I highlighted some of the stuff that is currently affecting me or has affected
me. I am sending it because I had an a friend make jokes about the whole PTSD
being an excuse for not working and becoming lazy and antisocial. After this
comment she made incensitive remarks about "Celebrating the Anniversary of 9-11"
in a moking way. I cant recall ever wanting to choke anyone this badly before
and it was a lucky thing this conversation occurred over the phone. My response
was to hangup and then later educated her by sending this information. Then I
thought it might come in handy for others.

Reggie "angry and panic striken" in Oklahoma









A National Center for PTSD Fact Sheet

Posttraumatic Stress Disorder, or PTSD, is a psychiatric disorder that can occur
following the experience or witnessing of life-threatening events such as
military combat, natural disasters, terrorist incidents, serious accidents, or
violent personal assaults like rape. People who suffer from PTSD often relive
the experience through nightmares and flashbacks, have difficulty sleeping, and
feel detached or estranged, and these symptoms can be severe enough and last
long enough to significantly impair the person's daily life.

PTSD is marked by clear biological changes as well as psychological symptoms.
PTSD is complicated by the fact that it frequently occurs in conjunction with
related disorders such as depression, substance abuse, problems of memory and
cognition, and other problems of physical and mental health. The disorder is
also associated with impairment of the person's ability to function in social or
family life, including occupational instability, marital problems and divorces,
family discord, and difficulties in parenting.

What are the consequences associated with PTSD?

PTSD is associated with a number of distinctive neurobiological and
physiological changes. PTSD may be associated with stable neurobiological
alterations in both the central and autonomic nervous systems, such as altered
brainwave activity, decreased volume of the hippocampus, and abnormal activation
of the amygdala. Both the hippocampus and the amygdala are involved in the
processing and integration of memory. The amygdala has also been found to be
involved in coordinating the body's fear response.

Psychophysiological alterations associated with PTSD include hyper-arousal of
the sympathetic nervous system, increased sensitivity of the startle reflex, and
sleep abnormalities.

People with PTSD tend to have abnormal levels of key hormones involved in the
body's response to stress. Thyroid function also seems to be enhanced in people
with PTSD. Some studies have shown that cortisol levels in those with PTSD are
lower than normal and epinephrine and norepinephrine levels are higher than
normal. People with PTSD also continue to produce higher than normal levels of
natural opiates after the trauma has passed. An important finding is that the
neurohormonal changes seen in PTSD are distinct from, and actually opposite to,
those seen in major depression. The distinctive profile associated with PTSD is
also seen in individuals who have both PTSD and depression.

PTSD is associated with the increased likelihood of co-occurring psychiatric
disorders. In a large-scale study, 88 percent of men and 79 percent of women
with PTSD met criteria for another psychiatric disorder. The co-occurring
disorders most prevalent for men with PTSD were alcohol abuse or dependence
(51.9 percent), major depressive episodes (47.9 percent), conduct disorders
(43.3 percent), and drug abuse and dependence (34.5 percent). The disorders most
frequently comorbid with PTSD among women were major depressive disorders (48.5
percent), simple phobias (29 percent), social phobias (28.4 percent), and
alcohol abuse/dependence (27.9 percent).

PTSD also significantly impacts psychosocial functioning, independent of
comorbid conditions. For instance, Vietnam veterans with PTSD were found to have
profound and pervasive problems in their daily lives. These included problems in
family and other interpersonal relationships, problems with employment, and
involvement with the criminal justice system.

Headaches, gastrointestinal complaints, immune system problems, dizziness, chest
pain, and discomfort in other parts of the body are common in people with PTSD.
Often, medical doctors treat the symptoms without being aware that they stem
from PTSD.

Understanding PTSD

PTSD is not a new disorder. There are written accounts of similar symptoms that
go back to ancient times, and there is clear documentation in the historical
medical literature starting with the Civil War, when a PTSD-like disorder was
known as "Da Costa's Syndrome." There are particularly good descriptions of
posttraumatic stress symptoms in the medical literature on combat veterans of
World War II and on Holocaust survivors.

Careful research and documentation of PTSD began in earnest after the Vietnam
War. The National Vietnam Veterans Readjustment Study estimated in 1988 that the
prevalence of PTSD in that group was 15.2% at that time and that 30% had
experienced the disorder at some point since returning from Vietnam.

PTSD has subsequently been observed in all veteran populations that have been
studied, including World War II, Korean conflict, and Persian Gulf populations,
and in United Nations peacekeeping forces deployed to other war zones around the
world. There are remarkably similar findings of PTSD in military veterans in
other countries. For example, Australian Vietnam veterans experience many of the
same symptoms that American Vietnam veterans experience.

