Post-traumatic stress disorder (PTSD)

2021-07-17 12:32 PM

It may include experiences of war, childhood sexual or physical abuse, rape, natural disasters or technological disasters.

The diagnostic criteria for PTSD according to the DSM-IV-TR are: the individual has experienced or witnessed an event that is fatal, poses a risk of death or serious injury, or threatens the physical integrity personality of the individual or others and their immediate reactions include intense fear, hopelessness or terror. In the long term, the individual will experience three sets of symptoms that last for at least a month:

Intrusive memory: trauma is re-experienced through intrusive thoughts, nightmares, or flashbacks. Such reoccurrence may be intentional because the individual ruminates over the traumatic events. Images can automatically arise in the mind, in the form of flashbacks. These images often feel as real as the event itself but can be patchy or partial. Trauma-related emotions and feelings can be relived with the same intensity as the event took place. The images are often depicted as if they were the movie of the event. First, individuals feel they are actually in the movie: when they feel they are watching the film as an outside observer, that is when they begin to emerge from the trauma and gradually recover.

Avoidance: The practice of avoiding actions or activities that are reminiscent of the traumatic event. Avoidance may involve psychological defense mechanisms, including becoming unable to recall images of the trauma, emotional paralysis, separation from others, as well as avoidance of contact and contact. things that may be reminiscent of the trauma.

Arousal: persistent, excessive arousal may be manifested by irritability, easily startled or over-cautious, insomnia or difficulty concentrating.

The events that cause PTSD are varied. It may include experiences of war, childhood sexual or physical abuse, rape, natural disasters, or technological disasters. Perhaps the most frequent cause of PTSD is a traffic accident: about 20% of people who have been in a traffic accident have some degree of PTSD (Ehler et al. 1998). Approximately 1% of the population suffers from PTSD at some point (Kessler et al. 1995). For groups that regularly witness traumatic events, the incidence of PTSD is much higher. For example, Bennett et al. found that 20% of emergency personnel experienced PTSD while the rate among Vietnam War veterans was 30% for men and 27% for women (Kulka et al. 1990). PTSD usually begins within a few weeks of the event. However, PTSD can also reappear after symptoms have subsided but due to another trauma or various life events such as celebrations related to the day of the trauma, bereavement, and change. health status. Here is Ron's story. Through the story, we see both the circumstances and the reactions of those around us that affect the development of PTSD in Ron.

At the time, I was working in a makeshift house in an industrial suburb. They are building a few more blocks and have a crane truck to move things out of the construction site. It's right next to our office. You can't see it because there's no window on that side of the building, but you know it's there... I don't know why but on the day of the accident they used a crane that wasn't fastened. it into the ground. As a result of this, the crane lost its balance and fell into the building where I was working. The first thing we noticed was a lot of mechanical sounds and screams, at which point we understood that the crane had toppled. Then there was a loud crash and the arm of the crane smashed through the building. I'm in there with my friend. Oddly enough, none of us were injured, but we were all trapped in the debris of the building. I think I was stunned for a moment because I can't remember the details of what happened, but maybe only for a minute or two. I wasn't seriously injured but I was stuck. The worst part was having to wait until it was time to get out. I was very afraid of broken gas pipes and the image of dying in a fire appeared in my mind. I hate the feeling of not being able to move and every image of what can happen when I'm unable to move pops into my head. I was really scared until I heard people coming and pulling us out, and they started to move the heavy things that were on top of me and I was able to move... I think I was stunned for a moment because I can't remember the details of what happened, but maybe only for a minute or two. I wasn't seriously injured but I was stuck. The worst part was having to wait until it was time to get out. I was very afraid of broken gas pipes and the image of dying in a fire appeared in my mind. I hate the feeling of not being able to move and every image of what can happen when I'm unable to move pops into my head. I was really scared until I heard people coming and pulling us out, and they started to move the heavy things that were on top of me and I was able to move... I think I was stunned for a moment because I can't remember the details of what happened, but maybe only for a minute or two. I wasn't seriously injured but I was stuck. The worst part was having to wait until it was time to get out. I was very afraid of broken gas pipes and the image of dying in a fire appeared in my mind. I hate the feeling of not being able to move and every image of what can happen when I'm unable to move pops into my head. I was really scared until I heard people coming and pulling us out, and they started to move the heavy things that were on top of me and I was able to move... The worst part was having to wait until it was time to get out. I was very afraid of broken gas pipes and the image of dying in a fire appeared in my mind. I hate the feeling of not being able to move and every image of what can happen when I'm unable to move pops into my head. I was really scared until I heard people coming and pulling us out, and they started to move the heavy things that were on top of me and I was able to move... The worst part was having to wait until it was time to get out. I was very afraid of broken gas pipes and the image of dying in a fire appeared in my mind. I hate the feeling of not being able to move and every image of what can happen when I'm unable to move pops into my head. I was really scared until I heard people coming and pulling us out, and they started to move the heavy things that were on top of me and I was able to move...

