Intro to Essay: Prevalence, children as well as adults, not always combat related,

differences between countries

Post-traumatic stress disorder (PTSD)
There is significant evidence to suggest that man-made trauma (i.e. warfare, terrorism,
vehicle accidents, abuse) will elicit PTSD more so than a natural disaster trauma (i.e. fire,
earthquake) (Gull, 2010). PTSD can also effect children (six years of age and older) as well as
adults, and is not always combat related (U.S. Department of Veteran Affairs, 2013). After a
traumatic event, it is estimated that 25-30% of individuals will develop PTSD (NICE: National
Institute for Health and Care Excellence, 2005). In the US, PTSD effects about 12% of the
population, but could actually be much higher considering the number of PTSD patients who are
never diagnosed (Sherman, 1998). The lifetime prevalence of PTSD according to the DSM-IV is
6.8%, but this percentage is also believed to be much higher as well (American Psychiatric
Association, 2013).
Intro to PTSD:
Post-traumatic stress disorder has made its appearances throughout history, even though
it was only added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) within the
last 35 years. In the writing of Greek historian Herodotus, modern day historians have found that
in his accounts of the battle of Thermopylae Pass in 480 B.C., the soldier Aristodemus had
become so disturbed by battle that he developed a physiological trembling and later hanged
himself out of shame. In that same battle, Spartan commander Leonidas has dismissed all of his
men from battle because he recognized the psychological and physiological change in his
soldiers, who had become unwilling to fight. Herodotus wrote They had no heart for the fight
and were unwilling to take their share of the danger. The surviving diary of Samuel Pepys, an
Englishman living in London who had experienced the Great Fire of London in 1666, provides
historians with a historical account of the development of PTSD. Pepys wrote So great was our
fear It was enough to put us out of our wits. Pepys writes about his sleep disturbances and his
inability to shake the fear of fire and the falling down of houses in the months following the
disaster. In 1678, the Swiss physicians became the first to recognize the behaviors and symptoms
of combat related stress disorders calling it nostalgia, while the Germans at the same time were
recognizing the same behaviors and symptoms of its soldiers calling it heimweh, which directly
translates to homesickness. Yet, both diagnosis incorrectly placed the cause of the psychological
and physiological changes as the soldiers longing to return home. By the American civil war,
physicians were recognizing the increasingly common psychophysiological effects of military
life on soldiers due to the advancement in technology that changed the fashion in which wars
were fought. It was believed that the stronger artillery of modern warfare cause a concussion that
disrupted the brain and its physiological functions, coining the term shell shock. By World
War I, physicians believed that it was not physiological but psychological disturbances, but
attributed this disturbance to the weakness of some mens character. During World War II,
psychiatric testing was conducting to filter out men who were more susceptible to a
psychological break down. The Vietnam War resulted in almost 30% of soldiers returning home
to develop full blown or partial PTSD (Bentley, 2005).
Post-traumatic stress disorder was first added by the American Psychological Association
(APA) in 1980 to the DSM-III (U.S. Department of Veteran Affairs, 2007). This addition to the
DSM distinguished PTSD as a result of an external traumatic event, rather than an internal
weakness such as traumatic neurosis (U.S. Department of Veteran Affairs, 2007). Revision in the
DSM-IV provided a more in-depth diagnosis of the DSM-III. The DSM-V made a number of
changes to the PTSD entry, most importantly identifying PTSD as not a fear-based anxiety
disorder and regrouping the disorder in a new group, Trauma- and Stressor- Related Disorders,
and out of the Anxiety Disorder group (U.S. Department of Veteran Affairs, 2007).
Post-traumatic stress disorder is a mental disorder that can effect individuals following a
major traumatic event (Bisson & Andrew, 2007). The newly written Diagnostic and Statistical
Manual of Mental Disorders fifth edition (DSM-V) defines Post-traumatic stress disorder as a
mental health disorder that is triggered by actual or threatened death, serious injury or sexual
violation (American Psychiatric Association, 2013). The trigger results from the individual
having either experienced the traumatic event directly, witnessed the traumatic event in person,
learns that the traumatic event occurred to a close family member or close friend, or experiences
first-hand repeated or extreme exposure to aversive details of the traumatic event (American
Psychiatric Association, 2013). The traumatic event causes the individual significant distress or
impairment in major areas of functioning needed to succeed in everyday life. The DSM-V also
determines whether or not the symptoms could be associated with another medical condition,
drug abuse, alcoholism or medication (American Psychiatric Association, 2013). To be
diagnosed with PTSD, the individual must meet the criteria provided in the DSM. The DSM-V
provides eight criteria, with two specification provided; delayed expression and a dissociative
subtype. Dissociative subtype being a new addition to the DSM-V.
