Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD), like acute stress disorder, is characterized by the onset of symptoms immediately after a traumatic event. Consequently, patients with PTSD always experience new symptoms or changes in symptoms that reflect the specifics of the trauma.

Although patients with posttraumatic stress disorder attach different levels of significance to the event, they all have symptoms related to the trauma. A traumatic event that leads to the development of posttraumatic stress disorder usually involves experiencing a threat of one's own death (or injury) or being present at the death or injury of others. When experiencing a traumatic event, people who will develop posttraumatic stress disorder must experience intense fear or horror. Such experiences can occur in both a witness and a victim of an accident, crime, combat, assault, child theft, or natural disaster. PTSD can also develop in a person who has learned that he or she has a fatal disease or who experiences systematic physical or sexual abuse. A direct relationship has been noted between the severity of psychological trauma, which in turn depends on the degree of threat to life or health, and the likelihood of developing posttraumatic stress disorder.

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What causes post-traumatic stress disorder?

It is believed that sometimes post-traumatic stress disorder occurs after an acute reaction to stress. However, post-traumatic stress disorder can also develop in people who did not show any mental disorders after an emergency (in these cases, post-traumatic stress disorder is considered a delayed reaction to the event). Somewhat less often, post-traumatic stress disorder occurs in people who have previously experienced an emergency as a result of repeated minor mental trauma. In some people who have experienced an acute reaction to stress, post-traumatic stress disorder develops after the transition period. In this case, victims of an emergency often develop the idea of the low value of human life.

The scientific study of posttraumatic stress disorder is a relatively new trend and is likely to increase in importance in forensic psychiatry. There have been references to posttraumatic stress disorder as a psychological harm in cases of stalking. Childhood trauma, physical abuse, and especially sexual abuse of children are closely associated with the development of the victim into an adult perpetrator and abuser. The borderline personality disorder model suggests a direct causal link to prolonged and repeated trauma from primary caregivers in childhood. Such prolonged and repeated trauma can greatly interfere with normal personality development. In adulthood, acquired personality disorder may be associated with repeated maladaptive or violent behaviors that “re-enact” elements of the trauma experienced in childhood. Such individuals are often found in prison populations.

Some characteristics of posttraumatic stress disorder are associated with crime. For example, sensation seeking (‘habituation to trauma’), seeking punishment to alleviate guilt, and the development of comorbid substance abuse are associated with crime. During ‘flashbacks’ (intrusive re-experiencing), a person may react in an extremely violent manner to environmental stimuli that recall the original traumatic event. This phenomenon has been noted in Vietnam War veterans and police officers, who may react violently to a stimulus that reflects a ‘battlefield’ situation.

How does post-traumatic stress disorder develop?

Because PTSD is a behavioral disorder that results from direct exposure to trauma, understanding its pathogenesis requires reference to the numerous studies of traumatic stress in experimental animals and humans.

Hypothalamic-pituitary-adrenal axis

One of the most frequently identified changes in post-traumatic stress disorder is the disruption of cortisol secretion regulation. The role of the hypothalamic-pituitary-adrenal (HPA) axis in acute stress has been studied for many years. A large amount of information has been accumulated on the influence of acute and chronic stress on the functioning of this system. For example, it has been found that although acute stress increases the levels of corticotropin-releasing factor (CRF), adrenocorticotropic hormone (ACTH), and cortisol, over time, a decrease in cortisol release is observed despite an increase in CRF levels.

In contrast to major depression, which is characterized by a disruption of the HPA axis regulatory function, post-traumatic stress disorder reveals an increase in feedback in this system.

Thus, patients with PTSD have lower cortisol levels with normal daily fluctuations and higher sensitivity of lymphocyte corticosteroid receptors than patients with depression and mentally healthy individuals. Moreover, neuroendocrinological tests show that PTSD is associated with increased ACTH secretion following CRF administration and increased cortisol reactivity in the dexamethasone test. It is believed that such changes are due to impaired HPA axis regulation at the hypothalamus or hippocampus. For example, Sapolsky (1997) argues that traumatic stress causes hippocampal pathology over time through its effect on cortisol secretion, and MRI morphometry shows that PTSD is associated with decreased hippocampal volume.

Autonomic nervous system

Since hyperactivation of the autonomic nervous system is one of the key manifestations of posttraumatic stress disorder, studies have been undertaken on the noradrenergic system in this condition. When yohimbine (an alpha2-adrenergic receptor blocker) was administered to patients with posttraumatic stress disorder, immersions in painful experiences ("flashbacks") and panic-like reactions occurred. Positron emission tomography indicates that these effects may be associated with an increase in the sensitivity of the noradrenergic system. These changes can be associated with data on HPA axis dysfunction, given the interaction of the HPA axis and the noradrenergic system.

