Post traumatic stress disorder, or "shell shock" as it was originally called, is a psychiatric disorder that was officially recognized after being observed in war veterans. The phenomenon has now been studied and better defined.
A Definition of PTSD
A person suffering with post traumatic stress disorder (PTSD) has been exposed directly to a traumatic event. This is an essential ingredient in PTSD. A traumatic event is one that is not considered usual in normal life. Generally, the traumatic event will involve an individual experiencing a close encounter with their own death, or it will involve observance of the unexpected or horrific death of others.
Who is at risk?
The traumatic event must engender intense feelings of fear, horror, or helplessness. Such events might be expected to occur to those who have experienced war, assault, rape, accidents, natural disasters and various other traumatic events.
Anyone with first hand sensory contact with the devastation - the sounds, smells, sights, physical sensations, and even tastes associated with the recent terrorist attacks in New York City and Washington DC- would be vulnerable to the development of PTSD.
Not everyone who experiences trauma gets PTSD
Curiously, though, the disorder does not develop simply because an individual was exposed to a traumatic event. The factors that determine if the disorder does or does not develop are not completely understood. However, it is known that PTSD is more likely to develop given the pre-existence of certain risk factors. We will review these factors later in this article.
PTSD Symptoms
Post traumatic stress disorder (PTSD) is characterized by the development of specific symptoms that must exist beyond 30 days. The symptoms can include:
Re-experiencing the trauma - This can occur in a variety of ways. It can involve mental images, thoughts, and re-experiencing sensations of the event. It can involve distressing dreams of the event. It can involve feeling as if the event is recurring or acting as if the event is recurring. This can involve:
- Illusions: real objects or stimuli which appear to be different than they actually are
- Hallucinations: the perception of people or voices or sounds or sensations that do not actually exist at the time they are perceived
- Depersonalization: the sense of being outside of one's self
- Disassociation: the loss of the awareness of time or one's surroundings
- Flashbacks: brief snippets during which an aspect of the traumatic event is relived
- Distress at "reminders": Intense psychological distress when being exposed to a person, place or sensations that remind one of the traumatic event. For example an odor associated with the traumatic event (such as the pulverized cement and gypsum from the collapse of the World Trade Center) could trigger feelings or memories or the traumatic event.
- Physiologic arousal: Finally, re-experiencing the event can involve physiologic arousal such as dilated pupils, perspiration, racing heart, muscle tension, shortness of breath and other similar signs.
Avoidance and numbing - This amounts to the individual attempting to protect themselves in primitive and basic ways from similar emotional assault.
- Avoidance: It can include a refusal to return to the site of the trauma. It can involve refusing to associate with people, places, or activities that remind the individual of the traumatic event. Conceivably, some firemen and policemen, despite being New York's Finest, might not be able to return to work, or to enter buildings on fire, or work in the area close to ground zero where the World Trade Buildings once stood.
- Zombie-like characteristics: It can involve the suppression of memories or important details of the traumatic event. It can involve a general sensation of numbing and withdrawal from people and from life. Such a person might appear to be zombie-like or they might appear to be dazed or in a trance.
- Robbed of the future: Some individuals may also carry within them the belief that their future is foreshortened and they will not be able to carry out their role as father, spouse, or to succeed at their career objectives. They would have a sense of having been robbed of their future life.
- Emotional drain: Some individuals with this disorder will be newly restricted in their ability to experience their normal range of emotion. For example, they might find it impossible to experience loving feelings. Imagine a fireman or policeman acting somewhat robotic, unable to feel compassion for victims, and no longer able to place themselves again at risk in their role as rescuer.
Persistent hyper-arousal - By this, we mean that individuals subjected to the trauma experience certain physiologic signs and higher levels of physiologic reactivity that were not present prior to the trauma. These signs can include:
- Inability to fall asleep or remain asleep
- Irritability or inappropriate outbursts of anger
- Difficulty with concentration
- Being hyper-vigilant: always being watchful and on guard and unable to relax
- Experiencing exaggerated startle response: for example the sound of a car backfiring might lead a person to fall to the ground or run for cover. For an individual who heard and saw a jetliner crash into a building, the sound of jets nearby could strike terror and cause them to take cover or become paralyzed.
PTSD vs. Acute Stress Disorder
When the signs above are present, but they last less than 30 days, the diagnosis is considered to be not PTSD, but ASD, or acute stress disorder. It would be quite normal for most everybody living through this crisis to have some of the mentioned symptoms.
Seeking Help
Important distinctions as to whether a person should seek out professional help would include the person's own determination of how bothersome the symptoms are. In determining this, it is useful to consider the judgment of important people in the individual's life such as family members, friends and co-workers. These people may be suffering too, from the loss of the emotional availability of the person they once knew. If so, they may help the affected individual realize the necessity of obtaining treatment. Job performance is another measure. If symptoms are causing impairment of the individual's ability to perform their normal job (or other important functions), then treatment is indicated.
Treatment for PTSD
It is important to know that PTSD is a treatable illness. People with this disorder routinely can experience complete recovery. Treatment consists of medication for immediate relief of physiologic signs that interfere with sleep, concentration, the ability to relate, and the ability to function. Additionally, cognitive and behavioral therapies are useful at providing a framework of understanding, promoting a return to self-confidence, a sense of again having control, and at restoring the ability to trust. Family sessions are also useful to underscore the importance of understanding the disorder and of learning how to provide emotional support. Needless to say, the understanding of employers and co-workers is also very therapeutic.
Given the massive nature of the trauma affecting New York City and Washington DC, it would be reasonable to anticipate that relevant social services, governmental entities, and private companies would take it upon themselves to understand the signs of this disorder, and be prepared to offer proper treatment and support for individuals who develop the disorder.
Risk Factors
Essentially, any prior experiences that have evoked terror, horror, or helplessness appears to lower the threshold for developing PTSD. People who have been exposed to childhood abuse, marital abuse, or prior traumatic events such as assaults or rapes are more likely to develop PTSD if they encounter new traumatic events. It is also thought that pre-existing psychiatric disorders lower the threshold and make it more likely for individuals to develop PTSD. Finally, a prior diagnosis of PTSD is thought to increase the risk of redeveloping further episodes when being subjected to new traumatic events.
Associated Disorders
PTSD, if left untreated, is associated with the development of depressive, anxious, and substance abuse disorders. Studies from combat veterans showed high percentages of veterans with battle fatigue or shell shock had gone on to develop generalized anxiety disorder, panic disorder, and phobias. Statistics also showed higher rates of major depressive disorder and alcohol abuse as well as the abuse of other substances. These disorders developed or remained present for as long as 20 years after the initial diagnosis of PTSD. Accordingly, early and complete treatment of PTSD is recommended as soon as the diagnosis is realized.
Summary
After experiencing a traumatic event, it is very common, in fact quite normal, to experience a range of unusual physical or emotional responses. The recent events involving the World Trade Center and the Pentagon are situations beyond routine experience. These events are equivalent to war time traumatic events. We are all struggling to cope with the images and reality of these events.
From a therapeutic perspective, some recommendations can be offered. Work is good, restoring normal routine is good, limiting exposure to repeated images of destruction and trauma is good.
However, it is also important not to avoid the reality of what has occurred. We all need to accept the reality in proportion to our abilities and in accord with our natural coping defenses. If you recognize the development of symptoms which are significantly bothersome or which impair your ability to function, you should seek out professional treatment from a psychiatrist or other trained mental health professional.
