movement, will help you feel better--climb the stairs, take a walk, sweep the floor.

Spend at least one half hour outdoors every day, even if it is cloudy or rainy.

Let as much light into your home or work place as possible--roll up the shades, turn on the lights.

Eat healthy food. Avoid sugar, caffeine (coffee, tea, chocolate, soda), alcohol and heavily salted foods. If you don't feel like cooking, ask a family member or friend to cook for you, order take out, or have a healthy frozen dinner.

Every day, do something you really enjoy, something that makes you feel good--like working in your garden, watching a funny video, playing with a small child or your pet, buying yourself a treat like a new CD or a magazine, reading a good book or watching a ball game. It may be a creative activity like working on a knitting, crocheting, or woodworking project, painting a picture, or playing a musical instrument. Keep the things you need for these activities on hand so they will be available when you need them.

Relax! Sit down in a comfortable chair, loosen any tight clothing and take several deep breaths. Starting with your toes, focus your attention on each part of your body and let it relax. When you have relaxed your whole body, notice how it feels. Then focus your attention for a few minutes on a favorite scene, like a warm day in spring or a walk at the ocean, before returning to your other activities.

If you are having trouble sleeping, try some of the following suggestions:
before going to bed:
avoid heavy meals, strenuous activity, caffeine and nicotine
read a calming book
take a warm bath
drink a glass of warm milk, eat some turkey and/or drink a cup of chamomile tea
listen to soothing music after you lie down
eat foods high in calcium like dairy products and leafy green vegetables
avoid alcohol--it will help you get to sleep but may cause you to awaken early
avoid sleeping late in the morning and long naps during the day
Ask a family member or friend to take over some or all of the things you need to do for several days--like taking care of children, household chores and work-related tasks--so you have time to do the things you need to take care of yourself.

Keep your life as simple as possible. If it doesn't really need to be done, don't do it. Learn that it is alright to say "no" if you can't or don't want to do something, but don't avoid responsibilities like taking good care of yourself and your children. Get help with these responsibilities if you need it.

Avoid nasty or negative people who make you feel bad or irritated. Do not allow yourself to be hurt physically or emotionally in any way. If you are being beaten, sexually abused, screamed at or suffering other forms of abuse, ask your health care provider or a crisis counselor to help you figure out how you can get away from whoever is abusing you or how you can make the other person or people stop abusing you.

Work on changing your negative thoughts to positive ones. Everyone has negative thoughts that they have learned, usually when they were young. When you are feeling badly, these negative thoughts can make you feel worse. For instance, if you find yourself thinking, "I will never feel better," try saying, "I feel fine," instead. Other common negative thoughts and positive responses:
No one likes me. Many people like me. I am worthless. I am a valuable person. I'm a loser. I'm a winner. I can't do anything right. I do many things right.
Repeat the positive responses over and over. Every time you have the negative thought, replace it with the positive one.

Things To Do when You are Feeling Better

When you are feeling better, make plans using the ideas in the previous section.
Things you can do right away to help yourself feel better, that will help you keep yourself well. Include simple lists of:

to remind yourself of things you need to do every day, like getting a half hour of exercise and eating three healthy meals;
to remind yourself of things that may not need to be done every day, but if you miss them they will cause stress in your life, like bathing, buying food, paying bills or cleaning your home.
of events or situations that, if they come up, may make you feel worse, like a fight with a family member, health care provider or social worker, or loss of your job;
and a list of things to do (relax, talk to a friend, play your guitar) if these things happen so you won't start feeling badly.
of early warning signs that you are starting to feel worse, like always feeling tired, sleeping too much, overeating, dropping things and losing things;
and a list of things to do (get more rest, take some time off, arrange an appointment with your counselor) to help yourself feel better.
of signs that things are getting much worse, like you are feeling very depressed, you can't get out of bed in the morning or you feel negative about everything;
and a list of things to do that will help you feel better quickly (get someone to stay with you, spend extra time doing things you enjoy, contact your doctor).
of information that can be used by others if you become unable to take care of yourself or keep yourself safe such as :
signs that indicate you need their help
who you want to help you (give copies of this list to each of these people)
the names of your doctor, counselor and pharmacist
any medications you are taking
things that others can do that would help you feel better or keep you safe
things you do not want others to do or that might make you feel worse Key to successful recovery: family members and close friends
One of the most effective ways to improve the way you feel is reaching out to a very good friend, family member, or health care professional, either telling them how you are feeling or sharing an activity with them. If you feel that there is no one you can turn to when you are having a hard time, you may need to work on finding some new friends.
GOOD FRIENDS ARE PEOPLE WHO HELP YOU FEEL GOOD ABOUT YOURSELF.
Here are some ways you could meet people with whom you may become friends. You may not be able to do these things until you feel better.