Serotonin

The most obvious evidence of the role of serotonin in PTSD comes from pharmacological studies in humans. There are also data obtained in animal models of stress that also suggest the involvement of this neurotransmitter in the development of PTSD. It has been shown that environmental factors can significantly affect the serotonergic system of rodents and great apes. Moreover, preliminary data show that there is a connection between the external conditions of upbringing of children and the activity of the serotonergic system in them. At the same time, the state of the serotonergic system in PTSD remains poorly understood. Additional studies using neuroendocrinological tests, neuroimaging, and molecular genetic methods are needed.

Conditioned reflex theory

It has been shown that posttraumatic stress disorder can be explained based on the conditioned reflex model of anxiety. In posttraumatic stress disorder, deep trauma can serve as an unconditioned stimulus and can theoretically affect the functional state of the amygdala and associated neural circuits that generate a feeling of fear. Hyperactivity of this system can explain the presence of "flashbacks" and a general increase in anxiety. External manifestations associated with trauma (for example, the sounds of battle) can serve as conditioned stimuli. Therefore, similar sounds by the mechanism of a conditioned reflex can cause activation of the amygdala, which will lead to a "flashback" and an increase in anxiety. Through the connections of the amygdala and the temporal lobe, activation of the neural circuit that generates fear can "revive" traces of the memory of a psychotraumatic event even in the absence of appropriate external stimuli.

Among the most promising studies were those examining the enhancement of the startle reflex under the influence of fear. The conditioned stimulus was a flash of light or sound, which was turned on after the presentation of the unconditioned stimulus - an electric shock. The increase in the amplitude of the startle reflex upon presentation of the conditioned stimulus made it possible to assess the degree of influence of fear on the reflex. This response apparently involves the neural circuit generating fear and described by LeDoux (1996). Although there are some discrepancies in the obtained data, they indicate a possible link between PTSD and the fear-potentiated startle reflex. Neuroimaging methods also indicate the involvement of formations related to the generation of anxiety and fear in PTSD, primarily the amygdala, hippocampus, and other structures of the temporal lobe.

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Symptoms of Post Traumatic Stress Disorder

Post-traumatic stress disorder is characterized by three groups of symptoms: constant re-experiencing of a traumatic event; desire to avoid stimuli that remind one of the psychological trauma; increased autonomic activation, including an increased startle response (startle reflex). Sudden painful immersions in the past, when the patient re-experiences what happened again and again as if it had just happened now (the so-called "flashbacks"), are a classic manifestation of post-traumatic stress disorder. Constant experiences can also be expressed in unpleasant memories, difficult dreams, increased physiological and psychological reactions to stimuli that are somehow related to traumatic events. To diagnose post-traumatic stress disorder, the patient must have at least one of the above symptoms that reflect constant re-experiencing of a traumatic event. Other symptoms of PTSD include attempts to avoid thoughts and actions related to the trauma, anhedonia, decreased memory for events related to the trauma, blunted affect, feelings of alienation or derealization, and feelings of hopelessness.

PTSD is characterized by an exacerbation of the instinct for self-preservation, which is characterized by an increase and maintenance of constantly elevated internal psycho-emotional tension (excitement) in order to maintain a constantly functioning mechanism for comparing (filtering) incoming external stimuli with stimuli imprinted in the consciousness as signs of an emergency.

In these cases, an increase in internal psycho-emotional stress is observed - hypervigilance (excessive vigilance), concentration of attention, an increase in stability (immunity to interference), attention to situations that the individual regards as threatening. There is a narrowing of the attention span (a decrease in the ability to hold a large number of ideas in the circle of voluntary purposeful activity and difficulty in freely operating them). An excessive increase in attention to external stimuli (the structure of the external field) occurs due to a reduction in attention to the structure of the subject's internal field with difficulty in switching attention.

One of the significant signs of post-traumatic stress disorder is disorders subjectively perceived as various memory disorders (difficulty remembering, holding this or that information in memory and reproducing it). These disorders are not associated with true disorders of various memory functions, but are caused primarily by difficulty concentrating on facts that are not directly related to the traumatic event and the threat of its recurrence. At the same time, victims cannot remember important aspects of the traumatic event, which is caused by disorders that occurred at the stage of acute stress reaction.

Constantly increased internal psycho-emotional stress (excitement) maintains a person's readiness to react not only to a real emergency, but also to manifestations that are to one degree or another similar to a traumatic event. Clinically, this is manifested in an excessive fear reaction. Events that symbolize an emergency and/or remind of it (visiting the grave of the deceased on the 9th and 40th day after death, etc.) are accompanied by a subjective deterioration in the condition and a pronounced vasovegetative reaction.

