Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder

What is Posttraumatic Stress Disorder or PTSD?
PTSD is an anxiety disorder that involves a very specific reaction following exposure to an extremely traumatic event or stressor (e.g., a serious injury to oneself, witnessing an act of violence, hearing about something horrible that has happened to someone you are close to).

Data from a number of studies indicates that between 51 and 89 percent of adults are exposed to at least one potentially traumatizing event in their lifetime. An immediate stress reaction (including many of the symptoms of PTSD) that disrupts daily functioning for a short time is a normal response to a traumatic event. How a person copes with his or her immediate reaction to the trauma, as well as other psychological and biological factors appear to contribute to the risk of developing more prolonged difficulties, including full blown PTSD. The prevalence rates of PTSD vary depending on the study reviewed. In one study, the lifetime prevalence rate of PTSD was 8%.

Official Criteria for PTSD
Based on criteria from the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000)

• Exposure to a Trauma – The person has been exposed to a trauma, in which he or she has experienced or witnessed an event involving the threat of death, serious injury, or a threat to the physical well-being of oneself or others. Note that only physical threats count in the definition of a trauma in PTSD. Situations that represent a psychological threat (e.g., a divorce, being criticized by a loved one, being teased) are not considered traumas in the definition of PTSD, even though they may lead to difficulties for the individual.

• A Response of Fear, Helplessness, or Horror – The immediate response to the trauma is one of fear, helplessness or horror (in children, it may be a response involving disorganized behavior or agitation). So, if an individual’s response to the trauma is one primarily of sadness or loss rather than fear (this is often the case following the death of a loved one who was ill), PTSD would likely not be diagnosed.

• Symptoms of Re-experiencing the Trauma – The individual persistently re-experiences the event in at least one of the following ways:

1. Recurrent and disturbing memories, images, and thoughts about the trauma.

2. Recurrent and disturbing dreams or nightmares about the trauma

3. Acting or feeling as if the trauma was occurring again (these experiences are often called flashbacks). This may include hallucinations (e.g., seeing things or hearing voices that were present during the trauma, even though they are not really there currently), misinterpreting things that are heard or seen (e.g., being convinced that the sound of fireworks in the distance is actually the sound of gunfire).

4. Becoming emotionally upset upon being exposed to reminders of the trauma, including physical sensations that were present during the trauma or situational reminders (e.g., the street where the trauma occurred, the anniversary of the trauma).

5. Becoming physically aroused (e.g., breathless, heart racing) upon being exposed to reminders of the trauma, including physical sensations that were present during the trauma or situational reminders (e.g., the street where the trauma occurred, the anniversary of the trauma).

• Symptoms of Avoidance and Emotional Numbing – The individual avoids triggers and reminders of the trauma, or experiences a sense of emotional numbing, as indicated by at least three of the following features:

1. Avoiding thoughts, feelings, or conversations that remind the individual of the trauma.

2. Avoiding activities, places or people that remind the individual of the trauma.

3. An inability to remember important aspects of the trauma.

4. A lack of interest or participation in significant activities, such as socializing, work, and hobbies.

5. Feeling detached or different from others.

6. An inability to enjoy things or to experience positive emotions (e.g., feeling “flat”).

7. A sense that one’s future will be shortened. For example, it may be difficult to imagine having a career, getting married, having children, or having a normal life span.

• Symptoms of Increased Arousal and Vigilance – The individual has symptoms of arousal and vigilance that were not present before the trauma, as indicated by at least two of the following features:

1. Difficulty falling or staying asleep.

2. Feeling irritable and grumpy, or experiencing outbursts of anger and temper tantrums.

3. Difficulty concentrating.

4. Hypervigilance (e.g., always being on guard, looking over one’s shoulder while walking down the street, etc.)

5. Becoming startled very easily (e.g., jumping when the telephone rings).

• The problem must last at least one month for a diagnosis of PTSD to be assigned.