Attend a support group. Support groups are a great way to make new friends. It could be a group for people who have similar health issues. You can ask your doctor or other health care professional to help you find one, or check support group listings in the newspaper.
Go to events in your community like fairs and concerts.
Join a special interest club. They are often free. They are usually listed in the newspaper. You will meet people with whom you already share a common interest. It might be a group that is focused on hiking, bird watching, stamp collecting, cooking, music, literature, sports, etc..
Take a course. Adult education programs, community colleges, universities and parks and recreation services offer a wide variety of courses that will help you meet people while learning something new or refreshing your skills. Another benefit is that you will learn something interesting that might open the doors to a new career, or a career change.
Volunteer. Offer to assist a school, hospital or organization in your community. When you feel you have developed a friendship with another person that feels like real friendship, and that person seems as interested and as eager to spend time with you as you are to spend time with them, make a plan to get together. The first time you meet could be a low key activity like taking a walk. Each time you get together, end that time by making a plan for the next time you will be together. If something comes up you want to share in the meantime, you can arrange a get-together by phone or in person.
Make phone calls to your new friend to chat. Use your common sense to determine when to call and how often. Don't ever call late at night or early in the morning until you both have agreed to be available to each other in case of emergency.
As you feel more and more comfortable with the other person, you will find that you talk more and share personal information more often.
Key points about friendships:

Let your friend know what you want and need. For instance, you may say, "Today I need you to just listen to me." Ask them what they need from you.
Spend as much time listening and paying attention to your friends and family as they spend paying attention and listening to you, unless you are feeling very depressed. Then be sure you pay attention to them another time.
Spend most of your time with friends doing fun, interesting activities together, taking turns suggesting activities.
Keep regular contact with your friends, even when things are going well.
Do everything you can to keep yourself well and stable. Others don't have a lot of patience with people who don't take good care of themselves. It takes time to make new friends. If you make one new friend every few months, you are doing very well. Make a list of your friends with their phone numbers. When you most need to reach out, it is hardest to remember who your friends are, or to find their phone number. Have copies of the list of your friends by your phone, on your bedside table and in your pocket.
In Conclusion
Don't try to do everything or make the changes suggested in this booklet all at once. You can incorporate them into your life gradually. As you do, you will notice that you will feel better and better.
If you would like more information, the author of this booklet, Mary Ellen Copeland, has written several books. They are available at bookstores, in libraries or through this website.
Other articles by Mary Ellen Copeland



Contact Info
Mary Ellen Copeland, MS, MA PO Box 301 West Dummerston, VT 05357
Phone: (802) 254-2092 Fax: (802) 257-7499 © 1995 - 2002 Mary Ellen Copeland
All Rights Reserved

http://www.m-a-h.net/library/ptsd/



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Post Traumatic Stress Disorder


On Site Articles

10 Ways To Recognize Post Traumatic Stress Disorder

After a loss, it is normal to go through a natural grieving process. Sometimes, however, after a tragedy, such as a sudden traumatic event, feelings of loss surface several weeks or months after the tragedy occurred. more >>

Post Traumatic Stress Disorder & Treatment
Many methods of therapy have been developed for survivors of trauma. more >>

Post Traumatic Stress Disorder: An Overview
The risk of exposure to trauma has been a part of the human condition since we have evolved as a species. Attacks by saber tooth tigers or twentieth century terrorists have probably produced similar psychological sequelae in the survivors of such violence. more >>

What Is Post Traumatic Stress Disorder?

Post-Traumatic Stress Disorder (PTSD) is a debilitating condition that follows a terrifying event. Often, people with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. PTSD, once referred to as shell shock or battle fatigue, was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. more >>

Eye Movement Desensitization and Reprocessing (EMDR)

Eye Movement Desensitization and Reprocessing (EMDR) is a relatively new clinical treatment that has been scientifically evaluated primarily with trauma survivors. EMDR's originator, Dr. Francine Shapiro, describes the procedure in detail in a recent book, and advises that therapists use EMDR only after completing an authorized advanced training in EMDR. more >>

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Anger

You can improve your negotiation skills, in order to keep intimate relationship intimate. Relationships are a team effort. I can think of a lot of situations such as dealing with a doper and drunks where you probably should not open your mouth. This is really for anger between friends, family and associates where negotiations are possible.

"Beware of the impulse to strike back."

When someone expresses hurt, frustration or irritation, especially criticism about something you have done, your immediate impulse may be to retaliate.
Striking back in retaliation—that is self-defense by means of a strong offense usually just converts a practical problem into a fight. Defending yourself by attacking back even in self-defense invites the other to strike another blow in response, augmenting the unpleasantness and leading further away from effectively solving the problem.

Negotiated Options: Acknowledge the situation. Attempt to say: “ I understand that there is anger between us.
"Ask “What would you prefer?” or “What would you like?” or “What would help?” These questions can help the other to clarify his/her emotions in a calmer manner.

“Beware listening to others like a lawyer."

Lawyers are paid to respond to an opposing lawyer’s comments or witness testimony in a way that focuses on what might be wrong, missing or inaccurate contesting a legal issue. In a relationship, listening like an adversary will derail the dialogue exchange of feelings hindering the ability to find a solution or in a compromise.

“Beware of the urge to critique“:

Critique: to expose the fallacies in his/her line of thought, to point out the inaccuracies of his/her facts, or to show that your view is better. Your viewpoint is the only one that matters.
Negotiated Options: "Listen for what is right, useful, or for what makes sense in what the other says." Restate and verbalize the sense it makes to you.

"Beware of listening like a judge."

Judges determine who is right and who is wrong based on legal precedents. The judge who hears only one point of view creates victims. While judgmental listening and judgmental decisions may be essential in the courtroom, it is a recipe for a disaster outside of a courtroom.
"Express empathy." Empathy involves hearing the other person’s self-description of his/her feelings. Empathy involves considering those feelings seriously and responding in a helpful, caring and friendly manner. Particularly effective is restating what the other feels and then add what makes sense to you about those feelings. Restating the other persons concerns reinforces the concept that you were listening.

" Use bilateral listening." On both sides: relating to or affecting both of two sides

Bilateral listening means hearing both your own concerns—and the concerns of the other person. Self-centered listening often results in a tug of war about whose concerns matter the most. The practical application of bilateral listening combined with empathy leads to compromise and the possibility of a just solution to a problem.

"Beware of bullying."