Along with the above-mentioned disorders, there are involuntary (without a sense of deliberateness) memories of the most vivid events associated with the emergency. In most cases, they are unpleasant, but some people themselves (by an effort of will) "evoke memories of the emergency", which, in their opinion, helps them to survive this situation: the events associated with it become less terrible (more ordinary).

Some people with PTSD may occasionally experience flashbacks - disorders that manifest themselves in the emergence of involuntary, very vivid representations of a psychotraumatic situation. Sometimes they are difficult to distinguish from reality (these conditions are close to syndromes of clouding of consciousness), and a person may display aggression at the moment of experiencing a flashback.

Sleep disorders are almost always detected in post-traumatic stress disorder. Difficulty falling asleep, as noted by victims, is associated with an influx of unpleasant memories of the emergency. Frequent night and early awakenings with a feeling of unreasonable anxiety "probably something happened" occur. Dreams are noted that directly reflect the traumatic event (sometimes dreams are so vivid and unpleasant that victims prefer not to fall asleep at night and wait until the morning "to sleep peacefully").

The constant internal tension in which the victim finds himself (due to the aggravation of the instinct of self-preservation) makes it difficult to modulate affect: sometimes victims cannot restrain outbursts of anger even for a minor reason. Although outbursts of anger can be associated with other disorders: difficulty (inability) in adequately perceiving the emotional mood and emotional gestures of others. Victims also exhibit alexithymia (inability to translate emotions experienced by themselves and others into verbal form). At the same time, difficulty in understanding and expressing emotional halftones is noted (polite, soft refusal, wary benevolence, etc.).

People suffering from post-traumatic stress disorder may experience emotional indifference, lethargy, apathy, lack of interest in the surrounding reality, a desire to have fun (anhedonia), a desire to learn something new, unknown, and a decrease in interest in previously significant activities. Victims are usually reluctant to talk about their future and most often perceive it pessimistically, seeing no prospects. They are irritated by large groups (the only exception is people who have experienced the same stress as the patient himself), they prefer to be alone. However, after some time, they begin to be oppressed by loneliness, and they begin to express dissatisfaction with their loved ones, reproaching them for inattention and callousness. At the same time, a feeling of alienation and distance from other people arises.

Particular attention should be paid to the increased suggestibility of victims. They are easily persuaded to try their luck in gambling. In some cases, the game is so addictive that victims often lose everything, right down to the allowance allocated by the authorities for the purchase of new housing.

As already mentioned, with post-traumatic stress disorder, a person is constantly in a state of internal tension, which, in turn, reduces the fatigue threshold. Along with other disorders (low mood, impaired concentration, subjective memory impairment), this leads to a decrease in performance. In particular, when solving certain problems, victims find it difficult to identify the main one, when receiving the next task, they cannot grasp its main meaning, they try to shift the responsibility for making responsible decisions to others, etc.

It should be especially emphasized that in most cases, victims are aware of (“feel”) their professional decline and, for one reason or another, refuse the offered job (it is not interesting, does not correspond to the level and previous social status, is poorly paid), preferring to receive only unemployment benefits, which are much lower than the offered salary.

The aggravation of the instinct of self-preservation leads to a change in everyday behavior. The basis of these changes are behavioral acts, on the one hand, aimed at early recognition of emergencies, on the other, representing precautionary measures in the event of a possible repeated development of a traumatic situation. Precautionary measures taken by the individual determine the nature of the stress experienced.

People who have experienced an earthquake tend to sit close to a door or window so that they can quickly leave the room if necessary. They often look at a chandelier or an aquarium to determine whether an earthquake is starting. At the same time, they choose a hard chair, since soft seats soften the shock and thus make it difficult to detect the moment the earthquake starts.

Victims of bombing, upon entering a room, immediately close the curtains, inspect the room, look under the bed, trying to determine whether it is possible to hide there during the bombing. People who took part in military actions, upon entering a room, try not to sit with their backs to the door and choose a place from which they can observe everyone present. Former hostages, if they were captured on the street, try not to go out alone and, conversely, if the capture occurred at home, do not stay alone at home.

People who have been exposed to emergencies may develop so-called acquired helplessness: the thoughts of the victims are constantly occupied with anxious anticipation of a repeat of the emergency, experiences associated with that time, and the feeling of helplessness they experienced. This feeling of helplessness usually makes it difficult to modulate the depth of personal involvement in contact with others. Various sounds, smells, or situations can easily stimulate memories of events associated with the trauma. And this leads to memories of one's own helplessness.