• The individual’s fear, anxiety, avoidance, or other PTSD symptoms cause significant distress (i.e., it bothers the person that he or she has the symptoms) or significant interference in the person’s day-to-day life. For example, the difficulties may make it difficult for the person to perform important tasks at work, meet new friends, attend classes, or interact with others.

What is Acute Stress Disorder?

Like PTSD, acute stress disorder is an anxiety disorder that involves a very specific reaction following exposure to a traumatic event or stressor (e.g., a serious injury to oneself, witnessing an act of violence, hearing about something horrible that has happened to someone you are close to). However, the duration of acute stress disorder is shorter than that for PTSD. For a diagnosis of acute stress disorder, the full range of symptoms must be present for at least two days and no more than four weeks. If the symptoms persist for longer than four weeks, a diagnosis of PTSD should be considered. It is normal to have some symptoms following a trauma and a diagnosis of acute stress disorder is given only if all the necessary features are present.

Official Criteria for Acute Stress Disorder

• Exposure to a Trauma – The person has been exposed to a trauma, in which he or she has experienced or witnessed an event involving the threat of death, serious injury, or a threat to the physical well-being of oneself or others. Note that only physical threats count in the definition of a trauma in acute stress disorder. Situations that represent a psychological threat (e.g., a divorce, being criticized by a loved one, being teased) are not considered traumas in the definition of acute stress disorder, even though they may lead to difficulties for the individual.

• Symptoms of Dissociation or Decreased Awareness – During or after the trauma, the individual experiences at least three of the following features:

1. A feeling of emotional numbness (a lack of emotional response), or feeling detached.

2. Reduced awareness of surroundings (e.g., feeling “in a daze”).

3. Feelings of unreality (e.g., feeling detached from one’s surroundings, perceptual changes, such as one’s surroundings seeming dream-like).

4. Depersonalization (i.e., feeling detached from one’s body or self).

5. Inability to remember one or more important aspects of the trauma.

• Symptoms of Re-Experiencing – The individual persistently re-experiences the event in at least one of the following ways:

1. Recurrent and disturbing memories, images, and thoughts about the trauma.

2. Recurrent and disturbing dreams or nightmares about the trauma

3. Acting or feeling as if the trauma was occurring again (these experiences are often called flashbacks). This may include hallucinations (e.g., seeing things or hearing voices that were present during the trauma, even though they are not really there currently), misinterpreting things that are heard or seen (e.g., being convinced that the sound of fireworks in the distance is actually the sound of gunfire).

4. Becoming emotionally upset upon being exposed to reminders of the trauma, including physical sensations that were present during the trauma or situational reminders (e.g., the street where the trauma occurred, the anniversary of the trauma).

• Avoidance of thoughts, feelings, conversations, activities, places, or people that remind the individual of the trauma.

• Significant symptoms of anxiety or arousal (e.g., difficulty sleeping, feeling irritable, poor concentration, hypervigilance, being easily startled, feeling restless or unable to sit still).

• The problem lasts at least two days and no more than four weeks, and it begins within four weeks of experiencing the traumatic event.

• The individual’s fear, anxiety, avoidance, or other acute stress disorder symptoms cause significant distress (i.e., it bothers the person that he or she has the symptoms) or significant interference in the person’s day-to-day life (e.g., work, school, social functioning). For example, the symptoms may make it difficult to get much needed help, or to tell family members or the authorities about the trauma.

• It must be established that the acute stress disorder symptoms are not being caused by a medical condition (e.g., thyroid condition, diabetes, heart condition) or by a drug or substance (e.g., cocaine use, caffeine, withdrawal from alcohol). In addition, they cannot simply be due to a worsening of another psychological problem.