Bullying occurs when one person insists on getting his/her way, overriding the other. You allow yourself be bullied when you give up something that is important to you. You abandon the opportunity of a negotiated compromise when you have not verbalized your concerns. The seeds of harbored feelings of constant victimization are planted. You may more likely become a bully if you have not sufficiently learned the art of bilateral listening. Bullying requires at least two players. One of the players is overly insistent with the other too willing to quit.

"Braid your dialogue."

Braided dialogue involves listening attentively while the other speaks, verbalizing what you hear, and then adding something from your own viewpoint on that topic while your partner takes the attentive listening role. When you make decisions like a team player working with the rest of the team, the results are negotiated solutions.

Anger and Atrial Fibrillation

Mar 1, 8:28 PM EST
Anger Linked to Stroke Risk in Men Anger and Atrial Fibrillation
By RENEE C. LEE
Associated Press Writer

DALLAS (AP) -- Hotheaded men who explode with anger seem to be at greater risk of having a stroke or dying, new research shows. Their risk is even greater than men who are simply stressed-out Type A personalities.
Angry women, on the other hand, don't run as high a risk of having a stroke or heart problems, according to a study released Monday in the American Heart Association journal Circulation.
The study showed that men who express their anger have a 10 percent greater risk than non-hostile men of developing an atrial fibrillation, a heart flutter that 2 million Americans have. It is non-threatening for many, but it can also increase the risk of stroke.
Men who unleashed their anger were also 20 percent more likely to have died from any cause during the study.
"There has been a perception that you can dissipate the negative health effects of anger by letting anger out instead of bottling it up," said Dr. Elaine Eaker, lead researcher and president of Eaker Epidemiology Enterprises in Chili, Wis. "But that was not the case in this study."
It also found that men who are generally hostile and contemptuous of other people are 30 percent more likely to develop the irregular heart rhythm than men with less hostility.
Atrial fibrillation can lead to stroke because the heart's two upper chambers don't beat effectively enough to pump out all the blood, allowing it to pool, form clots and increase stroke risk.
Researchers have long known about the link between anger and hostility and heart disease, but this study offers a more definitive association, said Dr. John Osborne, a cardiologist at Baylor University Medical Center in Grapevine, Texas, who was not involved in the study.
"There's a lot of things we understand about atrial fibrillation ... but the question is what triggers it," Osborne said. "I think this may give us a better appreciation."
The research also is significant because, unlike other studies, it was long-term and based on a large group of people, he said.
The study analyzed more than 3,000 adult children of the original participants of a landmark study begun in 1948 in Framingham, Mass.
Eaker said that the findings mean scientists can say with more confidence that anger and hostility serve as an independent risk factor. The researchers also determined there is no increased risk in men who rate high in Type A behavior - men who are often rushed, impatient and competitive.
More studies are needed to confirm the study, she said, because the Framingham study was not ethnically diverse and it's always helpful to have replication.
"While we're confident its accurate, it's not appropriate to say it's definitive," she said.
The study followed 1,769 men and 1,913 women who had no signs of heart disease for 10 years.
Even when other risk factors were accounted for, such as other heart problems, high blood pressure, cholesterol and age, certain men still developed an irregular heartbeat.
"It was related to their attitude and temperament," said Eaker, who conducted the study with colleagues at Boston University and the Framingham study.
Researchers did not find a significant link between anger and hostility and the risk of developing atrial fibrillation in the women in the study.
Men have more heart disease at a younger age than women, so researchers may need to follow the women longer, Eaker said.
Osborne said when he first heard about the study, he thought about the old phrase, "Don't get mad, get even."
"I interpret it as one more indication that women are smarter than men," he said. "They don't go into rages."

Copyright 2004 Associated Press. All rights reserved.

Release Date: November 9, 1999
Contact:Joseph A. Boscarino, PhD, MPH
(201) 269-6328
joseph_boscarino@merck.com


Post-Traumatic Stress Disorder May Result In Heart Disease


>Combat veterans with post-traumatic stress disorder (PTSD) appear to be at higher risk for coronary heart disease (CHD), according to a recent study of 4,462 male U.S. Army veterans who served during the Vietnam War. The study results suggest that PTSD and other types of severe psychological distress may actually cause heart disease. While the relationship between severe stress exposures and heart disease has been confirmed in animal studies, this association has been difficult to establish in human studies.

>In this study, electrocardiogram (ECG) examinations detected a higher rate of heart disorders, including evidence of past heart attacks, among Vietnam veterans who were suffering from PTSD at the time of the study than among other veteran subjects. The ECGs also showed that veterans who were experiencing depression or anxiety had a significantly higher rate of heart problems as well. The findings held true even after controlling for other factors, such as smoking history, drug abuse, alcohol consumption, income, education, race, and age.

>"We found a link between long-term, severe psychological distress and ECG results that serve as clear markers for coronary heart disease," said study head Joseph Boscarino, PhD, MPH, who was with the Department of Outcomes Research at Catholic Health Initiatives in Louisville, Kentucky, at the time the research was conducted. "For these men, combat exposure years ago in Vietnam was the principal reason for PTSD, anxiety, and depression, but we believe that the results would be similar when looking at the consequences of severe distress among other groups of people and within other occupations."
>"We believe that this research suggests a clear, definitive linkage between exposure to severe stress and the onset of coronary heart disease in humans," said Boscarino.

>In the research, the 4,462 veterans studied received comprehensive medical and psychiatric examinations and Board-certified cardiologists confirmed all the Veterans' ECG results.

