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 Post Traumatic Stress (PTS)

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Liz Pidgley
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PostSubject: Post Traumatic Stress (PTS)   Fri 23 May 2008, 12:54 pm

A bit about Post Truamatic Stress Disorder. (PTSD)

What is PTSD?
Post traumatic stress disorder is a psychological disorder that you may suffer if you experience or witness a life threatening or traumatic event.
It is a normal reaction to an abnormal situation.
Diagnosis.
For a doctor or medical professional to be able to make a diagnosis, he/she has strict diagnostic criteria, which has to be met.
This will be done by asking you a series of questions or listening to you talk about an event or events in your life in which you feel significantly changed your behaviour.
One recognized standard for assessing PTSD is the World Health Organization's ICD-10.

It was thought that PTSD could not be a result of "normal" events such as bereavement, business failure, interpersonal conflict, marital disharmony, working for the emergency services, etc, and most of the research on PTSD had been undertaken with people who had suffered a threat to life (e.g. combat veterans, especially from Vietnam, victims of accident, disaster, and acts of violence).
It is now recognized that PTSD can result from many types of shocking experience. (Like pre-eclampsia / HELLP syndrome & loss of pregnancies / babies)


Diagnostic Criteria

The diagnostic criteria for PTSD are as follows:

A. The person experiences a traumatic event in which both of the following were present:
The person experienced or witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others;
The person's response involved intense fear, helplessness, or horror.

B. The traumatic event is persistently re-experienced in any of the following ways:

 Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions.

 Recurrent distressing dreams of the event;

 Acting or feeling as if the traumatic event were recurring (e.g. reliving the experience, illusions, hallucinations, and flashback episodes, including those on wakening or when intoxicated



 Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event;

 Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) as indicated by at least three of:

 Efforts to avoid thoughts, feelings or conversations associated with the trauma;
 Efforts to avoid activities, places or people that arouse recollections of this trauma;
 Inability to recall an important aspect of the trauma;
 Markedly diminished interest or participation in significant activities;
 Feeling of detachment or estrangement from others;
 Restricted range of affect (e.g. unable to have loving feelings);
 Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children or a normal life span).


D. Persistent symptoms of increased arousal (not present before the trauma) as indicated by at least two of the following:


 Difficulty falling or staying asleep;
 Irritability or outbursts of anger;
 Difficulty concentrating;
 Hyper vigilance;
 Exaggerated startle response.


Diagnosis is made when:

Where the symptoms are the result of a series of events, the term Prolonged Duress Stress Disorder (PDSD) may be more appropriate. Whilst PDSD is not yet an official diagnosis in ICD-10, it is often used in preference to other terms such as "rolling PTSD" and "cumulative stress".

How does PTSD start?
PTSD can start after any traumatic event. A traumatic event is one where we can see that we are in danger, our life is threatened, or where we see other people dying or being injured. Some typical traumatic events would be:

 serious road accidents
 military combat
 violent personal assault (sexual assault, physical attack, abuse, robbery, mugging)
 being taken hostage
 terrorist attack
 being a prisoner-of-war
 natural or man-made disasters
 being diagnosed with a life-threatening illness.
Even hearing about an the unexpected injury or violent death of a family member or close friend can start PTSD.


When does PTSD start?
The symptoms of PTSD can start after a delay of weeks, or even months. They usually appear within 6 months of a traumatic event.

What does PTSD feel like?
Many people feel grief-stricken, depressed, anxious, guilty and angry after a traumatic experience. As well as these understandable emotional reactions, there are three main types of symptoms produced by such an experience:

1. Flashbacks & Nightmares

You find yourself re-living the event, again and again. This can happen both as a "flashback" in the day, and as nightmares when you are asleep. These can be so realistic that it feels as though you are living through the experience all over again. You see it in your mind, but may also feel the emotions and physical sensations of what happened - fear, sweating, smells, sounds, pain.

Ordinary things can trigger off flashbacks. For instance, if you had a car crash in the rain, a rainy day might start a flashback.

2. Avoidance & Numbing

It can be just too upsetting to re-live your experience over and over again. So you distract yourself. You keep your mind busy by losing yourself in a hobby, working very hard, or spending your time absorbed in crossword or jigsaw puzzles. You avoid places and people that remind you of the trauma, and try not to talk about it.

You may deal with the pain of your feelings by trying to feel nothing at all - by becoming emotionally numb. You communicate less with other people, who then find it hard to live or work with you.

3. Being "On Guard"

You find that you stay alert all the time, as if you are looking out for danger. You can't relax. This is called "hyper vigilance". You feel anxious and find it hard to sleep. Other people will notice that you are jumpy and irritable.

Other Symptoms

Emotional reactions to stress are often accompanied by:


 muscle aches and pains
 diarrhoea
 irregular heartbeats (palpitations & or shortness of breath)
 worsening of existing conditions like asthma & eczema
 headaches
 feelings of panic and fear
 depression
 drinking too much alcohol
 using drugs (including painkillers).


