Riverview Psychiatric Center

Psychology Articles by Dr. Arthur Dingley - Living With Posttraumatic Stress Disorder

Dr. Art Dingley

People who live through an horrific event may be affected by the experience for a long time. This has been recognized for centuries. Veterans of military combat were described as having “shell shock” or “combat fatigue” when they had psychological problems which persisted after the fight was over. United States military doctors and psychologists began to think differently about this phenomenon during the Viet Nam war. Their observations led to a more exact description and definition of what we now call Posttraumatic Stress Disorder (PTSD).

During the last thirty years, there has been growing recognition that civilians who have endured, or witnessed, terrible events sometimes exhibit the same persistent difficulties seen in combat veterans. Research by the Veterans Administration began to confirm that the symptoms of PTSD could appear later, not just immediately after the traumatic event. The VA also began to explore effective treatments for PTSD.

PTSD can result from experiencing near death, actual or threatened serious injury, or actual or threatened violation of one’s physical integrity. Sometimes, PTSD can result from witnessing the death or injury of another. PTSD has been known to result from having unexpectedly learned that a close friend or family member was killed or injured. Examples of non-combat events of this magnitude are assault, robbery, rape, kidnapping, motor vehicle accidents, and natural (or man-made) disasters.

During the event itself, a person may react with intense fear, helplessness, or horror. If the person has one of these reactions to such an event, he is at risk of developing PTSD. When that happens, he has three types of symptoms.

First, the traumatic event is persistently re-experienced. This may happen in dreams, or during wakefulness. The dreams or intrusive thoughts are vivid and create a sense that the traumatic event is actually happening. These unwanted recollections may result from cues that resemble or symbolize some aspect of the traumatic event.

Second, the person goes to some lengths to avoid these cues. He may make a conscious effort to avoid thoughts, feelings, people, places, or things which remind him of the event. He may also use unconscious methods to avoid cues, such as feeling numbed, forgetting aspects of the event, losing interest in activities, or keeping feelings flat or bottled up.

Third, the person has an exaggerated “fight-or-flight” response. He may have insomnia, irritability, decreased concentration, hypervigilance (unnecessary watchfulness), or may be easily startled.

When these symptoms have lasted more than a month, and when the symptoms cause impairment in functioning, the person has PTSD. Although everyone with PTSD, by definition, has all three symptom clusters, the intensity of each symptom differs with the individual and with the type of traumatic event he experienced. There is some evidence that if the traumatic event was inflicted by another person (as opposed to an accident or natural disaster) symptoms are more apt to include problems with regulating emotion, self-injury, impulsive behavior, hopelessness, and hostility.

What other conditions can be confused with PTSD? Acute Stress Disorder may follow a traumatic event. The symptoms are the same but resolve in less than four weeks. Other anxiety disorders, such as Obsessive-Compulsive Disorder, with its intrusive disturbing thoughts, may mimic PTSD. People who are becoming psychotic, especially people with paranoia, may be anxious, hypervigilant, avoidant, and having intrusive disturbing thoughts. People with Borderline Personality Disorder are exquisitely sensitive to perceived rejection and are quick to interpret negative interactions with family members and close associates as “abuse”. They may ruminate about past “abuse” when things go badly in real time. It is not clear that people can forget a traumatic event, such as childhood sexual abuse, then suddenly remember it years later. Many of these experiences are the work of incompetent psychotherapists who have unintentionally created false memories in their clients by the power of suggestion. “Recovered memories” of childhood abuse were the basis of many lawsuits against accused abusers ten to twenty years ago. Now, “false memory syndrome” is increasingly the basis of lawsuits brought by clients and family members against therapists whose work “uncovered” evidence of forgotten abuse.

What makes PTSD worse? Drugs and alcohol always make PTSD worse. The side effects of alcohol, and many illegal drugs, include depression, anxiety, paranoia, memory loss, decreased concentration, and greater impulsivity – things a person with PTSD doesn’t need. Avoidance, although it does not make PTSD worse, always makes it permanent. People with PTSD who avoid work, hobbies, relationships, and social interaction will never get better. Psychotherapy which focuses on the past, not the present or future, can increase the symptoms of PTSD.

How is PTSD treated? It was hoped that “debriefing”, or counseling, immediately after a traumatic event would help prevent PTSD. Although there was never any evidence for this, it seemed intuitively correct. Versions of “critical event debriefing” or “grief counseling” have been widely provided in disasters or in schools where there has been a traumatic event such as a student suicide. Research has shown this approach to be worthless.
There is some evidence that treating people who have been exposed to horrific events, immediately after the event, with medicines called “beta blockers” can prevent PTSD. Once the symptoms have developed, however, medicine is less useful. Although medicines can relieve some of the symptoms of PTSD, they should be prescribed sparingly. Indeed, to the extent that medicines simply allow the person to avoid the unpleasant aspects of her condition, pills may prolong the symptoms.

The most effective treatment for PTSD is cognitive-behavioral therapy. CBT teaches skills which make people more effective in controlling their thoughts, feelings, actions, relationships, and self-image. This form of treatment is most effective in a group setting. Participants complete “homework” assignments between sessions. The homework allows people to practice putting their skills to work in the real world, not just in therapy sessions. Avoidance techniques (conscious and unconscious) must be identified and overcome.

As with most psychiatric illness, recovery depends upon sobriety, family supports, and attention to physical health through diet, sleep, and exercise. Regular, purposeful activity (preferably, paid employment) is the equal of any other form of treatment.

In the next column, we’ll shift gears and look at dementia, particularly Alzheimer’s disease.

Dr. Dingley is a psychiatrist at Evergreen Behavioral Services in Farmington. He may be contacted at adingley@fchn.org

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Psychology Articles by Dr. Arthur Dingley - Living With Posttraumatic Stress Disorder

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