>Abnormal ECG results showed up in 28 percent of the veterans with PTSD, 24 percent of the veterans with depression, and 22 percent of the veterans with anxiety. Fifteen percent of all of the veterans studied had abnormal results.

>Approximately 30 percent of male veterans are known to have developed PTSD after Vietnam service. The study's medical implications are important in the health care of veterans who continue to suffer from PTSD as they age and will be afflicted both with the consequences of severe stress and aging. The results of the research appear in the current issue of Annals of Behavioral Medicine.
>The research was funded by the National Institute of Mental Health and the Sisters of Charity of Nazareth Health System in Louisville, Kentucky. Boscarino is now a senior director in the Center for Outcomes Measurement and Performance Assessment with Merck-Medco in Franklin Lakes, New Jersey.


>Annals of Behavioral Medicine is the official peer-reviewed publication of The Society of Behavioral Medicine. For information about the journal, contact Arthur Stone, PhD, 516-632-8833.


Center for the Advancement of Health
Contact: Petrina Chong
Director of Communications
202.387.2829

www.ncptsd.org/facts/specific/fs_physical_health.html

© 2003 Psychiatric Times. All rights reserved.
Special Report http://www.psychiatrictimes.com/p030435.html

Changes in the Concept of PTSD and Trauma
by Rachel Yehuda, Ph.D.
Psychiatric Times April 2003 Vol. XX Issue 4

Posttraumatic stress disorder develops in response to experiencing, witnessing or even learning about a terrifying event. The event--or trauma--is usually life-threatening, or at least capable of producing bodily harm, and it typically involves either interpersonal violence or massive disaster (e.g., rape, assault, torture, terrorism, car or plane crashes, earthquake, tornado, or flood). Traumatic events have in common the ability to elicit intense and immediate fear, helplessness, horror and distress. These subjective responses lead to a cascade of adverse psychological reactions that can result in the symptoms of PTSD and the resultant disability that is associated with this condition.
The diagnosis of PTSD did not appear in the DSM until 1980. This reflected the reluctance of the mental health field to recognize that the psychological effects of traumatic experiences could be long lasting. Prior to 1980, stress-related symptoms were generally viewed as transient and not requiring intensive treatment. This was in keeping with the pervasive feeling that, with time, people ought to be able to "get over" the effects of a traumatic experience and "move on" without noticeable impairment. According to the DSM and DSM-II, people who developed long-term symptoms following trauma were perceived as constitutionally vulnerable (Yehuda and McFarlane, 1995). The diagnosis of PTSD was meant to pave the way for an improved understanding of the long-term, and possibly even permanent, impact of trauma exposure. Ultimately, systematic testing of hypotheses about the relationship between trauma exposure and long-term symptoms has led to a better understanding of the causes of PTSD and its longitudinal course and biologic basis.

Clinical Features of PTSD

Posttraumatic stress disorder defines a rather specific syndrome in which trauma survivors are unable to get the traumatic event out of their minds. Three symptom clusters are associated with PTSD: 1) reexperiencing symptoms refers to distressing images, unwanted memories, nightmares or flashbacks of the event that cause distress and attendant physical symptoms such as palpitations, shortness of breath and other panic symptoms; 2) the avoidance of reminders of the event, including people, places or things associated with the trauma and becoming emotionally numb, constricted or generally unresponsive to the environment; and 3) hyperarousal, which is reflected in physiological symptoms such as insomnia, irritability, impaired concentration, hypervigilance and increased startle responses. To meet DSM criteria for PTSD, symptoms in each of the three domains must not only be present, but also must be severe enough to cause substantial impairment in social, occupational or interpersonal domains. Furthermore, symptoms must be present for at least one month.

Trauma Exposure

Posttraumatic stress disorder is the fourth most common DSM-III-R disorder, afflicting 7% to 14% of the population at some time in their lives (Yehuda, 2002). Although exposure to trauma is thought to be the major cause of PTSD, there is a marked discrepancy between the number of people exposed to trauma and the number of people who develop PTSD. If one considers the prevalence of PTSD solely among individuals who have been exposed to a potentially traumatic event as defined by the DSM-IV, it would become clear that only about 9% of men and 20% of women who are so exposed develop this disorder (Kessler et al., 1995).
The nature of the trauma experienced seems to be a highly significant factor in determining whether PTSD will develop. Events involving interpersonal violence, such as torture, rape, assaultive violence and combat, are more potent elicitors of PTSD than experiences such as motor vehicle accidents and natural disasters. The former events produce PTSD in as many as 50% to 75% of trauma survivors, whereas the latter types of events often result in PTSD <10% of the time (Kessler et al., 1995). A general point that can be made, however, is that for any given trauma, only a subset of people exposed will subsequently develop PTSD. These statistics suggest that viewing trauma survivors as a homogenous group and trying to base conclusions that might apply generally to such people may result in imprecise conclusions.