Does everyone get PTSD after a traumatic experience?
No. But nearly everyone will have the symptoms of post traumatic stress for the first month or so. This is because they help to keep you going, and help you to understand the experience you have been through. This is an "acute stress reaction". Over a few weeks, most people slowly come to terms with what has happened, and their stress symptoms start to disappear.

Not everyone is so lucky. About 1 in 3 people will find that their symptoms just carry on and that they can't come to terms with what has happened. It is as though the process has got stuck. The symptoms of post traumatic stress, although normal in themselves, become a problem - or Post Traumatic Stress Disorder - when they go on for too long.
What makes PTSD worse?
The more disturbing the experience, the more likely you are to develop PTSD. The most traumatic events:

 are sudden and unexpected
 go on for a long time
 you are trapped and can't get away
 are man-made
 cause many deaths
 cause mutilation and loss of arms or legs
 involve children.


What about ordinary "stress"?
Everybody feels stressed from time to time. Unfortunately, the word "stress" is used to mean two rather different things:
 our inner sense of worry, feeling tense or feeling burdened.
or
 the problems in our life that are giving us these feelings. This could be work, relationships, maybe just trying to get by without much money.

Unlike PTSD, these things are with us, day in and day out. They are part of normal, everyday life, but can produce anxiety, depression, tiredness, and headaches. They can also make some physical problems worse, such as stomach ulcers and skin problems. These are certainly troublesome, but they are not the same as PTSD.
Why does PTSD happen?
We don't know for certain. There are a several possible explanations for why PTSD occurs.

Psychological

When we are frightened, we remember things very clearly. Although it can be distressing to remember these things, it can help us to understand what happened and, in the long run, help us to survive.


 The flashbacks, or replays, force us to think about what has happened. We can decide what to do if it happens again. After a while, we learn to think about it without becoming upset.
 It is tiring and distressing to remember a trauma. Avoidance and numbing keep the number of replays down to a manageable level.
 Being "on guard" means that we can react quickly if another crisis happens. Sometimes survivors of an earthquake experience this, when there may be second or third shocks. It can also give us the energy for the work that's needed after an accident or crisis.
But we don't want to spend the rest of our life going over it. We only want to think about it when we have to - if we find ourselves in a similar situation.


Physical

 Adrenaline is a hormone our bodies produce when we are under stress. It "pumps up" the body to prepare it for action. When the stress disappears, the level of adrenaline should go back to normal. In PTSD, it may be that the vivid memories of the trauma keep the levels of adrenaline high. This will make a person tense, irritable, and unable to relax or sleep well.
 High levels of stress hormones, like adrenaline, can stop the ‘memories’ processing part of the brain from working properly. This means that flashbacks and nightmares continue because the memories of the trauma can't be processed. If the stress goes away and the adrenaline levels get back to normal, the brain is able to repair the damage itself, like other natural healing processes in the body. The disturbing memories can then be processed and the flashbacks and nightmares will slowly disappear.


How do I know when I've got over a traumatic experience?
When you can:

 think about it without becoming distressed
 not feel constantly under threat
 not think about it at inappropriate times.


Why is PTSD often not recognised?

 None of us like to talk about upsetting events and feelings.
 We may not want to admit to having symptoms, because we don't want to be thought of as weak or mentally unstable.
 Doctors and other professionals are human. They may feel uncomfortable if we try to talk about gruesome or horrifying events.
 People with PTSD often find it easier to talk about the other problems that go along with it - headache, sleep problems, irritability, depression, tension, substance abuse, family or work-related problems.


How can I tell if I have PTSD?
Have you have experienced a traumatic event of the sort already described?
If you have, do you:

 have vivid memories, flashbacks or nightmares?
 avoid things that remind you of the event?
 feel emotionally numb at times?
 feel irritable and constantly on edge but can't see why?
 eat more than usual, or use more drink or drugs than usual?
 feel out of control of your mood?
 find it more difficult to get on with other people?
 have to keep very busy to cope?
 feel depressed or exhausted?
If it is less that 6 weeks since the traumatic event, and these experiences are slowly improving, they may be part of the normal process of adjustment.


If it is more than 6 weeks since the event, and these experiences don't seem to be getting better, it is worth talking it over with your doctor.
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PostSubject: More About PTS   Fri 23 May 2008, 12:54 pm

The NICE Guidelines.
On 23 March 2005, NICE published its guidelines for PTSD. These are highly recommended statements of the evidence on efficacy of different treatment approaches based on current clinical trial evidence. The following are some more information about the Guidelines themselves and press releases supporting and promoting these guidelines and the good they will do:
Links to further information & Support below.

How can PTSD be helped?
Helping yourself
Do .........
 keep life as normal as possible
 get back to your usual routine
 talk about what happened to someone you trust
 try relaxation exercises
 go back to work
 eat and exercise regularly
 go back to where the traumatic event happened
 take time to be with family and friends
 drive with care - your concentration may be poor
 be more careful generally - accidents are more likely at this time
 speak to a doctor
 expect to get better.