PTSD is not only a problem for veterans, however. Although there are unique
cultural- and gender-based aspects of the disorder, it occurs in men and women,
adults and children, Western and non-Western cultural groups, and all
socioeconomic strata. A national study of American civilians conducted in 1995
estimated that the lifetime prevalence of PTSD was 5% in men and 10% in women.

How does PTSD develop?

Most people who are exposed to a traumatic, stressful event experience some of
the symptoms of PTSD in the days and weeks following exposure. Available data
suggest that about 8% of men and 20% of women go on to develop PTSD, and roughly
30% of these individuals develop a chronic form that persists throughout their
lifetimes.

The course of chronic PTSD usually involves periods of symptom increase followed
by remission or decrease, although some individuals may experience symptoms that
are unremitting and severe. Some older veterans, who report a lifetime of only
mild symptoms, experience significant increases in symptoms following
retirement, severe medical illness in themselves or their spouses, or reminders
of their military service (such as reunions or media broadcasts of the
anniversaries of war events).

How is PTSD assessed?

In recent years, a great deal of research has been aimed at developing and
testing reliable assessment tools. It is generally thought that the best way to
diagnose PTSD-or any psychiatric disorder, for that matter-is to combine
findings from structured interviews and questionnaires with physiological
assessments. A multi-method approach especially helps address concerns that some
patients might be either denying or exaggerating their symptoms.

How common is PTSD?

An estimated 7.8 percent of Americans will experience PTSD at some point in
their lives, with women (10.4%) twice as likely as men (5%) to develop PTSD.
About 3.6 percent of U.S. adults aged 18 to 54 (5.2 million people) have PTSD
during the course of a given year. This represents a small portion of those who
have experienced at least one traumatic event; 60.7% of men and 51.2% of women
reported at least one traumatic event. The traumatic events most often
associated with PTSD for men are rape, combat exposure, childhood neglect, and
childhood physical abuse. The most traumatic events for women are rape, sexual
molestation, physical attack, being threatened with a weapon, and childhood
physical abuse.

About 30 percent of the men and women who have spent time in war zones
experience PTSD. An additional 20 to 25 percent have had partial PTSD at some
point in their lives. More than half of all male Vietnam veterans and almost
half of all female Vietnam veterans have experienced "clinically serious stress
reaction symptoms." PTSD has also been detected among veterans of the Gulf War,
with some estimates running as high as 8 percent.

Who is most likely to develop PTSD?

1. Those who experience greater stressor magnitude and intensity,
unpredictability, uncontrollability, sexual (as opposed to nonsexual)
victimization, real or perceived responsibility, and betrayal

2. Those with prior vulnerability factors such as genetics, early age of onset
and longer-lasting childhood trauma, lack of functional social support, and
concurrent stressful life events

3. Those who report greater perceived threat or danger, suffering, upset,
terror, and horror or fear

4. Those with a social environment that produces shame, guilt, stigmatization,
or self-hatred

How is PTSD treated?

PTSD is treated by a variety of forms of psychotherapy and drug therapy. There
is no definitive treatment, and no cure, but some treatments appear to be quite
promising, especially cognitive-behavioral therapy, group therapy, and exposure
therapy. Exposure therapy involves having the patient repeatedly relive the
frightening experience under controlled conditions to help him or her work
through the trauma. Studies have also shown that medications help ease
associated symptoms of depression and anxiety and help with sleep. The most
widely used drug treatments for PTSD are the selective serotonin reuptake
inhibitors, such as Prozac and Zoloft. At present, cognitive-behavioral therapy
appears to be somewhat more effective than drug therapy. However, it would be
premature to conclude that drug therapy is less effective overall since drug
trials for PTSD are at a very early stage. Drug therapy appears to be highly
effective for some individuals and is helpful for many more. In addition,
the recent findings on the biological changes associated with PTSD have spurred
new research into drugs that target these biological changes, which may lead to
much increased efficacy.



Effects 0f Traumatic Experiences

A National Center for PTSD Fact Sheet

by Eve B. Carlson, Ph.D. and Josef Ruzek, Ph.D.