Once I was out, I went to the clinic and was sent home. I told them I was fine just because I wanted to go home and get out of this. I was sent home and spent the day in the house. I just retracted. I don't want to talk about it. I was able to sleep. I don't like to lose my job so I go to work the next day. My co-workers took me to see the collapsed house and they all told us how lucky we were to have survived. Everyone I meet says the same! I know they're being friendly

but that made it worse and i started to think about the past more and more. i felt shaky and nauseous.. in the end, i had to go home.

The nightmares started a few days later. I dreamed that I was in that house - this time I saw the crane fall and felt trapped when it hit even though in reality I couldn't see anything. All dreams are very scary and I'm sweating and breathing heavily when I wake up. I can dream two or three times in one night. I have to get up early and watch TV, drink a cup of tea, and do something to calm me down after the dream... I can't get back to sleep. I had to take eight, nine weeks off work because of all this. I was too exhausted and tired to work.

I was also quite restless and nervous the whole time. Usually, I'm a very laid-back person. Yet my wife and I had trouble with each other because it was difficult to live with at that time.. The dreams got better slowly and I also forced myself to go back to work. I had some panic attacks when I started working again because my new job was a makeshift, windowless house. So I panicked at the thought that something was going on outside. Later, my office had large windows and that was really good for me.

Causes of post-traumatic stress disorder

Biological factors

It is thought that involved in PTSD are brain structures involved in emotional processing and memory. More specifically, it's the seahorse and almond zone. The hippocampus is responsible for processing and recalling memories. It is connected to the amygdala, a specialized area of ​​the brain involved in the formation of conditioned fear responses. Both the hippocampus and the amygdala are activated during memory formation about related events and emotions, or when recalling them. Two hormones appear to be particularly involved in traumatic memory formation: norepinephrine and cortisol. Increased levels of these two hormones generally reinforce memory, although hormone levels during trauma can be toxic to brain tissue and cause neuronal death. destroy the memory system. It has been found that the release of norepinephrine increases feelings of fear and evokes strong memories and flashbacks in some cases (Leskin et al. 1998). Brewin (2001) suggests that flashbacks can occur when information is transmitted from the amygdala to the hippocampus. The sympathetic nervous system (see chapter 3), controlled by the hippocampus and norepinephrine levels, is responsible for producing high levels of physiological arousal in relation to the environment.

Condition pattern

The conditional model of PTSD (Foa et al. 1989) is based on the two-factor theory of Mowrer (1947). It is the classical conception of PTSD as a conditioned emotional response. Confronting similar situations or stimuli evokes traumatic memories and conditioned fear responses. Avoiding things that are reminiscent of the trauma not only helps prevent stress, but it also helps avoid accustoming to a fear response to the trauma-related stimulus. Thus, chance encounters with corresponding stimuli cause flashbacks and other related memories. The fundamental limitation of this approach is that it cannot explain why so many people still experience flashbacks and memories without any hint or hint: for example, people with PTSD often experience the same symptoms. memories in the form of dreams.
of PTSD.

Cognitive pattern

There are two cognitive models of PTSD: a social cognitive model that emphasizes massive re-adaptation, which is often necessary to integrate traumatic experiences into the individual's worldview, and a theoretical model of information processing. Information focused on how trauma-related information is represented in the memory system.

The first social cognitive model of PTSD was developed by Horowitz (1986). This model is strongly influenced by psychoanalytic theory. Horowitz argues that PTSD occurs when the individual is caught up in events that are too terrifying to reconcile with the individual's worldview. For example, believing that they might die in an accident can disrupt previous beliefs about invulnerability. To avoid this ego-destroying inconsistency, negative or paralyzing defenses are activated. However, these mechanisms must compete with a second innate impulse known as the tendency to perfection. It requires the individual to integrate the memory of the trauma with the existing world map or model: either seeing it in terms of existing beliefs or changing those beliefs.

Perfection bias keeps trauma-related information inactive memory in order to process it. However, defense mechanisms try to prevent those memories from entering consciousness. Thus the symptoms experienced by the individual are the result of that competitive process. When perfectionism overcomes defenses, memories enter consciousness in the form of flashbacks, nightmares, and unwanted thoughts or emotional memories. When the defense mechanism is working effectively, the individual will experience a process of denial or numbness. Once the trauma-related information integrates into the shared belief system, the symptoms stop appearing.

Brewin (2001) added a second order of information processing to the conditional model of PTSD. His model suggested that individuals could selectively choose to mention their traumatic memories and that those memories could also enter cognition without consciously recalling them. The intentional processing of traumatic memories is the process of penetrating what Brewin calls Verballi accessible memories (VAMs). These memories can be intentionally recalled and readjusted gradually. He also called memories inaccessible a

Intentionally accessible memories (SAMs). These are conditioned memories, often appearing as flashbacks or nightmares. It is triggered by conscious processing of VAMs or external, conditioned triggers. Brewin suggested that the hippocampus is the nerve center involved in the processing of VAMs. The amygdala may be involved in processing more emotional SAMs. Like Horowitz, Brewin argues that emotional processing results from an impulse to resolve conflicts between old diagrams and new information. Activation of SAMs provides specific information needed to affect cognitive adaptation to trauma. Once the integration is successful, the symptoms of PTSD should disappear.

Psychosocial pattern

Without focusing much on the cognitive processes associated with PTSD, Joseph et al. (1995) have explored a broad set of factors that influence the development and progression of the disorder. Those factors include:

Event stimulus: the images representing the event are stored in the immediate memory region.

Event perception: Memories that underlie re-experience or intrusive memories - similar to Brewer's SAMs.

Review and re-evaluate: individual thoughts on the event - similar to Brewer's VAMs. It is the interpretation of fact-related information using past experiences. They may take the form of automatic diagrams associated with strong emotional states caused by traumatic stimuli or an attempt to reassess the meaning of the event.

Attempts to cope: flashbacks and emotional memories of the event can induce coping efforts to reduce emotional stress disorders. These efforts often take the form of avoiding reminders, memories, or similar emotions, or actions associated with the trauma. A coping strategy may be to try to suppress unwanted memories (although this can be very difficult).

Personality: Personality affects perceptions and emotions experienced during trauma, judgments formed as responses to trauma, and subsequently coping strategies. Thus, personality has a strong influence on whether an individual develops PTSD and the progression of the disorder.

Social support: is an important mediator of trauma response. For example, talking to others helps the individual take on new meanings about events and encourages the expression of negative emotions.

Joseph and cs. (1995) provided evidence linking each element in their model. Here, we examine the relationship between factors related to two emotions characteristic of PTSD: shame and guilt. These two emotions relate to the role of internal control and negative consequences (I could have done something to stop it - but I didn't). These emotions can in turn be driven by the individual's style. Whether the individual feels guilt or shame affects the coping strategy they adopt. Strong guilt can be associated with intrusive thoughts and images. The individual responds to these intrusive thoughts and images with some form of repetitive action. Feelings of shame can lead to attempts at avoidance and denial. Final,

Two personality constructs appear to be particularly relevant in the development of PTSD. According to several studies, negative emotion, or neuroticism, is thought to be a predictor of the development of PTSD symptoms (Bennett et al. 2001). PTSD can be predicted by the tendency to rate the event as negative and threatening and to be obsessive about the event. Many studies have also found a link between the avoidance and stiffness of PTSD and alexithymia (Fukunishi et al. 1996), which is characterized by poor experience and sensory perception. emotions, accompanied by a poverty of imagination and a tendency to focus on the mundane and touchable/existent (especially possibly physical symptoms of an emotional response).

Treatment of post-traumatic stress disorder

Prevention of PTSD by psychological debriefing

Psychological interviewing is an interview that takes place immediately after a traumatic event to help those involved cope with their emotional reactions to the trauma, and to prevent the development of PTSD. It involves encouraging individuals to talk about the event and their emotional reactions to the event in detail and how to handle it. It is thought to help integrate event memories into the general memory system. Psychological interviewing is now often used after a traumatic event, despite growing doubts about its effectiveness. For example, Rose et al. (2002) concluded based on a meta-analysis of the results of four trials of psychological interviews. These four trials suggest that psychological interviewing is not only ineffective in preventing PTSD but may also increase the risk for the disorder. None of the studies using this approach demonstrated a reduced risk of PTSD 3 or 4 months after the event. Two long-term follow-up studies found that psychological interviewees were almost twice as likely to experience PTSD as those who did not receive this intervention. That means psychological interviewing seems to limit long-term recovery from trauma. Several explanations for these findings are offered, although they are still speculative: That means psychological interviewing seems to limit long-term recovery from trauma. Several explanations for these findings are offered, although they are still speculative: That means psychological interviewing seems to limit long-term recovery from trauma. Several explanations for these findings are offered, although they are still speculative:

Secondary trauma can occur by recalling images of the traumatic event shortly after the event.

Psychological interviewing can address common stress disorders but increases the risk of developing psychological symptoms in people who may not already have them.

Psychological interviews can prevent potentially protective reactions such as denial and distance. These reactions may appear immediately after the traumatic event.

Although the psychodynamic approach is somewhat effective for people with PTSD (Marmar 1991), the most commonly used intervention for PTSD is cognitive-behavioral.

The facing technique

The underlying principle for the coping approach in PTSD therapy is that the individual will ultimately benefit from re-encountering the memories of the event and the emotions involved. The conditioning model suggests that stress decreases as the individual's emotional responses to memories become more familiar over time. A more cognitive explanation: confrontation leads to reconciling the memory and meaning of the traumatic event into a pre-existing world map. Only by penetrating and processing those memories will the symptoms gradually disappear.

Confrontational therapy may initially exacerbate stress when distressing images, which had previously been avoided, are intentionally re-triggered. To reduce this stress and to avoid aborting treatment, Leskin et al. (1998) recommend using a step-by-step face-to-face process. In this process, the individual initially talks about a particular element of the traumatic event at a specific level of their choosing for a period of time until they no longer respond to the stress response. Any new and potentially more stressful memories will be avoided this time and become the focus of the next levels of treatment. Reactivating memories by this process involves specifically describing the experience, focusing on what happened, the thoughts and feelings experienced during that time, and any other memories. left by the event. This core approach can be augmented by a range of cognitive-behavioral skills including relaxation training and cognitive restructuring. Relaxation can help individuals control their arousal during the re-enactment of the event or at times of the day when they feel stressed or angry. Cognitive restructuring can help individuals address any distorted perceptions they have in response to events and make them less threatening ('I'm dying!... I feel see I'm dying, but in reality, it's more fear than reality...'). Relaxation can help individuals control their arousal during the re-enactment of the event or at times of the day when they feel stressed or angry. Cognitive restructuring can help individuals address any cognitive distortions they have in response to events and make them less threatening ('I'm dying!... I feel see I'm dying, but in reality, it's more fear than reality...'). Relaxation can help individuals control their arousal during the re-enactment of the event or at times of the day when they feel stressed or angry. Cognitive restructuring can help individuals address any distorted perceptions they have in response to events and make them less threatening ('I'm dying!... I feel see I'm dying, but in reality, it's more fear than reality...').

Several studies have shown that coping techniques-based therapy is superior to no therapy and other active interventions include supportive counseling and non-face-to-face relaxation therapy (Keane et al. . 1989). For example, Foa et al. (1991) divided female rape victims into groups on a waiting list control (this is a type of control group, consisting of people with the same status as the intervention groups, however, only followed up without any intervention to compare with the intervention groups - ND), ego self-directed training group, counseling/psychological support group and program face to face. Participants inactive interventions showed more progress than those on the waiting list condition. Immediately after the intervention, Those who join the group direct the ego to be in top shape. Three months later, however, those in the face-to-face program had fewer intrusive memories and attacks than those in the other conditions. Marks et al. (1996) also found similar results by comparing relaxation therapy, face-to-face, cognitive restructuring and face-to-face with cognitive restructuring. When the intervention is over, all other therapies are equally and equally effective than relaxation. Three to six months after therapy ends, a face-to-face program is thought to be the best. It appears that ego-directing and other cognitive techniques can help participants cope with anxiety and other emotions that arise in the early stages of a coping program. while dealing with traumatic memories is thought to be beneficial in the long run. The best therapy seems to be to combine ego coaching and other cognitive techniques in the early stages of therapy with gradual coping with traumatic memories.

Treating people with PTSD may not require much-specialized training. Gillespie et al. (2002) taught health care workers with minimal knowledge of cognitive behavioral therapy how to intervene in PTSD based on coping techniques after the big bomb detonation in the small city of Omagh in Northern Ireland in 1998. Staff members underwent a two-day conference and phone call with PTSD therapists and therapists. The effectiveness of their intervention is similar to that of other specialists' therapeutic outcomes that previous studies have found.

Eye movement desensitization and information reprocessing

The most recent and controversial therapy is eye movement desensitization and reprocessing (EMDR), discovered incidentally by Shapiro (1995). Shapiro noticed that as she walked through the forest her disturbing, her disturbing thoughts gradually disappeared, and when recalled, those thoughts became less irritating than before. This change involves the eyes moving naturally, quickly, back, forward, and up in a diagonal. The process has since evolved into a standardized intervention and is the subject of numerous clinical trials in the treatment of PTSD.

The main treatment is that the client recalls certain memories as images with negative perceptions, presented in the present-day language ('I'm terrified' ). Next, the client will rate the intensity of the emotion evoked during this process. The client is asked to watch the therapist's finger move rapidly in and out of the client's field of vision. After about 24 such movements, the client was instructed to “let it go” or “release it” and asked to rate his or her emotional level. This process is repeated until the client experiences the lowest level of stress in the presence of negative images and perceptions. If no change occurs, the direction of eye movement is changed.

EMDR is suitable for dealing with some elements of the traumatic stimulus. An important question is whether the addition of eye movement techniques enhances the effectiveness of face therapy. It seems that's not the case. EMDR is more effective than no intervention, but it is not more effective than standard face-to-face programs. Davidson and Parker (2001) used meta-analysis to test the effectiveness of EMDR in PTSD treatment compared with no therapy, nonspecific therapy, and coping strategies described above. The results show that EMDR has only a very modest advantage over no therapy and nonspecific therapy, its effectiveness being equal or less than the face-to-face approach. In a similar study, Devilly and Spence (1999) randomly assigned individuals with PTSD to a program based on coping techniques combined with an irrational cognitive challenge related to trauma and EMDR. Results from multiple PTSD measurements showed a clear advantage in the face-to-face group over the EMDR group immediately after the intervention ended, two weeks and three months later. The difference between the two groups is getting bigger and bigger.

Pharmacological intervention

Many different drugs have been used to treat PTSD with some efficacy, including antidepressant MAOIs, SSRIs, and tricyclic antidepressants (see chapter 3). For example, Stein et al. (2002) analyzed the results of a 9-month study of antidepressants in the treatment of PTSD. Compared with placebo, the drugs were equally effective in significantly reducing the baseline symptoms of PTSD of avoidance and aggression. SSRIs are probably the most effective pharmacological intervention