Neural/Hormonal Correlates

Exposure to traumatic stress results in a fear response that involves the initiation of concurrent and instantaneous biological responses that help assess the level of danger and then organize an appropriate behavioral response. The amygdala begins the process of activating the neurochemical and neuroanatomical circuitry of fear by activating the startle response, the parasympathetic and sympathetic nervous systems, and the hypothalamic-pituitary-adrenal responses to stress. The hippocampus is involved in helping to terminate these responses. Indeed, this coordinated response to stress is ultimately contained by the release of cortisol from the adrenal gland. The important question in PTSD has been whether and to what extent the normal processes involved in the mounting and containment of stress responses are relevant.
Recent data from prospective studies suggest that, in individuals who develop PTSD, there is an attenuated rise in cortisol in the immediate aftermath of the trauma, and there is evidence of greater sympathetic nervous system arousal (i.e., increased heart rate), suggesting that the fear response is not effectively contained (Yehuda et al., 1998). Relatively lower cortisol levels following trauma may constitute a biologic risk factor for PTSD. Indeed, relatively lower cortisol levels have been noted in adults with chronic PTSD (Yehuda, 2002).
Thus, one model explaining the development of PTSD following trauma proposes that the increased sympathetic nervous system activity leads to an exaggerated sympathetic nervous system response to the trauma, manifested by an increased concentration of adrenaline. This in turn initiates a process in which traumatic memories become over-consolidated or inappropriately remembered due to an exaggerated level of distress. The primary mechanism through which adrenaline facilitates memory formation is by maintaining organisms at a high level of arousal. If cortisol fails to adequately shut down adrenaline, this arousal might be prolonged and the consolidation of the memory facilitated. The increased distress every time there are traumatic reminders would further activate stress-responsive systems, resulting in secondary biological alterations associated with anxiety and hyperarousal (Yehuda, 2002).

Risk and Resilience

The observation that the development of PTSD is the exception rather than the rule in the aftermath of trauma has led to the search for risk factors that contribute to the development of chronic PTSD following exposure to trauma (Yehuda, 1999). In addition to the nature and severity of the traumatic event, previous exposure to trauma, particularly in childhood; a history of psychological and behavioral problems; and familial factors such as parental PTSD and family history of anxiety and depression have been noted as risk factors for PTSD. Gender also appears to be a potent risk factor for the development of this disorder, and studies consistently demonstrate a twofold increase in the prevalence of PTSD in women (Breslau et al., 1991). This issue can only be resolved by studying the prevalence of PTSD in men and women who have been exposed to similar events.
Epidemiological studies that have attempted to examine risk factors have identified clusters of factors that are clearly interrelated. For example, lower levels of education and income, differences in ethnicity, poverty, and lower intellectual functioning have been identified as risk factors for the development of PTSD. These variables are also associated with a greater exposure to traumatic events (Breslau et al., 1991).
A history of family instability is associated with increased incidence of PTSD, and numerous studies have indicated that familial psychiatric history may place an individual at higher risk of PTSD (Davidson et al., 1998). In particular, parental PTSD appears to be a very specific risk factor for the development of PTSD in offspring (Yehuda et al., 2001). It is not clear whether the tendency to develop PTSD is genetic. An intriguing finding examining PTSD in twins has demonstrated that as much as 30% of some PTSD symptoms may have a genetic basis (True et al., 1993).
The development of PTSD may also be associated with the interpretations of the traumatic event and with pre-existing ideas about personal safety. Individuals who believe that the trauma has wide-ranging negative implications for the safety of the world, for the trust they can place in others and for their own ability to cope are more likely to develop chronic PTSD following a trauma. In addition, interpreting initial symptoms as signs of falling apart or being permanently altered for the worse may serve to maintain them. Since such coping styles appear to be shaped by prior experience, they may, in part, explain why earlier trauma can place an individual at risk. Unfortunately, at this time, little is known about resiliency factors that prevent the development of PTSD or increase recovery once this condition develops.
One of the major difficulties in understanding issues related to risk and resiliency in PTSD is that PTSD is not a dichotomous variable. Although it is not technically possible to diagnose PTSD in the immediate aftermath of a trauma because of the diagnostic stipulation that symptoms occur for at least one month, it is true that nearly all (94%) trauma survivors exhibit some degree of acute symptoms (Rothbaum and Foa, 1993). So, initially, most trauma survivors seem to have some type of PTSD response that gradually recedes in most people over time (Kessler et al., 1995). Thus, PTSD may represent the failure to recover from a universal set of reactions (Yehuda, 2002).
If PTSD does represent a failure to recover, it could be assumed that during a specific time period immediately following the traumatic event, the manifestation of symptoms is normal. This raises questions about whether, or more precisely, when, to provide mental health treatment in the aftermath of trauma. The most obvious answer to this, of course, is when the survivor requests treatment, but many trauma experts advocate for treating survivors in the immediate aftermath of trauma, even before they have a chance to fully process what has happened to them. The justification for this approach is that it might help symptoms remit faster and forestall the development of PTSD.
One of the difficulties is that it is unclear at the time of a traumatic event who is experiencing the beginning of a psychiatric disorder and who is manifesting normal symptoms that will abate with time. There is a concern that certain interventions can interfere with the process of normal recovery (Mayou et al., 2000), so this issue is by no means trivial.

PTSD and the Future

The next great challenge in the study of PTSD is to tackle the questions of when and how to define a pathologic state and in whom the risk factors are greatest. The issue of whether PTSD should be defined as the presence of symptoms after an arbitrary cutoff point should be re-examined. Indeed, there is emerging evidence for an alternative approach: to consider those who develop PTSD as those who are most likely to develop the disorder as a result of prior risk factors. In this case, the development of PTSD would represent an alternative trajectory to the normative response. It may very well be that the failure to contain or control the initial biologic response to stress leads to a cascade of events resulting in symptoms of hyperarousal, recollection of intrusive events and avoidance of reminders. In this case, the challenge in the aftermath of a trauma would be to determine who is at risk for failing to recover.
As we contemplate the 23-year history of the diagnosis of PTSD, it seems that the pendulum has swung from failing to acknowledge the effects of trauma to an almost zealous embracing of trauma as a necessary etiologic agent. Although current events provide us with a natural laboratory of recently traumatized people to study and follow, it is essential that the phenomenology and neurobiology of the chronic course serve to ground the perspectives from studies of those acutely distressed.
Dr. Yehuda is professor of psychiatry at the Mount Sinai School of Medicine and founder and director of the Traumatic Stress Studies Program at the Mount Sinai School of Medicine and Bronx Veterans Affairs Hospital.

