Posttraumatic Stress Disorder

Scientific and Professional Dimensions

Julian D Ford, Damion J. Grasso, Jon D. Elhai, Christine A. Courtois

• Publisher: Academic Press
• Year: 2015
• Edition: 2
• eBook ISBN:
  9780128014394
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

This comprehensive overview of research and clinical practice in PTSD includes new insights into assessment with regard to DSM-5 and ICD-11, discussion of ongoing controversies in the field as to what constitutes safe and effective care, and new research as to assessment, diagnosis, treatment, and prevention of PTSD. The second edition includes new coverage of the neurobiology of PTSD, PTSD in special populations, and forensic issues relating to PTSD. - Synthesizes research and clinical developments on PTSD - Highlights key controversies, issues, and developments in the field - Provides case studies for better understanding of clinical care - Encompasses DSM-5 and ICD-11 major revisions to PTSD symptoms - Includes new coverage of neurobiology and genetics of PTSD - Includes advances in prevention and treatment of PTSD - Includes new coverage of forensic issues related to PTSD

1

Understanding psychological trauma and posttraumatic stress disorder (PTSD)

Traumatic stressors and the resultant psychological trauma have been sources of both horror and fascination for thousands of years. Both have been documented in many different art forms and in written histories across the ages. Events or experiences that confront a person—or an entire community or society—with actual or imminent death or destruction are terrifying and life-changing. Something unique happens when you are overwhelmed and “see your life flash before your eyes”—and that “something” is a biological, psychological, communal/social, and spiritual shock that is called traumatic stress. Exposure to traumatic stressors most often results in posttraumatic reactions, but when these reactions become persistent and debilitating, they are no longer just “normal reactions to abnormal circumstances”; they have become a posttraumatic stress disorder (PTSD).

Keywords

Psychological trauma; traumatic stressor; traumatic stress; intrusive re-experiencing; avoidance; emotional numbing; hyperarousal; hypervigilance; posttraumatic stress disorder; posttraumatic emotions; posttraumatic beliefs

Traumatic stressors and the resultant psychological trauma have been sources of both horror and fascination for thousands of years. Both have been documented in many different art forms and in written histories across the ages. Events or experiences that confront a person—or an entire community or society—with actual or imminent death or destruction are terrifying and life-changing. Something unique happens when you are overwhelmed and “see your life flash before your eyes”—and that “something” is a biological, psychological, communal/social, and spiritual shock that is called traumatic stress. Exposure to traumatic stressors most often results in posttraumatic reactions, but when these reactions become persistent and debilitating, they are no longer just “normal reactions to abnormal circumstances”; they have become a posttraumatic stress disorder (PTSD).

Technically, PTSD is a psychiatric disorder that affects as many as one in 14 adults and adolescents at some time in their lives and as many as 1 in 20 children before they begin kindergarten. Trauma-related disorders were the second or third most costly health problem in the United States in every year surveyed from 2000 to 2012. (the most recent year for which costs have been officially tallied), according to the federal Agency for Healthcare Research and Quality (Box 1.1, Figures 1.1 and 1.2). Only heart disease was consistently more costly than trauma-related disorders, and cancer was generally slightly less costly (except in 2004). This was true even though the cost per person was three to four times higher for heart disease and cancer (due to expensive high-technology and pharmacological treatments and the high rates of death or total disability). This means many more persons suffer from trauma-related disorders than from either heart disease or cancer, and the costs, including treatment, to both them and society exceed those of any other disorder or illness except heart disease.

Box 1.1

Top 5 Most Costly Medical Conditions in the United States in 2012

Condition	Cost ($ billions)
1. Heart conditions	101
2. Trauma disorders	93
3. Cancer	88
4. Mental disorders	87
5. Asthma	76

Source: Soni, A. Trends in the Five Most Costly Conditions among the U.S. Civilian Noninstitutionalized Population, 2002 and 2012. Statistical Brief #470. April 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st470/stat470.shtml. Accessed April 13, 2015

Figure 1.1 Expenditures for the five most costly conditions, 2002 and 2012. Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012.

Figure 1.2 Number of persons with expenses for the top five most costly conditions, 2002 and 2012. Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012.

This book explains how and why exposure to traumatic stressors can cause psychological trauma (both reactions and symptoms) and how and for whom these events or experiences can lead to the debilitating disorder of PTSD (which actually is a biological as well as psychological phenomenon). With this knowledge, it is possible to make informed decisions about how to conduct further research on PTSD, how to accurately assess and effectively treat PTSD in clinical practice, and how to prevent trauma survivors from developing and suffering from the symptoms of PTSD. The large and rapidly growing published scientific and clinical literature on psychological trauma and PTSD is cited as a scholarly evidence base for rigorous discussion of these crucial issues, as well as a guide for readers interested in learning more about PTSD and its treatment. Many questions about PTSD, its origins, prevention, and treatment that remain unanswered are covered to provide information about hypotheses that are still being tested or will be tested by future generations of researchers and psychotherapists.

This chapter provides a survey of the history and current state of scientific knowledge and popular conceptions of psychological trauma, from the earliest writings several thousand years ago to modern definitions and diagnoses. Controversies are highlighted, such as whether infants can experience traumatic stress responses and if they remember psychological traumas, whether military personnel can be protected from PTSD and if their lives (and those of civilian victims) are ever the same after experiencing the horrors of war, whether PTSD is a psychiatric disorder or a “normal response to abnormal events,” whether trauma survivors have to return to the past and confront terrifying memories if they are to recover from PTSD, and whether psychological trauma can lead to growth. This chapter also touches on the major topics covered in subsequent chapters. As we do in all of the chapters, we begin with a real-life case example and evidence-based facts. These case studies are based on the lives of real people, disguised to preserve the privacy of each individual. These examples show how experiencing psychological trauma and living with PTSD affect people from every walk of life, of all genders and in all developmental stages, every sexual orientation, ethnocultural and socioeconomic background, and nationality. We will see important differences based on these diverse characteristics in the specific ways in which potentially traumatizing events occur and subsequent PTSD symptoms develop, but there are also universal features in the events that threaten people’s lives (and those of the people they rely on for safety and intimacy) and in our reactions to these close encounters with the specter of death that occur biologically simply because we all share an essential humanness.

“Is there a life after trauma?”: The case of Marian M.

Marian is a 55-year-old woman of mixed racial background who grew up in a family that was going through the throes of transition from living in the “Old World”—a family tree with branches of many generations before World War II in Eastern Europe and the Middle East—to the postwar modern Western world. Her parents were the first generation to grow up in the United States with English as their primary language and a secular view of religion. Her mother’s parents had survived the Holocaust and emigrated after losing all of their family members in Nazi death camps. Her father’s parents had experienced genocide as children in Armenia. Marian’s parents grew up “poor but safe” in New York during the Great Depression and became the first generation in their families to attend college. Her mother was a teacher, and her father was a successful businessman. Marian was the youngest of three daughters, and when she was born, her parents were still struggling to acquire the “American Dream” of a car, a house in Levittown (the prototype for postwar suburbia), and good schools for their children.

For many years, Marian believed that her first brush with psychological trauma, in this relatively sheltered life, was a dramatic incident in which she was caught in a terrorist attack when she was attending the 1972 Munich Olympics as a college student traveling through Europe on summer vacation. While visiting a friend in the Olympic village, they happened to be walking past the Israeli team’s residence just as it was being attacked by terrorists. Years later, in therapy, Marian could vividly describe the sudden contrast between the soft, happy sounds of a summer evening and the explosive staccato of gunfire and the screams of people running for their lives. Although she can’t exactly recall how much time passed because everything seemed both to grind to a halt and race past in a blur, she also remembered the wailing as people carried out bodies and horribly wounded young men to the ambulances. The next hours and days continued to be “a blur,” but somehow Marian found her way to the airport, and 2 days later, she was back in New York. Marian decided not to tell her parents about her experience. Although her family and friends were intensely interested in what she had seen on her travels, Marian felt oddly detached and emotionally empty. She explained, “I told them what had happened like I was a narrator in a movie. It didn’t really bother me to tell it again and again, and that’s what bothers me now. How could I be so cold and unfeeling? I wasn’t like that before.” She spent the next year finishing college, “right on schedule, as if nothing had happened,” but she spent most of her time alone in the library, in contrast to having been “always around other people, talking, laughing, very social” in the past.

After that incident, Marian began to have nightmares in which she was being hunted, captured, and tortured. She would wake up screaming for help. She said, “It was nothing like either of the experiences, just these mixed-up, jump-right-out-of-your-skin visions of being pursued, trapped, and annihilated, again and again each night—until I just couldn’t really go to sleep, always staying just alert enough to catch the beginning of that dream and wake myself up so I wouldn’t have to go through it.” She learned that the only way to sleep was to “drink myself under the table,” and she preferred the inevitable hangover to being in a daze because of sleeplessness. She remained determined to complete college and did so with great effort despite feeling like her mind had become “a sieve.” Marian said she felt like “everything I read or heard at lectures just went right down the drain, where I used to have an absolute steel-trap mind and memory, never had to read anything twice or take notes, and now I could barely retain information long enough to pass a test, and only then if I went over all of my notes again and again.” The library was her sanctuary. Gradually she was able to cope with the emotional “ups and downs,” bad dreams, and mental “Swiss cheese. She got a job as an art museum curator, married, and had children.

When her youngest child turned 20, he decided to travel through Europe for the summer before completing college. Marian’s stress reactions returned with a vengeance, for no apparent reason: “My life was wonderful, not without the usual hassles, and I worried about everything, always ‘doom and gloom,’ as my husband and children would say affectionately. So I was a worrier, it could be worse, but I was happy and ready to enjoy life as an empty nester. Then Eric went off on his trek, and I fell apart. I really was happy to have him out of the house and have some peace and quiet for the whole summer, after years of the endless noise that is the curse and blessing of a family. But I wasn’t happy. I was miserable—nightmares of terrorists, drunk drivers, worse than 35 years ago! My heart would start pounding, and I’d break into a sweat—and it wasn’t the change of life because I’d already been through that. It wasn’t this bad if someone just walked up behind me and I didn’t know they were there. My husband learned fast to send a clear signal before he came within five feet of me. It was like being in that car all over again and someone’s about smash into me even though it’s just someone walking over to say Hi.” Marian became intensely fearful that all of her chi...

Table of contents

• Posttraumatic Stress Disorder: Scientific and Professional Dimensions
• 1 Understanding psychological trauma and posttraumatic stress disorder (PTSD)
• 2 The impact of psychological trauma
• 3 Etiology of PTSD
• 4 Epidemiology of PTSD
• 5 Neurobiology of traumatic stress disorders and their impact on physical health
• 6 Assessment of psychological trauma and PTSD
• 7 Treatment of adults with PTSD
• 8 Treatment of children and adolescents with PTSD
• 9 Prevention of PTSD
• 10 Forensic issues in the traumatic stress field
• 11 Social, cultural, and other diversity issues in the traumatic stress field
• 12 Careers and ethical issues in the traumatic stress field
• Afterword
• Index