Thus, victims of emergencies experience a decrease in the general level of functioning of the individual. However, a person who has survived an emergency, in most cases, does not perceive the deviations and complaints he has as a whole, believing that they are within the norm and do not require medical attention. Moreover, most victims consider the deviations and complaints they have as a natural reaction to everyday life and do not associate them with the emergency that has occurred.

The victims' assessment of the role that the emergency played in their lives is interesting. In the vast majority of cases (even if no one close to them suffered during the emergency, the material damage was fully compensated, and their living conditions improved), they believe that the emergency had a negative impact on their fate ("The emergency crossed out their prospects"). At the same time, a kind of idealization of the past occurs (underestimated abilities and missed opportunities). Usually, in natural emergencies (earthquakes, mudflows, landslides), the victims do not look for the guilty ("God's will"), while in man-made disasters they strive to "find and punish the guilty". Although if the microsocial environment (including the victim) attributes "everything that happens under the moon" to the "will of the Almighty", both natural and man-made emergencies, a gradual de-actualization of the desire to find the guilty occurs.

At the same time, some victims (even if they were injured) indicate that the emergency played a positive role in their lives. They note that they re-evaluated their values and began to "truly value human life." They describe their life after the emergency as more open, in which providing assistance to other victims and patients plays a large role. These people often emphasize that after the emergency, government officials and the microsocial environment showed concern for them and provided great assistance, which prompted them to begin "public philanthropic activities."

In the dynamics of the development of disorders at the first stage of the PSR, the individual is immersed in the world of experiences associated with the emergency. The individual seems to live in the world, situation, dimension that took place before the emergency. He seems to be trying to return the past life ("to return everything as it was"), tries to understand what happened, looks for the guilty and seeks to determine the degree of his guilt in what happened. If the individual has come to the conclusion that the emergency is "the will of the Almighty", then in these cases the formation of a feeling of guilt does not occur.

In addition to mental disorders, somatic deviations also occur in emergencies. In about half of the cases, an increase in both systolic and diastolic pressure is noted (by 20-40 mm Hg). It should be emphasized that the observed hypertension is accompanied only by an increase in pulse rate without deterioration of the mental or physical condition.

After an emergency, psychosomatic diseases (peptic ulcer of the duodenum and stomach, cholecystitis, cholangitis, colitis, constipation, bronchial asthma, etc.) often worsen (or are diagnosed for the first time). It should be especially noted that women of childbearing age often experience premature menstruation (less often delayed), miscarriages in the early stages of pregnancy. Among the sexological disorders, a decrease in libido and erection is noted. Often, victims complain of coldness and a tingling sensation in the palms, feet, fingers and toes, excessive sweating of the extremities and deterioration of nail growth (splitting and brittleness). Deterioration of hair growth is noted.

Over time, if a person manages to "digest" the impact of an emergency, memories of the stressful situation become less relevant. He tries to actively avoid even talking about the experience, so as not to "awaken difficult memories." In these cases, irritability, conflict, and even aggression sometimes come to the fore.

The types of response described above mainly occur in emergencies in which there is a physical threat to life.

Another disorder that develops after the transition period is generalized anxiety disorder.

In addition to an acute stress reaction, which usually resolves within three days after an emergency, psychotic-level disorders may develop, which are called reactive psychoses in Russian literature.

The course of post-traumatic stress disorder

The likelihood of developing symptoms, as well as their severity and persistence, are directly proportional to the reality of the threat, as well as the duration and intensity of the trauma (Davidson, Foa, 1991). Thus, many patients who have experienced a prolonged, intense trauma with a real threat to life or physical integrity develop acute stress reactions, against which post-traumatic stress disorder may develop over time. However, many patients do not develop post-traumatic stress disorder following acute stress manifestations. Moreover, the full-blown form of post-traumatic stress disorder has a variable course, which also depends on the nature of the trauma. Many patients experience complete remissions, while others experience only mild symptoms. Only 10% of patients with post-traumatic stress disorder - probably those who have experienced the most severe and prolonged trauma - have a chronic course. Patients often encounter reminders of the trauma, which can provoke an exacerbation of chronic symptoms.

Diagnostic criteria for post-traumatic stress disorder

A. The person experienced a traumatic event in which both conditions were present.

1. The person was a participant in or witnessed an event involving actual or threatened death, serious physical harm, or a threat to the physical integrity of himself or herself or others.
2. The person experienced intense fear, helplessness, or terror. Note: In children, this may be replaced by inappropriate behavior or agitation.