References

Breslau N, Davis GC, Andreski P, Peterson E (1991), Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 48(3):216-222.
Davidson JR, Tupler LA, Wilson WH, Connor KM (1998), A family study of chronic post-traumatic stress disorder following rape trauma. J Psychiatr Res 32(5):301-309.
Kessler RC, Sonnega A, Bromet E et al. (1995), Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 52(12):1048-1060.
Mayou RA, Ehlers A, Hobbs M (2000), Psychological debriefing for road traffic accident victims: three-year follow up of a randomised controlled trial. Br J Psychiatry 176:589-593 [see comments].
Rothbaum BO, Foa FB (1993), Subtypes of posttraumatic stress disorder and duration of symptoms. In: Posttraumatic Stress Disorder: DSM-IV and Beyond, Davidson JRT, Foa EB, eds. Washington, D.C.: American Psychiatric Press, pp23-35.
True WR, Rise J, Eisen S et al. (1993), A twin study of genetic and environmental contributions to liability for posttraumatic stress disorder. Arch Gen Psychiatry 50(4):257-264 [see comment].
Yehuda R (1999), Risk Factors For Posttraumatic Stress Disorder. Washington, D.C.: American Psychiatric Press.
Yehuda R (2002), Post-traumatic stress disorder. N Engl J Med 346(2):108-114.
Yehuda R, Halligan SL, Bierer LM (2001), Relationship of parental trauma exposure and PTSD to PTSD, depressive and anxiety disorders in offspring. J Psychiatr Res 35(5):261-270.
Yehuda R, McFarlane AC (1995), Conflict between current knowledge about posttraumatic stress disorder and its original conceptual basis. Am J Psychiatry 152(12):1705-1713 [see comments].
Yehuda R, McFarlane AC, Shalev AY (1998), Predicting the development of posttraumatic stress disorder from the acute response to a traumatic event. Biol Psychiatry 44(12):1305-1313.

Psychological Effects of Combat

http://www.killology.com/art_psych_price.htm (excerpt)

The Price of Overcoming the Resistance to Killing
The extraordinarily high firing rate resulting from modern conditioning processes was a key factor in America's ability to claim that US ground forces never lost a major engagement in Vietnam. But conditioning that overrides such a powerful, innate resistance carries with it enormous potential for psychological backlash. Every warrior society has a "purification ritual" to help returning warriors deal with their "blood guilt" and to reassure them that what they did in combat was "good." Features of the ritual are a "group therapy" session and a ceremony embracing the veteran back into the tribe. Modern Western rituals traditionally involve long periods while marching or sailing home, parades, monuments, and unconditional acceptance from society and family.

Risk Factors of PTSD

An estimated 70 percent of adults in the United States have experienced a traumatic event at least once in their lives and up to 20 percent of these people go on to develop posttraumatic stress disorder, or PTSD.
An estimated 5 percent of Americans -- more than 13 million people -- have PTSD at any given time.
Approximately 8 percent of all adults -- 1 of 13 people in this country -- will develop PTSD during their lifetime.
An estimated 1 out of 10 women will get PTSD at some time in their lives. Women are about twice as likely as men to develop PTSD.

Extreme Trauma and PTSD

PTSD may develop following exposure to extreme trauma.
Extreme trauma is a terrifying event or ordeal that a person has experienced, witnessed, or learned about, especially one that is life-threatening or causes physical harm.
The experience causes that person to feel intense fear, horror or a sense of helplessness.
The stress caused by trauma can affect all aspects of a person's life including mental, emotional and physical well-being.
Research suggests that prolonged trauma may disrupt and alter brain chemistry. For some people, this may lead to the development of PTSD.

Recognizing and Diagnosing PTSD

Three categories -- or "clusters" -- of symptoms are associated with PTSD. A diagnosis may be considered if:
A specific number of symptoms from each of the three clusters have lasted for one month or longer, and
The symptoms cause severe problems or distress in personal life, at work, or in general affect daily life.
Clusters:
Re-living the event through recurring nightmares or other intrusive images that occur at any time. People who suffer from PTSD also have extreme emotional or physical reactions, such as chills, heart palpitations or panic when faced with reminders of the event. One or more of these symptoms must be present for diagnosis.
Avoiding reminders of the event including places, people, thoughts or other activities associated with the trauma. PTSD sufferers may feel emotionally detached, withdraw from friends and family and lose interest in everyday activities. Three or more of these symptoms must be present for diagnosis.
Being on guard or hyper-aroused at all times, including feeling irritable or sudden anger, having difficulty sleeping or a lack of concentration, being overly alert or easily startled. Two or more of these symptoms must be present for diagnosis.
People with PTSD may have low self-esteem or relationship problems, or may seem disconnected from their lives.
Other problems that may mask or intensify symptoms include:
Psychological problems such as depression or other anxiety disorders, including panic disorder.
Physical complaints such as chronic pain, fatigue, stomach pains, respiratory problems, headaches, muscle cramps or aches, low back pain or cardiovascular problems.
Self-destructive behavior, including alcohol or drug abuse, as well as suicidal tendencies.
Responses to trauma vary widely and many people who experience extreme trauma do not develop PTSD. However, for those who do, PTSD symptoms usually appear within several weeks of the trauma, but some people don't experience symptoms until months or even years later.