Sometimes, when they find themselves suddenly in danger, people are overcome
with feelings of fear, helplessness, or horror. These events are called
traumatic experiences. Some common traumatic experiences include being
physically attacked, being in a serious accident, being in combat, being
sexually assaulted, and being in a fire or a disaster like a hurricane or a
tornado. After traumatic experiences, people can find themselves having problems
that they didn't have before the event. If these problems are severe and the
survivor does not get help for them, they can begin to cause problems in the
survivor's family. This brochure will begin by explaining how traumatic
experiences affect people who go through them. Next family members' reactions to
the traumatic event and to the trauma survivor's symptoms and behaviors will be
described. Finally, suggestions will be made about what a veteran and his or her
family can do to get help for PTSD.

How Do Traumatic Experiences Affect People ?

People who go through traumatic experiences often have symptoms and problems
afterwards. How serious the symptoms and problems are depends on many things,
including a person's life experiences before the trauma, a person's own natural
ability to cope with stress, how serious the trauma was, and what kinds of help
and support a person gets from family, friends, and professionals immediately
following the trauma.

Because most trauma survivors don't know how trauma usually affects people, they
often have trouble understanding what is happening to them. They may think it is
their fault that the trauma happened, that they are going crazy, or that there
is something wrong with them because other people who were there don't seem to
have the same problems. They may turn to drugs or alcohol to make them feel
better. They may turn away from friends and family who don't seem to understand.
They may not know what they can do to get better.

What Do Trauma Survivors Need to Know ?

Traumas happen to many competent, healthy, strong, good people. No one can
completely protect themselves from traumatic experiences.

Many people have long-lasting problems following exposure to trauma. Up to 8% of
persons will have PTSD at some time in their lives.

People who react to traumas are not going crazy. What is happening to them is
part of a set of common symptoms and problems that are connected with being in a
traumatic situation.

Having symptoms after a traumatic event is not a sign of personal weakness. Many
psychologically well-adjusted and physically healthy people develop PTSD. Given
exposure to a trauma that is bad enough, probably all people would develop PTSD.

By understanding trauma symptoms better, a person can become less fearful of
them and better able to manage them.

By recognizing the effects of trauma and knowing more about symptoms, a person
will be better able to decide about getting treatment.

What are Common Basic Effects of Trauma?

Because they get overwhelmed with fear during a trauma, survivors often have
particular symptoms that begin soon after the traumatic experience. The main
symptoms are re-experiencing of the trauma - mentally and physically - and
avoidance of trauma reminders. Together, these symptoms create a problem that is
called Posttraumatic Stress Disorder (PTSD). PTSD is a specific set of problems
resulting from a traumatic experience that is recognized by medical and mental
health professionals.

Re-experiencing Symptoms:

Trauma survivors commonly continue re-experiencing their traumas.
Re-experiencing means that the survivor continues to have the same mental,
emotional, and physical experiences that occurred during or just after the
trauma. This includes thinking about the trauma, seeing images of the event,
feeling agitated, and having physical sensations like those that occurred during
the trauma. Trauma survivors find themselves feeling and acting as if the trauma
is happening again: feeling as if they are in danger, experiencing panic
sensations, wanting to escape, getting angry, thinking about attacking or
harming someone else. Because they are anxious and physically agitated, they may
have trouble sleeping and trouble concentrating. These experiences are not
usually voluntary; the survivor usually can't control them or stop them from
happening. Mentally re-experiencing the trauma can include:

Upsetting memories such as images or other thoughts about the trauma.

Feeling as if it the trauma is happening again ("Flashbacks").

Bad dreams and nightmares.

Getting upset when reminded about the trauma (by something the person sees,
hears, feels, smells, or tastes).

Anxiety or fear - feeling in danger again.

Anger or aggressive feelings ñ feeling the need to defend oneself.

Trouble controlling emotions because reminders lead to sudden anxiety, anger, or
upset.

Trouble concentrating or thinking clearly.

People also can have physical reactions to trauma reminders such as:

Trouble falling or staying asleep.

Feeling agitated and constantly on the lookout for danger.

Getting very startled by loud noises or something or someone coming up on you
from behind when you don't expect it.

Feeling shaky and sweaty.

Having your heart pound or having trouble breathing.

Because they have these upsetting feelings, trauma survivors often act as if
they are in danger again when they get stressed or reminded of their trauma.
They might get overly concerned about keeping safe in situations that really
aren't very dangerous. For example, a person living in a good neighborhood might
still feel that he has to have an alarm system, double locks on the door, a
locked fence, and a guard dog. Because traumatized people often feel like they
are in danger even when they aren't, they may be overly aggressive, lashing out
to protect themselves when there is no need. For example, a person who was
attacked might be quick to yell at or hit someone who seems to be threatening.
This happens because, when threatened, people have a natural physical "fight or
flight" reaction that prepares them to respond to them danger.