B. The traumatic event is the subject of ongoing experiences, which may take one or more of the following forms.

1. Recurring, intrusive, oppressive memories of the trauma in the form of images, thoughts, sensations. Note: young children may have constant games that are plot-related to the trauma they experienced.
2. Recurring distressing dreams that include scenes from the event experienced. Note: Children may have frightening dreams without any specific content.
3. The person acts or feels as if he or she is reliving the traumatic event (in the form of reliving experiences, illusions, hallucinations, or dissociative episodes such as "flashbacks", including upon awakening or during intoxication). Note: Children may repetitively act out episodes of trauma.
4. Intense psychological discomfort when exposed to internal or external stimuli that symbolize or resemble a traumatic event.
5. Physiological reactions to contact with internal or external stimuli that symbolize or resemble a traumatic event.

B. Persistent avoidance of stimuli associated with the trauma, as well as a number of general manifestations that were absent before the trauma (at least three of the following symptoms are required).

1. The desire to avoid thinking, feeling, or talking about the trauma.
2. The desire to avoid actions, places, people that can remind you of the trauma.
3. Inability to remember important details of the injury.
4. A marked limitation of interests and desire to participate in any activity.
5. Detachment, isolation.
6. Weakening of affective reactions (including the inability to experience feelings of love).
7. Feelings of hopelessness (lack of any expectations related to career, marriage, children, or the length of life ahead).

D. Persistent signs of increased excitability (not present before the injury), which are manifested by at least two of the following symptoms.

1. Difficulty falling asleep or staying asleep.
2. Irritability or outbursts of anger.
3. Impaired concentration.
4. Increased alertness.
5. Strengthened startle reflex.

D. The duration of symptoms specified in criteria B, C, D is not less than one month.

E. The disorder causes clinically significant discomfort or disrupts the patient's functioning in social, professional or other important areas.

The disorder is classified as acute if the duration of symptoms does not exceed three months; chronic - if symptoms persist for more than three months; delayed - if symptoms appear no earlier than six months after the traumatic event.

To diagnose PTSD, at least three of the listed symptoms must be present. At least two of the symptoms of increased arousal (insomnia, irritability, increased excitability, increased startle reflex) must be present. PTSD is diagnosed only if the noted symptoms persist for at least a month. Before reaching a month, acute stress disorder is diagnosed. DSM-IV identifies three types of PTSD with different courses. Acute PTSD lasts less than three months, chronic PTSD lasts longer. Delayed PTSD is diagnosed when its symptoms become apparent six or more months after the trauma.

Since severe trauma can cause a whole range of biological and behavioral reactions, the patient who survived it may develop other somatic, neurological, or mental disorders. Neurological disorders are especially likely when the trauma involved not only psychological but also physical impact. Patients who have experienced trauma often develop affective disorders (including dysthymia or major depression), other anxiety disorders (generalized anxiety or panic disorder), and drug addiction. Research has noted a connection between some mental manifestations of posttraumatic syndromes and premorbid status. For example, posttraumatic symptoms occur more often in individuals with premorbid anxiety or affective manifestations than in individuals who were mentally healthy. Thus, analysis of premorbid mental status is important for understanding symptoms that develop after a psychotraumatic event.

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Differential diagnosis

Caution is required in diagnosing PTSD to rule out other syndromes that may develop after the injury. It is especially important to recognize treatable neurological or somatic disorders that may contribute to the development of posttraumatic symptoms. For example, traumatic brain injury, drug abuse, or withdrawal symptoms may be the cause of symptoms that appear immediately after the injury or several weeks later. Identifying neurological or somatic disorders requires a detailed anamnesis, a thorough physical examination, and sometimes a neuropsychological examination. In classic uncomplicated PTSD, the patient's consciousness and orientation are not affected. If a neuropsychological examination reveals a cognitive deficit that was not present before the injury, organic brain damage should be excluded.

The symptoms of posttraumatic stress disorder can be difficult to differentiate from those of panic disorder or generalized anxiety disorder, since all three conditions involve marked anxiety and increased reactivity of the autonomic nervous system. Establishing a temporal relationship between the development of symptoms and the traumatic event is important in the diagnosis of posttraumatic stress disorder. In addition, posttraumatic stress disorder is characterized by persistent reliving of traumatic events and a desire to avoid any reminder of them, which is not typical of panic disorder and generalized anxiety disorder. Posttraumatic stress disorder often has to be differentiated from major depression. Although these two conditions can be easily distinguished by their phenomenology, it is important not to miss comorbid depression in patients with PTSD, which can have an important impact on the choice of therapy. Finally, PTSD should be differentiated from borderline personality disorder, dissociative disorder, or deliberate malingering, which may have clinical manifestations similar to PTSD.

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