Unseen Scars: Understanding the Impact of Post-Traumatic Stress Disorder
It’s been months since you were in an accident. Another car ran a red light and hit your SUV as you entered the intersection on your way to the grocery store. Since the accident, you’ve not been able to sleep. Repeated nightmares of the crash which totaled your car play out in your dreams almost every night. Your husband and friends say that you’re not yourself since that day, noticing you seem to be more irritable and on edge. When you need to do grocery shopping, you find yourself driving out of your way to avoid the intersection where the accident occurred, else you see the damaged car in your brain accompanied by a sense of panic.
You may have a loved one, a relative, a close friend, a co-worker, or a boss who is moody, irritable, angry all the time, and may no longer join you for an afterwork happy hour. If you are in a relationship with someone who has experienced repeated trauma in childhood you may question why they don’t talk about their early years, have repetitive nightmares involving fighting and screaming, or seem to be different around their birthdays or holidays without really knowing why they feel that way.
These scenarios describe individuals who are likely dealing with undiagnosed Post Traumatic Stress Disorder (PTSD). PTSD is a stress-related mental and behavioral disorder generally occurring in response to traumatic events. Symptoms of trauma-related mental illnesses date back to the ancient Greeks and more recently thoroughly documented in a diary from 1666 that described a man’s intrusive thoughts and distress from the great fire in London. During World War I, thousands of soldiers suffered from what was called battle fatigue or were considered to be shell-shocked from the repeated exposure to combat. Currently, these individuals would be classified as having PTSD.
What is PTSD?
Current studies suggest that 50% - 70% of individuals in the United States have experienced an event that could trigger PTSD. Although usually seen in individuals who have experienced major trauma such as sexual abuse or in veterans who have faced combat, other events such as being in a car accident, being diagnosed with cancer, or witnessing traumatic events firsthand such as 9/11 or the damage to a neighborhood after a tornado may trigger PTSD.
The syndrome is generally a response to a singular traumatic event. However, individuals who have experienced prolonged or repetitive exposures to a series of traumatic events within which individuals perceive little or no chance to escape are felt to have Complex Post-Traumatic Stress Disorder (CPSD or C-PTSD). These individuals, besides having the typical symptoms of PTSD, have additional complications from the trauma that lead to prolonged feelings of terror, worthlessness, altered self-image, hypervigilance, and other complex psychological problems. Typically, in C-PTSD arising from childhood trauma, often one of the individual’s caregivers was a source of abuse, neglect, abandonment, or other trauma when the person was a child.
In the field of psychiatry and mental disorders, PTSD is a relatively new diagnosis, only added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980 to describe a constellation of signs and symptoms triggered by a traumatic event. Since then, more is known about the causes, the prevalence of the disorder, and treatment options. The World Health Organization (WHO) recommended adding C-PTSD to the classification of diseases in 2018 for those individuals whose symptoms reflect a higher degree of trauma and a more prolonged exposure.
How common is PTSD?
Overall, in the US, 6% of the populations will go on to develop PTSD in their lifetime, affecting millions of people. Why one person will develop PTSD triggered from a traumatic event and another person witnessing the same event doesn’t is not currently well understood but is the subject of considerable research. The risk of PTSD in male veterans is 7%, slightly higher than civilians but much lower than the 13% risk in female veterans. Mental health problems of all kinds are quite common in the US population with fifty five million individuals seeking treatment in 2020.
Besides being such a common problem in the US, the WHO considers PTSD and C-PTSD as major world-wide health concern, clearly reflecting the effects of ongoing famine, war, and displacement across the world.
What are the consequences of having PTSD?
Women with PTSD are seven times more likely to commit suicide compared to women without PTSD. The risk of suicide in men with PTSD is higher compared to other men but much less than that for women. Sadly, over twenty veterans from recent wars and battle zone deployments take their own lives on a daily basis.
Besides increasing the risk of suicide, PTSD is associated with a higher lifelong risk of chronic conditions, such as heart disease, obesity, high blood pressure, diabetes, and cancer—contributing to a lower life expectancy in these individuals. Because of the wide-spread increase in the number of people dealing with PTSD and the associated complications, the health education field has put forth a call to action for Trauma Informed Care (TIC) education across the country for physicians and nurses in the workforce as well as students in all field of healthcare.