Examples of Traumas that can lead to PTSD or Acute Stress Disorder

• military combat
• violent personal assault (e.g., sexual assault, physical attack, mugging, robbery)
• being kidnapped or taken hostage
• torture
• incarceration as a prisoner of war or in a concentration camp
• natural disaster (earthquake, fire, tornado, hurricane)
• terrorist attack
• severe automobile accident
• severe accident at work or in the home
• sexual abuse during childhood
• sexual assault or abuse
• being diagnosed with a life-threatening illness
• unexpectedly observing serious injury or unnatural death of another person

Effective Treatments for PTSD and Acute Stress Disorder

Biological treatments (i.e., medications), psychological treatments, and their combination, have been found to be effective for treatment of PTSD and related problems.

Biological Treatments
A number of medications have been shown to be useful for treating PTSD. The most common of these are the antidepressants (see list below), particularly the SSRIs. In addition, mood stabilizers such as divalproex (Depakote) may be used in cases where a person experiences only a partial response to an antidepressant. The addition of a mood stabilizer (along with an antidepressant) is also recommended for particular PTSD symptoms, such as marked irritability or anger.

In addition to antidepressants and mood stabilizers, anti-anxiety medications such as alprazolam (Xanax), clonazepam (Klonapin or Rivotril), and lorazepam (Ativan) may be useful on a short term basis. Caution should be used with these medications, due to the potential for dependence.

Antidepressants for PTSD

Type of Medication	Generic Name	Brand Name
SSRI Antidepressants	Citalopram Fluoxetine Fluvoxamine Paroxetine Sertraline	Celexa Prozac Luvox Paxil Zoloft
Tricyclic Antidepressant	Amitriptyline Imipramine	Elavil Tofranil
Other Antidepressants	Nefazodone Venlafaxine	Serzone Effexor

Medications are warranted particularly when symptoms are significant and daily functioning is severely impaired, the person has severe insomnia, an additional psychiatric condition (e.g., depression) is present, or if significant symptoms are still present following psychological treatment. Among medications, selective serotonin reuptake inhibitors (SSRIs) have the most data supporting them. These medications are most effective for PTSD in nonveterans.

When symptoms have lasted less than three months (acute PTSD) it is generally recommended that medication be continued for 6 to 12 months. When symptoms have lasted more than three months (chronic PTSD) it is generally recommended that medication be continued for one to two years. Longer treatment may be required if significant symptoms are still present.

The decision of whether to take medication for PTSD, and which medication to take should be based on the individual’s past treatment history, the individual’s medical history, possible interactions between the medication and other drugs that person may be taking, potential side effects, and any other relevant factors.

Psychological Treatments
The psychological treatment shown to be most effective for PTSD is cognitive behavior therapy (CBT). CBT for PTSD involves a number of useful strategies including:

• Psychoeducation – includes a number of components: information about common reactions to trauma (e.g., that it is normal to be upset and have distressing symptoms shortly after a trauma); emotional support and reassurance to help relieve irrational feelings of guilt; encouragement to seek support from family and friends by talking about the trauma and associated feelings; education for the family about the importance of listening and being tolerant of the individual’s emotional reactions and need to retell the event.

• Anxiety Management – involves teaching skills to help manage the symptoms of PTSD including relaxation and breathing retraining, positive self-talk, and assertiveness training.

• Cognitive Therapy – involves identifying anxious thoughts (e.g., guilty thoughts about the trauma, exaggerated thoughts about danger) and replacing them with more realistic thoughts. For example, if an individual has the thought “I will never be safe again, the world is a very dangerous place,” cognitive therapy would focus on helping the individual to consider evidence for and against the belief.

• Exposure to Trauma Cues and Feared Situations – involves confronting feared situations or triggers repeatedly, in a gradual way, until fear is extinguished. For example, a person who is avoiding driving after being in a very severe car accident is encouraged to drive again, beginning in easier situations (e.g., light traffic) and gradually progressing to more difficult situations (e.g., heavy traffic, night, in the rain).

• Exposure to Trauma Memories – involves confronting trauma memories repeatedly until they are no longer associated with extreme distress. This strategy is combined with anxiety management strategies and cognitive therapy.