The first criteria is exposure to a stressor. To meet the criteria the individual must have
been exposed to: death, threatened death, actual of threatened serious injury, or actual or
threatened sexual violence. This criteria can be met by either direct exposure, witness to the
event, indirectly via someone close to the individual who directly experienced a traumatic event,
or repeated indirect exposure to traumatic events excluding indirect nonprofessional exposure
provided by the media (this is usually met by those whose profession require the individual to
work with traumatic events, such as first responders). The second criteria requires that the
individual exhibit an intrusive symptom in which the individual re-experiences the traumatic
event. This criteria can be met by either the presence of recurrent, intrusive or involuntary
memories (for children over six year of age my present this symptom as repetitive play),
traumatic nightmares (children may have nightmares that do not directly relate to the traumatic
event), dissociative reactions that can occur in brief flashback episodes to complete loss of
consciousness (for children this could include reenacting the traumatic event in play), intense or
prolonged distress after reminders of the traumatic event are experienced, or physiological
reactivity to stimuli that are related to the traumatic event. The third criteria is avoidance of
trauma related stimuli. This criteria can be met by experiencing either avoiding thoughts or
feelings related to the trauma or avoidance of trauma-related reminders such as people, objects,
tasks and places. The fourth criteria is the appearance of negative changes in the mood and
cognitions. This criteria is met when the individual meets two of the criterion. These criterion are
the inability to correctly or completely recall the traumatic event, persistent negative cognitions
about themselves or the world around them, continuous blame on the self or others for the cause
of the traumatic event or the consequences of the event, persistent negative emotions related to
the trauma (such as fear, shame, guilt, or horror), disinterest in activities that were performed
prior to the traumatic event, detachment or estrangement from others, or the persistent inability
for the individual to experience positive emotions. The fifth criteria is the changes in arousal and
reactivity. This criteria is met when the individual meets two of the criterion. These criterion are
aggressive or irritable behavior, behavior that is self-destructive or reckless, hypervigilance,
exaggerated startle response, problems when concentrating, and disturbances with sleep. The
sixth criteria requires that the individual meet criteria two, three, four and five for more than one
month. The seventh criteria states that the individual must experience significant stress related to
the symptoms or experience impairment in necessary functions (such as socially or
occupationally). The eighth criteria requires that the individuals symptoms are not caused by
medication, substance use or a different illness. In addition to these eight criteria, the DSM-V
also suggests that the diagnosis specify if the individual experiences depersonalization or
derealization with dissociative symptoms, and specify if full diagnosis is met within six months
even though symptoms may appear immediately after the traumatic event (American Psychiatric
Association, 2013).
Post-traumatic stress disorder can be treated using various methods. Trauma-focused
cognitive behavior therapy (TFCBT), eye movement desensitization and reprocessing (EMDR),
medication, psychodynamic therapy and emotional freedom technique (EFT) are all proven to
help reduce the symptoms of PTSD. Trauma-focused cognitive behavior therapy and eye
movement desensitization and reprocessing are recommended by NICE as the most effective
methods to treating patients with PTSD when given on an individual basis (NICE: National
Institute for Health and Care Excellence, 2005).
Intro to EMDR:
Eye movement desensitization and reprocessing is a therapy that involves directing a
patients attention to an external stimulus (bilateral saccadic eye movements) while they are
simultaneously being exposed to trauma-related stimuli or memories. While this therapy is
completely theoretical, the idea is that the left to right eye movements cause the brain to decrease
the intensity of the traumatic memories in the brain that are triggered by sensory stimulation
(EMDR UK and Ireland, 2013).
Intro to TFCBT:
It has been found that trauma-focused CBT is more effective than medication in
controlling PTSD symptoms (Gull, 2010). TFCBT focuses on negative and distorted thoughts an
individual might be having and replacing them with more positive beliefs and feelings to reduce
anxiety and distress (Gull, 2010). The treatment is also used in combination with imaginal or in
vivo exposure (Foa, 2009). TFCBT establishes a trusting relationship between patient and
healthcare professional, allowing the patient to feel comfortable opening up about a traumatic
event (NICE: National Institute for Health and Care Excellence, 2005). TFCBT has been
recommended as the most effective method to treating children and adolescent patients when
implemented to fit their understanding and level of development (NICE: National Institute for
Health and Care Excellence, 2005). TFCBT is effective when given within the first three months
of a traumatic event and it has eight components. These components are psycho-education of the
traumatic event and teaching the patient how to properly express themselves, relaxation to teach
the patient to calm themselves while in the presence of traumatic stimuli or while remembering
traumatic events, teaching the patient to be expressive and exerting control of their feelings,
changing the negative thoughts and beliefs, trauma narrative where the patient recounts the
traumatic events openly with the health care professional, in vivo or imaginal exposure to
trauma-related stimuli, sessions that involve family members or friends for support, and
developing ways to handle symptoms of PTSD and learning to manage in future similar
situations (Gull, 2010). It is generally completed in 8-15 sessions, but fewer than 8 can suffice
for patients showing symptoms only one month after a traumatic event. Sessions usually last for
about 90 minutes and are held about once a week and require the patient to complete homework
weekly (NICE: National Institute for Health and Care Excellence, 2005) (Foa, 2009).
Compare TFCBT and EMDR:
Contrast TFCBT and EMDR:
TFCBT more helpful to children
EMDR generally has fewer sessions and is more effective for treating depression and improving
social functioning
Conclusion: