In today’s world your ZIP Code—even more than your genetic code—determines whether you will lead a safe and healthy life. [Your] income, family structure, housing, employment, and educational opportunities affect not only the risk of developing traumatic stress but also access to effective help to address it.
Poverty, unemployment, inferior schools, social isolation, widespread availability of guns, and substandard housing all are breeding grounds for trauma. Trauma breeds further trauma: hurt people hurt other people.
B.A. Van Der Kolk, 2014
The Body Keeps the Score
Mark, a 25-year-old male veteran, wakes up in the middle of night screaming and wide-eyed as he looks frantically about the room for something. His heart is pounding and his face is sweating. He was dreaming of a being in a foxhole again during his military service in the war. It felt so real, again.
Sally, a 52- year-old woman, stops paralyzed with fear as a large hooded man walks by her on a quiet street in the late evening, recalling a night just like that many years ago when she was mugged and raped. It felt so real, again.
Ben, a 13-year-old boy is referred to the school counselor for trouble concentrating, poor grades, irritability, and aggressive outbursts in class. He struggles daily to stop thinking about his mother’s brutal beating by his alcoholic father. It felt so real, again.
What do each of these three people have in common?
Post traumatic stress disorder. Although they are different ages and genders, and from different causes, each suffers from recurring emotional distress even though the original physical stressor is gone. As a healthcare professional, could you recognize the symptoms? Do you know what qualifies for the diagnosis and what treatments are available for each of these patients? They need you, to help them feel real, again.
Post traumatic stress disorder (PTSD) is a mental health disorder that can develop in anyone who experiences physical or emotional trauma. Anyone who experiences—or witnesses—a single traumatic even,t such as a terrorist attack or a tornado, or chronic trauma, such as war, sexual abuse, or family violence, may develop PTSD. An experience of shock, danger, or fear automatically results in the body’s natural sympathetic response of fight or flight; however, when that stress reaction continues even though they are not in danger, PTSD can develop (NIH, 2016). Examples of traumatic events include:
- Robbery or other violent crime
- Sexual assault
- Serious personal injury
- Stalking and bullying (either in person or online)
- Plane crashes or other major transportation accidents
- Sudden death (from other than natural causes) or serious illness of a loved one
- Such natural disasters as earthquakes, hurricanes, floods, and fires (NIH, 2016)
Traumatic events usually occur unexpectedly, triggering fear and the body’s natural sympathetic response, known as stress. This is a normal response intended to protect a person from harm. Stress stimulates the nervous system, the endocrine system and the immune system, causing the release of adrenergic hormones and chemicals. Heart rate and blood pressure increase, blood glucose levels rise, all in an effort to prepare the person to escape danger or deal with it more effectively if escape is not possible.
Recent advances in neuroscience and imaging technology have made it possible to visualize and measure the physiologic effects of traumatic stress on the brain, the mind, and the body, and the network of connections among them. Imaging studies show distinct changes in the physical brain of those suffering from PTSD, including the hippocampus and prefrontal cortex that involve mental reasoning (Bremner, 2007).
Almost everyone will experience emotional reactions after a traumatic event but most people recover from those responses within a short time. For some people, however, the disturbing images and emotions surrounding the event linger, impeding recovery and possibly leading to either acute or chronic PTSD. As pioneer researcher and physician Bessel Van Der Kolt explains,
Being traumatized means continuing to organize your life as if the trauma were still going on—unchanged and immutable—as every new encounter or event is contaminated by the past (2014, p. 53).
PTSD is a relatively new name for a mental health disorder that has been around for centuries and is commonly associated with military service. Doctors who treated soldiers during America’s Civil War mistook their patients’ psychological suffering for a cardiac condition brought on by “overreaction and overwork,” and referred to it as “Soldier’s Heart” (Wolfinger, 2016). During World War I, what we now call PTSD was called “battle fatigue,” and in World War II the term was “shell shock.”