• For children, play therapy is often used to treat PTSD. Topics are addressed in an indirect manner using games to facilitate processing of traumatic memories.

Controversial Psychological Treatments for PTSD and Related Problems
Eye Movement Desensitization and Reprocessing (EMDR) – EMDR is a therapy that was developed in the late 1980s by psychologist, Francine Shapiro. It involves bringing to mind an image of a traumatic event while visually tracking a therapist’s finger as it moves back and forth in front of the patient’s visual field. A number of variations on this treatment have been developed, including tracking a light moving back and forth, or listening to tones alternating from one ear to the other. Research on EMDR suggests that it does lead to a reduction in PTSD symptoms, though it is no more effective than other forms of CBT. Interestingly, the eye movements and other forms of sensory stimulation appear to have nothing to do with the effectiveness of EMDR. Critics of EMDR have argued persuasively that the main reason EMDR works is the exposure to the traumatic image. In other words, EMDR is thought to be no more than “dressed up” form of imaginal exposure.

Critical Incidence Stress Debriefing (CISD) – CISD is a procedure that is often used with groups of individuals within one to three days of having experienced a trauma (e.g., a natural disaster, accident, terrorist attack, etc.). The treatment encourages trauma victims to share their thoughts and experiences, and the therapist discusses thoughts and emotional reactions that the individuals are likely to experience. Participants are typically encouraged to stay with the procedure. The strategies listed here are similar to those listed earlier in the section on psychoeducation for PTSD. The difference is that in CISD, all trauma victims are exposed to the treatment, not just those who develop PTSD or other adjustment problems. The data on CISD are mixed, but generally not supportive of the procedure. Some studies have shown the people having undergone CISD following a trauma are no better off than people who did not receive this treatment. Furthermore, a few studies have actually shown that people who undergo CISD are functioning more poorly later on, relative to those who have not undergone the procedure. Critics of CISD have recommended against using this procedure for all trauma victims. Instead, they encourage professionals to help victims with their basic needs (e.g., contacting insurance companies, etc.), provide support, and allow them to discuss the trauma only if they want to. More intensive treatment should be reserved for people who are still experiencing anxiety symptoms some time after the trauma has passed.

Combining Medications and CBT
There is a lack of research comparing CBT to medications or examining the combination of these approaches for treating PTSD. In other anxiety disorders, CBT, medications, and combined treatments are often similar in effectiveness across groups of individuals, although any one person may respond better to one of these approaches than to the other treatments. For most anxiety disorders, the effects of CBT tend to be more long lasting than the effects of medication. In other words, once treatment has stopped, anxious individuals who have been treated with CBT are less likely to experience a return of their symptoms than are individuals who have been treated with medication. In light of these findings, CBT may be the best approach initially. For individuals who do not respond to CBT, adding an SSRI is a reasonable next step in treatment. More research is needed before recommendations regarding the relative and combined effectiveness of medications and CBT can be made with confidence.

Did you know ...?

• PTSD is generally more severe or long-lasting when the trauma is of human design (e.g., torture, terrorist attack) vs. a natural disaster (e.g., earthquake)

• The chance of developing PTSD increases as the severity, duration, and physical proximity to the trauma increases. Other factors that increase the risk for developing PTSD include history of previous trauma and negative reactions from friends and family.

• When the duration of PTSD symptoms is less than three months it is termed acute. If the duration of PTSD symptoms is three months or more it is termed chronic.

• Although symptoms of PTSD usually begin within the first three months after the trauma, there may be a delay of months or even years before symptoms appear. Delayed onset of PTSD is said to have occurred when the symptoms begin at least six months after the trauma.

• PTSD is related to increased rates of major depressive disorder, substance-related disorders, and other anxiety disorders.

• Research on individuals at-risk for the development of PTSD has found the highest rates of onset (30 to 50%) in survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

• PTSD can occur at any age, including childhood.

• Individuals with PTSD often report painful feelings of guilt about surviving when others did not or about things they had to do to survive.