Risk Factors

Those at risk for developing PTSD include:
Anyone who has been victimized or has witnessed a violent act, or who has been repeatedly exposed to life-threatening situations. This includes survivors of:
Domestic or intimate partner violence
Rape or sexual assault or abuse
Physical assault such as mugging or carjacking
Other random acts of violence such as those that take place in public, in schools or in the workplace
Children who are neglected or sexually, physically or verbally abused, or adults who were abused as children
Survivors of unexpected events in everyday life such as:
Car accidents or fires
Natural disasters, such as tornadoes or earthquakes
Major catastrophic events such as a plane crash or terrorist act
Disasters caused by human error, such as industrial accidents
Combat veterans or civilian victims of war
Those diagnosed with a life-threatening illness or who have undergone invasive medical procedures
Professionals who respond to victims in trauma situations, such as, emergency medical service workers, police, firefighters, military, and search and rescue workers
People who learn of the sudden unexpected death of a close friend or relative
Estimated risk for developing PTSD for those who have experienced the following traumatic events:
Rape (49 percent)
Severe beating or physical assault (31.9 percent)
Other sexual assault (23.7 percent)
Serious accident or injury, for example, car or train accident (16.8 percent)
Shooting or stabbing (15.4 percent)
Sudden, unexpected death of family member or friend (14.3 percent)
Child's life-threatening illness (10.4 percent)
Witness to killing or serious injury (7.3 percent)
Natural disaster (3.8 percent)

From The Posttraumatic Stress Disorder (PTSD) Alliance

Memory and emotion…… Thanks for no memory
Nov 13th 2003
From The Economist print edition
Copyright © 2003 The Economist Newspaper and The Economist Group. All rights reserved.

http://www.economist.com/science/displayStory.cfm?story_id=2208626

Some evidence about how and why memories are suppressed
ACCORDING to Freud's theory of repression, the mind hides memories of traumatic events in places where they cannot easily be retrieved, in order to prevent overwhelming anxiety. It is these “repressed memories” that the memory-recovering techniques beloved of some psychiatrists aim to unearth.
The existence of repressed memories is taken as a truism by psychiatry. Unfortunately, it has never been verified by rigorous scientific experiment. And that is not a matter of mere academic interest, since memories apparently recovered by psychiatric techniques such as hypnosis—particularly memories of childhood abuse—have sometimes been enough to put people in prison, even when there has not been any corroborating evidence. Moreover, even in cases where an individual has undoubtedly witnessed something traumatic, the reliability of his memories can be critical to convicting the true perpetrator. Witnesses frequently disagree, and this may reflect the way memory forms. Some actual data on the relationship between unpleasant experiences and memory would therefore be welcome.

In this week's Proceedings of the National Academy of Sciences Bryan Strange, of University College, London, and his colleagues provide some. Rather than abuse their experimental subjects, though, they merely showed them streams of words on a computer screen.

Totalless recall
Some of these words (murder, massacre and so on) had bad connotations. Others (meeting, gathering and conference, for example) were emotionally neutral. The subjects of the experiment, who did not know in advance what was required of them, were asked to look at the stream, which was presented one word at a time. Then, when they had been shown it, they were asked to recall the words in it. In the past, this technique has showed that emotionally charged words are more likely to be recalled than neutral ones. What Dr Strange wanted to look at was how well people remember neutral words adjacent to the emotionally charged ones in the stream. He discovered that words immediately preceding emotionally charged ones were less likely to be remembered than normal.

Intrigued, he pushed a little further. Previous work had established that emotion-associated enhancement of memory is caused, at least in part, by the action of stress hormones, in particular norepinephrine, on a part of the brain called the amygdala. He wondered if a similar mechanism was at work in the emotion-associated memory loss the team discovered.
The action of norepinephrine on the amygdala can be blocked by a drug called propranolol. When the researchers repeated their experiments on volunteers who had been dosed with this drug, they found, as expected, that those volunteers did not remember emotional words any better than neutral ones. In addition, however, they found that memory for neutral words which preceded emotional ones improved.
The team was also able to draw on evidence from a patient who suffers from Urbach-Wiethe disease, a rare genetic disorder that can cause damage to the amygdala. They used brain-imaging techniques to confirm that her amygdalas (people actually have two, one in each hemisphere of the brain) were, indeed, damaged. They also measured her cognitive functions—intelligence, attention and both short-term and long-term memory—and found that these were normal. But her memory was not affected by emotion; she remembered emotionally charged and neutral words equally well, regardless of the order they were presented in.

The memory gap
The kind of memory Dr Strange studied is called explicit memory. It concerns facts and experiences—knowledge that can be recalled by conscious effort and can be reported verbally. Researchers believe that explicit memory is formed in several steps. The first is translating newly learned information into so-called neural correlates. This does not involve permanent changes to the brain's structure. In the second stage, consolidation, structural changes such as the formation and destruction of connections between nerve cells take place. This process involves the expression of genes and the synthesis of new proteins, and Dr Strange suspects that emotion interferes with these biochemical events. As a result, no memory is formed.

Another line of evidence that supports this interpretation is work on post-traumatic stress disorder (PTSD) carried out by Roger Pitman, of Harvard University. Dr Pitman recently conducted a trial to see if propranolol could prevent the development of this disorder, which afflicts those who have been exposed to horrific events, such as battles or plane crashes, with emotionally disturbing flash-back memories. He reasoned that excessive amounts of stress hormones released at the time of a traumatic event might be responsible for overly strong memory formation. Because memory takes time to form, he conjectured that drugs which block the action of these hormones soon after the trauma might decrease the intensity of the memory. This turned out to be true: a course of propranolol started shortly after an acute traumatic event was able to reduce the symptoms of PTSD one month later.