Not until 1980 did the American Psychiatric Association create the diagnosis post traumatic stress disorder (PTSD), to describe the cluster of symptoms that reflected what clinicians were seeing in the veterans they treated. This new diagnosis was created in response to lobbying by a group of Vietnam veterans, aided by New York psychoanalysts Chaim Shatan and Robert J. Lifton (Van Der Kolk, 2014).
Since that diagnosis was created, research on the complex effects of trauma on the brain, mind, and body has increased due to better recognition of the disorder and more veterans to study. Better understanding of the physiologic effects of trauma is expanding the possibilities for more effective treatments beyond the currently used psychological and pharmacologic therapies.
PTSD can only be diagnosed if symptoms persist over 1 month. Symptoms generally begin within 1 month of the traumatic event and are grouped into four classes: intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions that disrupt personal relationships and behaviors (Mayo, 2016; APA, 2015).
Prevalence and Incidence of PTSD
Unfortunately, trauma is universal and occurs to people of every gender, age, color, ethnicity, socioeconomic status, and religion. A World Health Organization survey (WHO, 2013) of 21 countries found that more than 10% of respondents reported witnessing violence (21.8%) or experiencing interpersonal violence (18.8%), accidents (17.7%), exposure to war (16.2%), or trauma to a loved one (12.5%). An estimated 2.6% of the world’s population has suffered from post traumatic stress disorder (PTSD) in the previous year.
PTSD affects 3.5 % to 15% of the U.S. adult population—about 7.7 million Americans. Up to 31% of Vietnam veterans were found to experience PTSD. Women are more than twice as likely to develop the condition as men and about 37% of those cases are classified as severe. While PTSD can occur at any age, the average age of onset is in the early twenties, accounting mostly for those in military service and women victims of sexual violence (National Center for PTSD, 2015).
PTSD, however, is not exclusive to troops, as the incidence occurs even among nurses. One study found that 24% of ICU nurses and 14% of general staff nurses tested positive for PTSD due to job stress and work-related violence in emergency departments and critical care settings (Mealer et al., 2007).
Ordinary people who are exposed to violence or violent people are also at an increased risk of PTSD if they do not know how to handle stressful events effectively themselves. People who experience a sudden death of a loved one—or even observe violence or trauma—are at increased risk to replay the stressful event over and over in their mind until it becomes disruptive to a healthy life.
PTSD and Complications
Although the relived trauma of the triggering event of PTSD is a validated challenge, complications of untreated PTSD compound the problem. PTSD can disrupt relationships as well as the ability to work and function daily. Without diagnosis and treatment, people with PTSD are at greater risk of depression, anxiety, issues with drug and alcohol abuse, eating disorders, and suicidal thoughts and actions than those without the disorder. Most of the additional disorders are due to maladaptive efforts to cope with the relived trauma and emotional distress. Men are far more likely to commit suicide than women, are and veterans are more likely than nonveterans to end their own lives (Hudenko et al., 2017).
From 1999 to 2010, the suicide rate in the U.S. population among males was 19.4 per 100,000, compared to 4.9 per 100,000 in females. Based on the most recent data available (fiscal year 2009), the suicide rate among male Veteran VA users was 38.3 per 100,000, compared to 12.8 per 100,000 in females.
Research indicates that there is a correlation between many types of trauma and suicidal behaviors; for example, there is evidence that traumatic events such as childhood abuse may increase a person’s suicide risk. A history of military sexual trauma (MST) also increases the risk of suicide and intentional self-harm, suggesting a need to screen for suicide risk in this population.
Test Your Knowledge
Which of the following patients could be diagnosed with PTSD?
- A military Veteran who meets with his colleagues to relive his military days.
- A college girl who can’t focus on school work after being the victim of a date rape 6 weeks ago.
- A young man who attends counseling after being the only survivor of a motor vehicle accident with his friends.
- A teenager who has hyperactivity disorder for 2 years and can’t sit still during class.
Apply Your Knowledge
Q: What makes the difference between a person who experiences the fight or flight response during a stressful event and someone with PTSD?
A: Everyone who experiences stress will have the body’s natural response of the sympathetic system. People with PTSD continue to relive the stressful event even after the stressor is gone, causing both physical and emotional stress to continue.