Wednesday, September 23, 2015

Taking a Closer Look at PTSD

I wrote a previous post about PTSD (post-traumatic stress disorder), but I decided the subject could use more elaboration. There seems to be  misinformation about PTSD floating around. In addition, there is some dispute in the mental health field about how to categorize PTSD patients who've had different experiences.

PTSD can result from a wide range of traumatic experiences. The Diagnostic and Statistical Manual of Mental Disorders states that PTSD can result from exposure to "actual or threatened death, serious injury, or sexual violence." This covers many types of situations.

It's normal for people exposed to one of the above situations to have symptoms including fears, flashbacks and intrusive memories, for up to one month following the incident. If symptoms last only one month or less, the syndrome is called "Acute Stress Disorder," but in my opinion it is not a disorder at all, but a normal reaction. Most people who have witnessed an accident or a crime that involved serious injury or death to another person will have some of these symptoms. For example, I counseled someone who, while working at a bank, witnessed the bank's armed robbery. In another case, the patient witnessed the sudden death of a co-worker from natural causes. These individuals had some symptoms, but they were not serious.  These types of patients might not need long term treatment and may only need support. If the incident happened at a workplace, sometimes it is helpful for employees to meet as a group for support. I have facilitated some groups for this purpose.

The PTSD cases I've treated have been diverse. At least two patients I've seen had PTSD from terrible accidents. One case resulted from a construction accident in which one person was killed and another seriously injured. Another patient was a driver in a car accident that killed several people--his friends. These individuals had severe PTSD that included hallucinations. In these hallucinations, they saw their dead friends sitting next to them on the sofa and in some cases were able to "touch" the dead friend. The presence of such symptoms does not indicate a chronic psychotic disorder. In fact, visual hallucinations are not uncommon in PTSD, whereas chronic psychotic disorders such as schizophrenia are more likely to involve auditory hallucinations ("hearing voices"). Both patients got somewhat better over time with treatment, but unfortunately one of them developed a drug addiction, which complicated matters.

I've also worked with combat veterans from conflicts including Vietnam, Lebanon, Kosovo,  Iraq and Afghanistan. It is normal for any combat veteran to have some stress disorder symptoms. In some cases, however, symptoms persist long after the person leaves the combat zone. Why does this happen with some individuals and not others? There can be many factors, including the severity of combat experienced, and, as I mentioned in my previous post, guilt feelings.  The guilt can be either irrational or rational. Irrational guilt feelings can be treated in psychotherapy through examining the irrational thoughts and how they developed. Helping someone who feels guilty about doing something that was actually wrong is a bit more complicated. In those cases the treatment might involve helping the person to make amends in some way or helping the person to put  actions in a context. In some cases, when a person has voiced religious views, I have suggested that he speak with clergy from his denomination. I can't answer the question "am I going to Hell?" 

 Exposure to wartime combat may change views on life and prompt philosophical questions. In my opinion dealing with such issues can be an important part of therapy, but unfortunately, there is a trend in the field to emphasize behavioral approaches to PTSD that may be helpful in symptom management but ultimately fail to address the roots of the disorder. Many people who have been exposed to trauma suffer a loss of a previous, idealized view of the world that is common but also inaccurate. I believe that trauma survivors, far from being merely damaged individuals, often have  wisdom that should be appreciated.

About 20 years ago, a psychiatrist named Judith Lewis Herman proposed a new diagnosis called "Complex PTSD" for people who have survived long-term captivity in an abusive situation. This category includes survivors of childhood abuse, as children have no power to leave their abusive situations. This diagnosis has never been formally accepted by the American Psychiatric Association, which is a puzzle to me, because PTSD from long-term childhood abuse is going to result in a different symptom profile than PTSD from a one-time incident or even PTSD from wartime combat.  Long-term exposure to trauma, especially if it starts during childhood, can cause personality changes.

In short, there are many factors to consider when evaluating stress disorder symptoms. These include whether the trauma was a one-time incident or a prolonged series of incidents, whether or not the patient feels guilt about the trauma, and if so, is the guilt  rational or irrational, at what age was the trauma experienced and for how long, and also the identity of the perpetrator if there was one (or more than one). There are probably more factors that I can't think of at the moment. Treatment for PTSD in my opinion should involve a combination of insight-oriented and cognitive or behavioral interventions and in some cases medication may be necessary. Group therapy can sometimes be helpful, perhaps especially for combat veterans and for survivors of childhood sexual abuse. 








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