The current DSM section on PTSD has established criteria that apply to adults, adolescents, and children over 6 years of age with a subsection for children under 6 years of age. Individuals must meet specific criteria from eight major categories to be diagnosed. For example, the criteria assess exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Directly experiencing the event.
Witnessing, in person, the event(s) as they occur.
Learning that the event occurred to a close family member or friend.
Experiencing repeated or extreme exposure to details of a traumatic event, but not by TV or social media
Although the DSM doesn’t formally recognize C-PTSD as a distinct condition, it lists a sub-type of PTSD that most experts believe reflects what happens to an individual with repeated exposure to trauma.
What are the common signs and symptoms of PTSD?
Nightmares are very common, seen in 50% of patients
Hypervigilance
Intrusive thoughts of events or individuals associated with the trauma or abuse
Avoiding reminders of the event
Negative thoughts about self and the world. “It’s all my fault” or “I can’t be loved by anyone”
Feelings of guilt and shame
Anger, irritability or short temper
Withdrawal from others and reduced interest in activities
Vivid flashbacks of traumatic events
Exaggerated start response to noises and other stimuli
Difficulty in establishing and maintaining relationship
Who is at risk for developing PTSD?
Military in combat setting
First responders: police, firefighters, EMTs
Healthcare workers
Truck drivers
People who work at banks, post offices, or in stores
Genetic factors, with evidence that susceptibility to PTSD is hereditary, just as alcohol, nicotine, and drug dependence share genetic similarities.
What events may trigger the development of PTSD?
The risk of developing PTSD varies by the type of trauma, with exposure to sexual violence at the top of the list. Nearly 20% of individuals who have been raped develop PTSD. Other exposures include:
War-related trauma
Motor vehicle accidents for both adults and children
Childhood trauma
Intimate partner violence
Victim of violent crime or life threatening event
Life threatening illness: heart attack, ICU stay
Cancer diagnosis, being admitted to the ICU
Unexpected death of a loved one
Natural disasters
Why do people develop PTSD?
Despite decades of research, it is not clear why one person develops PTSD after a traumatic event and another person with a similar experience doesn’t. Essentially, PTSD symptoms result when traumatic events or abuse cause an ongoing over-reactive “fight or flight” response. We have a specific endocrine system that provides a feedback loop of hormones to orchestrate and regulate your body’s stress reaction. The hypothalamic-pituitary-adrenal (HPA) axis is a communication system between these three organs. The main function of our HPA axis is to release cortisol and adrenaline almost instantaneously to allow us to respond to stress. The increases in heart rate, sense of alertness, and rise in blood sugar are an automatic and instinctual process. Normally, when the stressful event is over, the body returns to baseline relatively quickly. However, in patients with PTSD, the body continues to have a fight or flight response even when there is no danger. A traumatic event, abuse, and chronic stress leads to abnormal communication among these three organs affecting the levels of cortisol and adrenaline levels in our bodies. In most patients with PTSD, adrenaline levels are elevated but cortisol levels are low. which creates abnormal patterns or road maps deep in the brain. But in some patients the cortisol levels are elevated.
These patterns of dysfunction can persist long after the event that triggered fear, making an individual hyper-responsive to future fearful situations. During traumatic experiences, the elevated levels of adrenaline, cortisol dysfunction and other stress hormones affect the normal pathways of the brain and thereby lead to symptoms of PTSD.
In addition, individuals with PTSD may have low levels of serotonin or dysfunction in the serotonin system in the brain, which contributes to some of the symptoms associated with the disorder and provides an avenue for treatment through the use of sertraline and other selective serotonin uptake inhibitors.
With C-PSTD, these traumatic events may occur daily over a period of years. When they occur in children, normal pathways in the brain never have the opportunity to become established; therefore, these abnormal imprints from a continuous fight or flight state become the norm at an early age. The child’s brain doesn’t know any better.
Can PTSD be prevented?
There are no definitive treatments that prevent the development of PTSD in individuals at high risk for PTSD after experiencing a traumatic event. However, results of early use of Cognitive Behavior Therapy (CBT) with an experienced counselor may decrease the likelihood of developing PTSD in the next year. There have been small studies demonstrating the potential of taking hydrocortisone, an adrenal hormone, early on to prevent subsequent PTSD.
How is PTSD treated?
Recent studies have shown that psychological treatment alone is as effective as the combination of medications and therapy. The hallmark of treatment for the disorder are behavioral and cognitive-behavioral therapy (CBT), in which the patient learns to identify thoughts causing fear or other symptoms and replacing them with less distressing thought patterns. The primary goal of therapy is for the patient to understand what their triggers are and why they react or feel the way they do. Part of this therapy may include re-visualization of the events in therapy sessions or in some circumstances physically visiting the location of where the trauma occurred.
In the past two decades, eye movement desensitization and reprocessing (EMDR) psychotherapy has been shown to be effective in treatment. Research indicated that a person’s eyes move rapidly when thinking about distressing memories and when a patient is guided to control eye movements to a slower pace by a counselor trained in EMDR, the person’s thoughts become less disturbing. Large, controlled trials using EMDR have not yet been done to establish it as a standard of care.
What is the healthcare system doing to address PTSD
An article in the August 2023 journal Academic Medicine called for the establishment of trauma-informed care (TIC) competencies for medical students across the US. In similar fashion, an editorial in the June 2021 journal Nurse Educ Today called for the establishment of TIC education across the entire nursing education system and not just for advanced practice nurses who opt to specialize in behavioral health.
Over the last hundred years, the healthcare system has incorporated dozens of major shifts into the care of the population. Early and mid-20th century focus on vaccines to prevent communicable disease decreased deaths and complications. Smallpox was eliminated and the effectiveness of getting the three injections of the polio vaccine is over 99%. The scientific discovery of the virus that caused AIDS and how ongoing triple-drug anti-viral therapy allows individuals with HIV to have normal lives. The rapid development and implementation of the COVID vaccine is estimated to have prevented the deaths of 20 million people world-wide and over 140,000 deaths in the US.
Extensive research has established that trauma exposure is nearly universal and is the root cause of numerous health and social problems, contributing to 6 of the 10 leading causes of death in the US, and may have significant and costly lifelong consequences. Therefore, the country needs to increase public awareness of health consequences of exposure to trauma or abuse as well incorporating a greater focus of TIC to all health providers.
Underlying behavioral health problems are frequently seen in clinical practice for providers. The number of visits increased dramatically in the height of the COVID pandemic facilitated by the use of telemedicine. In 2021, over 26 million adults with mental illness received health services, which includes outpatient or inpatients treatment, counseling, or medications. However, estimates suggest that only half of people with behavioral health problems receive treatment. More than 1 in 5 US adults and teenagers currently live with a mental illness. In 2020, an estimated 1.2 million people in the US had PTSD, one of the more difficult behavioral health problems to treat, along with schizophrenia and bi-polar disorder.
One of the obstacles to achieving education goals on trauma-induced care is the lack of well-established programs to serve as models for patient care. Thus, curriculum, teaching methods, supporting textbooks or first-hand accounts need to be developed. A second obstacle is the difficulty in teaching and understanding conditions that are complex, have been present for years, and which require long-term treatment.
Medical education in the US acknowledges the lack of experiential methods of teaching whereby students see patients over time. Nursing and medical students learn in a classroom for the first two years and then have rotations on various clinical services, such as surgery, pediatrics, family medicine, and psychiatry, among others. Students rarely see patients in follow-up from a previous visit since rotations are usually only two weeks, a month, or three months, which is the norm for medical students. Thus, trauma informed care will require new methods of teaching healthcare workers.
Summary
Exposure to trauma is very common and is associated with significant behavioral health problems which contribute to six of the ten leading causes of death. A shift in healthcare delivery towards incorporating trauma-informed care into the current practices of doctors, nurses, and counseling specialists is recommended as well as restructuring the educational processes and curriculum of medical students, nurses, individuals pursuing degrees in psychology or becoming licensed behavioral health professionals.
How do I get help?
For immediate help on suicidal thoughts or other mental health concerns, call the national hotline at 1-800-662-HELP (4357) or log on to the website: SAMHSA’s National Helpline | SAMHSA
US veteran or service members who are in crisis can call 988 and then press “1” for the Veterans Crisis Line, or text 838255.
If you are in counseling, also reach out to your provider and tell them you are in crisis and having suicidal thoughts.
To learn more, take a look at the resources page on this website.