On the face of it, there is something slightly contradictory about these results. It is odd that the amnesia observed by Dr Strange is for events just before an emotionally charged incident, when what is actually desirable is to wipe away any recollection of the incident itself. But a simple laboratory experiment using what are, after all, ultimately harmless words, is not the same as a case of child abuse or the horrors of war. And it seems clear that the amnesia, as well as the memory formation, is in some way a result of the stress hormones.

What is undoubtedly true is that memory, like everything else in biology, is an evolved, functional response. If individuals tend to be better off by not remembering certain things, natural selection will tend to construct their brains that way. Indeed, the existence of post-traumatic stress disorder suggests that individuals are better off without those memories. And in fact, most people do come out of trauma with their psyches intact, so it is possible that what has happened to PTSD sufferers is that the memory-prevention mechanism has gone wrong.

Freud might thus have been right about the reason for what he thought he had observed about trauma and memory. But it looks as though he was wrong about the mechanism. The evidence, though limited at the moment, suggests that memories are not repressed. Rather, they are never formed in the first place. Obviously, no psychiatric technique can recover something that was not there to start with. That is something of which the courts should be acutely aware when they assess the credibility of witnesses. It is also something psychiatrists may care to ponder when they are trying to dredge up “forgotten” childhood memories.

Coping Strategies


Many survivors find it difficult to cope during flashbacks, or times of great stress. It can help to be able to "ground" yourself (knowing where you are, who you are, when it is, and that you're safe right now). Listed below is a compilation of coping strategies from members of the SADM list that many survivors have found useful in helping to ground themselves, feel safer, calm down, and be able to deal with survivor issues, as well as every day events.

1. Wrap yourself in a warm blanket and listen to music
2. Pet a cat or dog (or bird, rabbit, hamster, or other loved pets)
3. Spending time outdoors in nature
4. Go to a local mall and walk off the anxiety in a safe place
5. Lose yourself in a craft project
6. Visit with a neighbor or loved one that has a baby you can hold
7. Call a friend just to hear an understanding voice
8. Set watch alarm in increments of 10-30 minutes -- when it beeps, do a check-in with yourself
9. Get "lost on the computer -- in a game, an interesting site, etc.
10. Get out of the house -- go for a walk, call a friend, write, play a game, be silly, etc.
11. Sit in a pile of stuffed animals, and cuddle them
12. Relax...make posters of good things in your life.. If you cannot think of anything good...ask for
help.
13. Get out of bed...open the curtains...depressed people tend to want to hide.
14. Do self talk
15. Remember you have choices now...that was then this is now...you will not die from emotions
16. Know that it is your responsibility to go to the hospital if you are not safe.
17. Write "I have a choice. I can get angry. I can be mad. I can feel pain. I do not have to hurt
myself.
18. Balance the day with work on therapy, friends, family, and fun..
19. Write a make-believe story
20. Go swimming
21. Call therapist
22. Watch TV
23. Listen to music you can sing along with
24. Eating chocolate or something else really yummy -- slowly, savoring every sensation
25. Writing -- to gain control over emotions -- put the feelings down on paper-they're elsewhere
then
26. Creating a special file where you keep everything that has special meaning for you
-- thank you cards, special messages from friends, affirmations
27. Read an exciting book -- for distraction
28. Go for a walk
29. Reach out -- call a friend, therapist, crisis line, emergency room, etc.
30. Repeat mantras over and over to affirm existence -- example: "We are capable and lovable",
"No one can make us feel inferior without our consent", "I am special and make a difference"
31. Keep a journal of thoughts and feelings
32. Offer love, support and encouragement to others -- makes you feel good
33. Exhale very slowly
34. Ground yourself - look at feet touching floor; look around room
35. Take medication faithfully (if on medication)
36. Cry!!
37. Rock in rocking chair with a stuffed animal
38. Work out at Gym
39. Take a bubble bath
40. Drink Herbal Tea
41. Look into eyes of outside children
42. Vent feelings of sorrow and anger, share feelings of joy and happiness-talk to people you trust
43. Send out love to others
44. Remember that there is always someone out there worse off than you are
45. Playing with ALL your stuffed animals
46. Playing outside in the rain
47. Putting hands into water
48. Covering feet with sand
49. Touching materials/textures you like
50. Looking at stuff in pretty containers
51. Reading brand new, beautiful books
53. Going to a library
54. Do a crossword puzzle
55. Go dancing
56. Go for a drive
57. Going to the movies
58. Staying indoors
59. Sleeping in on a weekend morning
60. Spending the day in bed out of choice
61. Write poetry
62. Draw
63. Go to the Zoo
64. Play tennis -- hit the ball really hard!
65. Make a contract with therapist or friend to not hurt yourself
66. Drink something really cold
67. Punch a pillow
68. Make up a comfort box -- put things like trinkets, pictures, tea, stuffed animals, etc. into it
and get it out when you need to be surrounded with pleasant things
69. Play a musical instrument
70. Try something new that you have never tried before
71. Write a letter to your perpetrator and put everything you have ever wanted to say to that
person in the letter, and then tear it up, shred it, burn it, cut it into small pieces
72. Write name of perpetrator on bottom of shoes and then go for a brisk, pounding walk or run
73. Always have a list of things that work for you in order, and start doing them one by one until
you find something that helps -- always keep a list of people you can call by the phone,
and phone them in order until you reach someone



This page is © Danielle Bond 1999. It was created on September 13, 1999