Don't ........


 beat yourself up about it - PTSD symptoms are not a sign of weakness. They are a normal reaction, of normal people, to terrifying experiences
 bottle up your feelings. If you have developed PTSD symptoms, don't keep it to yourself because treatment is usually very successful.
 avoid talking about it.
 expect the memories to go away immediately, they may be with you for quite some time.
 expect too much of yourself. Be gentle to yourself.
 stay away from other people.
 drink lots of alcohol or coffee or smoke more.
 get overtired.
 miss meals.
 take holidays on your own
.

Treatment
Just as there are both physical and psychological aspects to PTSD, so there are both physical and psychological treatments for it.
Psychotherapy
All the effective psychotherapies for PTSD focus on the traumatic experiences that have produced your symptoms rather than your past life. You cannot change or forget what has happened. You can learn to think differently about it, about the world, and about your life.
You need to be able to remember what happened, as fully as possible, without being overwhelmed by fear and distress. These therapies help you to put words to the traumatic experiences that you have had. By remembering the event, going over it and making sense of it, your mind can do its normal job, of storing the memories away and moving on to other things.
If you can start to feel safe again and in control of your feelings, you won't need to avoid the memories as much. Indeed, you can gain more control over your memories so that you only think about them when you want to, rather than having them erupt into your mind spontaneously.

All these treatments should all be given by specialists in the treatment of PTSD. The sessions should be at least weekly, every week, with the same therapist, and should usually continue for 8-12 weeks. Although sessions will usually last around an hour, they may sometimes last up to 90 minutes.

Cognitive Behavioural Therapy (CBT) is a way of helping you to think differently about your memories, so that they become less distressing and more manageable. It will usually also involve some relaxation work to help you tolerate the discomfort of thinking about the traumatic events.

EMDR (Eye Movement Desensitisation & Reprocessing) is a technique which uses eye movements to help the brain to process flashbacks and to make sense of the traumatic experience. It may sound odd, but it has been shown to work.

Group therapy involves meeting with a group of other people who have been through the same, or a similar traumatic event. The fact that other people in the group do have some idea of what you have been through can make it much easier to talk about what has happened.

Medication
SSRI antidepressant tablets will both reduce the strength of PTSD symptoms and relieve any depression that is also present. They will need to be prescribed by a doctor.

This type of medication should not make you sleepy, although they all have some side-effects in some people. They may also produce unpleasant symptoms if stopped quickly, so the dose should usually be reduced gradually. If they are helpful, you should carry on taking them for around 12 months. Soon after starting an antidepressany, some people may find that they feel more:

 anxious
 restless
 suicidal

These feelings usually pass in a few days, but you should see your doctor regularly.
If these don't work for you, tricyclic or MAOI antidepressant tablets may still be helpful. For more information, see our factsheet on antidepressants.

Occasionally, if someone is so distressed that they cannot sleep or think clearly, anxiety-reducing medication may be necessary. These tablets should usually not be prescribed for more than 10 days or so.

Body-focussed Therapies

These can help to control the distress of PTSD. They can also reduce hyper-arousal, or the feeling of being "on guard" all the time. These therapies include physiotherapy and osteopathy, but also complementary therapies such as massage, acupuncture, reflexology, yoga, meditation and tai chi. They all help you to develop ways of relaxing and managing stress.

Effectiveness of Treatments

At present, there is evidence that EMDR, psychotherapy, cognitive behavioural therapy and antidepressants are all effective. There is not enough information for us to say that one of these treatments is better than another. There is no evidence that other forms of psychotherapy or counselling are helpful to PTSD.

Which treatments first?

The National Institute for Clinical Excellence (NICE) guidelines suggest that trauma-focussed psychological therapies (CBT or EMDR) should be offered before medication, wherever possible.
For friends, relatives & colleagues[/
Do .......

 watch out for any changes in behaviour - poor performance at work, lateness, taking sick leave, minor accidents
 watch for anger, irritability, depression, lack of interest, lack of concentration
 take time to allow a trauma survivor to tell their story
 ask general questions
 let them talk, don't interrupt the flow or come back with your own experiences.
Don’t….
 tell a survivor you know how they feel - you don't
 tell a survivor they're lucky to be alive - they'll get angry
 minimise their experience - "it's not that bad, surely ..."
 suggest that they just need to 'pull themselves together'.
What can interfere with getting better?
You may find that other people will
 not let you talk about it
 avoid you
 be angry with you
 think of you as weak
 blame you


These are all ways in which other people protect themselves from thinking about gruesome or horrifying events. It won't help you because it doesn't give you the chance to talk over what has happened to you.
You may not be able to talk easily about it. A traumatic event can put you into a trance-like state which makes the situation seem unreal or bewildering. It is harder to deal with if you can't remember what happened, can't put it into words, or can't make sense of it.
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