Trauma's Aftermath: Coping with PTSD

In an era where the threat of terrorism looms over daily life, post-traumatic stress disorder has become as part of the everyday language. This condition, which is known as PTSD, is a reaction that can occur following any kind of traumatic event or series of events.

The best approach to preventing and treating PTSD has been hotly debated in trauma centers and in the media in recent years. And a controversial drug now being studied may help suppress memories that could lead to PTSD. Below, Dr. James Chu, the chief of hospital clinical services at McLean Hospital in Belmont, Massachuttes, and an associate professor of psychiatry at Harvard Medical School, discusses how PTSD, and the way one copes with it, varies from person to person.

What is PTSD?
PTSD is exposure to extremely traumatic events—including situations where one witnesses death or serious injury to somebody else, or where someone is in fear for their own life. It is actually fairly common. Many people get through these events without many residual effects. But some people who have such an experience later go on to develop post-traumatic stress disorder. They can either develop it immediately after the event, or in some cases they may develop it months or years after the event occurred.

How do you know you have PTSD?
A diagnosis of PTSD is usually made when four symptom clusters come together. The first is that event itself took place. The second cluster is the experience of intrusive memories, thoughts, nightmares and/or flashbacks of the event. The third cluster has to do with trying to avoid thinking about or remembering the event. People may try to avoid situations that might remind them about the event, and they tend to feel emotionally constricted or numb and avoid social contact. The fourth cluster has to do with how the body responds physically. People develop what psychiatrists call chronic hyperarousal, which means they are chronically anxious, jumpy, irritable and experience panic attacks and disturbed sleep.

What kind of events can lead to PTSD?
Clinicians who work in the trauma field divide traumatic experiences—somewhat artificially—into single-event trauma and chronic traumatization. Single-event trauma can be something like an automobile accident or being caught in a hurricane. Of course, even among single-event traumas, there are things that are less traumatic or more traumatic. In general, events that cause intrusive bodily harm, such as being raped, are more traumatic. It's not only physically painful and intrusive, but it's intentionally aggressive, sadistic and exploitive.

Certain kinds of chronic traumatization are almost universally damaging. Ongoing traumatization usually includes some kind of captivity, either physical or psychological. Examples include domestic battering, ongoing child abuse and certain kinds of wartime situations such as being a prisoner of war or being tortured.

Who is particularly vulnerable to PTSD?
There are probably some people who are born with more potential to be traumatized than others. Conversely, people who have had a lot of personal support in their lives, who have good coping mechanisms and who maintain positive attitudes may be at slightly less risk for developing PTSD.

The vulnerability to PTSD is also clearly related to the severity of the trauma. If the traumatic experience is a little bit milder, people are probably less likely to develop PTSD. However, if a traumatic event is horrible enough and goes on for a long period of time, almost everybody will develop PTSD in response to it.

How long does PTSD last?
If you do nothing, some cases of PTSD, particularly relatively minor forms following single-event trauma, will resolve on their own. In fact, some experts have suggested that flashbacks are nature's way of trying to desensitize you, to get you to re-experience it enough that eventually you'll be able to tolerate it.

"If it is a single traumatic event, with some reasonable psychotherapy," says Chu, "I think that somebody might expect to improve over a period of weeks or months." But, the response to treatment is extremely variable. It's probably in direct proportion to both the severity of the PTSD and the severity of the traumatic event that caused it. With people who have been the victims of major trauma, particularly ongoing trauma, it often can take many months or even years for them to significantly improve.

How is PTSD treated?
Treating PTSD very much depends on how severe it is and what people bring in terms of their own personal strength and abilities to the treatment. There is some general agreement that if someone can confront the traumatic events and feelings and gain some perspective over them, then what was once overwhelming is then much better understood, accepted and integrated into their other experiences.

However, people come to treatment with a very wide range of abilities to confront the traumatic events. People must have a kind of solid ground to stand on—in terms of structure in their lives, solid coping abilities and a good social network—before starting to cope with memories of the trauma. Trying to confront traumatic events without developing such skills can lead to feeling overwhelmed and out of control again.

For example, the first priority for a woman involved in an ongoing domestic battering is to make sure that she is safe from future battering. Talking about the abuse before she can be physically safe and secure could be extremely overwhelming. Any kind of involvement in destructive activities such as drinking or self-destructive behaviors has to be addressed prior to trauma-focused work. This is the standard of care that has developed over the last 25 years and is called stage-oriented treatment.

What kind of therapy is recommended?
Most of the therapy that's done for people who are traumatized is a mixture of different approaches that include psychodynamic, interpersonal and cognitive behavioral perspectives. There are some kinds of specific cognitive behavioral approaches that have been shown through research to be helpful. For example, there is stress inoculation training (SIT) through which people learn a series of skills in terms of coping with anxiety, coping with their bodily reactions, such as jumpiness, and learning how to deal with stress. There are also types of exposure therapies such as progressive desensitization, in which people gradually approach remembering the trauma in increments that they can tolerate.

Are psychiatric medications a part of treatment?
There are a number of psychiatric medications that do have an official FDA indication for PTSD. Those are mostly some of the newer anti-depressants, the selective serotonin reuptake inhibitors (SSRIs). However, the effectiveness of those medications and a variety of other psychiatric medications varies enormously by patient. Anti-anxiety drugs can be used to try to deal with the panic, jumpiness, and insomnia. Some PTSD patients may do well on mood stabilizers, beta blockers, which help control the manifestations of bodily overactivation, or even anti-psychotic medications that may help agitation and anxiety.

Can be PTSD be prevented?
In the wake of the 9/11 tragedies, help was rushed to the various sites to do grief counseling and to provide early interventions that might prevent the emergence of PTSD. The problem is that there really isn't any time schedule whereby people develop PTSD. Some people will immediately feel the stress and continue to be symptomatic. Other people may feel numb and not have much in the way of symptoms until much later. In fact, two years after 9/11, when some people were just starting to have symptoms, many of the programs that have been put in place immediately after the event were being dismantled.

"I think the prevailing feeling in the trauma field is that we should take the lead from the traumatized people as to when, where and how therapy ought to be done. It's going to vary enormously upon the person," says Chu. Talking compulsively about the trauma might be very helpful for one individual, given who they are and the way they cope. However, encouraging everyone to do so may be very destructive for those who need to feel much more in control and aren't yet ready to begin to talk about those events.

Can the drug propranolol affect memory and prevent PTSD?
The use of propranolol to prevent the development of PTSD is still highly experimental. It blocks some of the body's normal "fight or flight" hormonal reactions. These hormonal reactions are thought to heighten and enhance memory of the events, so that if they are blocked, the event is remembered in a more normal, non-traumatic manner.

What is your advice to someone who thinks that they may have PTSD?
Most importantly, people who think they might have PTSD should realize that this is a medical condition. PTSD is, for the most part, a treatable problem. If people think that they have a real problem that's interfering with their lives, they ought to consult a mental health professional to get a good assessment and some recommendations for treatment.

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