Although reexperiencing symptoms are unpleasant, they are a sign that the body
and mind are actively struggling to cope with the traumatic experience. These
symptoms are automatic, learned responses to trauma reminders: trauma has become
associated with lots of things so that they remind the person of the trauma and
give them feeling that they are in danger again. It is also possible that
reexperiencing symptoms are actually part of the mind's attempt to make sense of
what has happened.

Avoidance Symptoms:

Because thinking about the trauma and feeling as if you are in danger is so
upsetting, people who have been through traumas want to avoid reminders of
trauma. Sometimes they are aware of this and avoid trauma reminders on purpose
and sometimes they do it without realizing what they are doing.

Ways of avoiding thoughts, feelings, and sensations associated with the trauma
can include:

Actively avoiding trauma-related thoughts and memories.

Avoiding conversations and staying away from places, activities, or people that
might remind you of trauma.

Trouble remembering important parts of what happened during the trauma.

"Shutting down" emotionally or feeling emotionally numb.

Trouble having loving feelings or feeling any strong emotions.

Finding that things around you seem strange or unreal.

Feeling strange or "not yourself".

Feeling disconnected from the world around you and things that happen to you.

Avoiding situations that might make you have a strong emotional reaction.

Feeling weird physical sensations.

Feeling physically numb.

Not feeling pain or other sensations.

Losing interest in things you used to enjoy doing.

Avoiding thinking about trauma or avoiding treatment for your trauma-related
problems may keep a person from feeling upset in the short run. But avoiding
treatment of continuing trauma symptoms prevents progress on coping with trauma
so that people's trauma symptoms don't go away.

What are Common Secondary and Associated Post-Traumatic Symptoms ?

Secondary symptoms are problems that come about because of having post-traumatic
re-experiencing and avoidance symptoms. For example: because a person wants to
avoid talking about a trauamatic event that happened, she might get cut off from
friends and begin to feel lonely and depressed. As time passes after a traumatic
experience, more and more secondary symptoms may develop. Over time, secondary
symptoms can become more troubling and disabling than the original
re-experiencing and avoidance symptoms.

Associated symptoms are problems that don't come directly from being overwhelmed
with fear, but happen because of other things that were going on at the time of
the trauma. For example: a person who gets psychologically traumatized in a car
accident might also get physically injured and then get depressed because he
can't work or leave the house.



All of these problems can be secondary or associated trauma symptoms:

Depression: can happen when a person has losses connected with the trauma
situation or when a person avoids other people and becomes isolated.

Despair and hopelessness: can happen when a person is afraid that he or she will
never feel better again.

Loss of important beliefs: can happen when a traumatic event makes a person lose
faith that the world is a good and safe place.

Aggressive behavior toward oneself or others: can happen due to frustration over
the inability to control PTSD symptoms (feeling that PTSD symptoms "run your
life"). It can also happen when other things that happened at the time of trauma
made the person angry (the unfairness of the situation). Some people are
aggressive because they grew up with people who lashed out when they were angry
and never taught them how to cope with angry feelings. Because angry feelings
keep people away, they also stop a person from having positive connections and
getting help. Anger and aggression can cause job problems, marital and
relationship problems, and loss of friendships.

Self-blame, guilt, and shame: can happen when PTSD symptoms make it hard to
fulfill current responsibilities. It can also happen when people fall into the
common trap of second-guessing what they did or didn't do at the time of a
trauma. Many people, in trying to make sense of their experience, blame
themselves. This is usually completely unfair. At best, it fails to take into
account the other reasons why the events occurred. Self-blame causes a lot of
distress and can prevent a person from reaching out for help. Society sometimes
takes a "blame-the-victim" attitude, and this is wrong.

Problems in relationships with people: can happen because people who have been
through traumas often have a hard time feeling close to people or trusting
people. This may be especially likely to happen when the trauma was caused or
worsened by other people (as opposed to an accident or natural disaster).

Feeling detached or disconnected from others: can happen when a person has
difficulty in feeling or expressing positive feelings. After traumas, people can
get wrapped up in their problems or get numb and then stop putting energy into
their relationships with friends and family.

Getting into arguments and fights with people: can happen because of the angry
or aggressive feelings that are common after a trauma. Also, a person's constant
avoidance of social situations (such as family gatherings) may annoy family
members.

Less interest or participation in things the person used to like to do: can
happen because of depression following a trauma. Spending less time doing fun
things and being with people means a person has less of a chance to feel good
and have pleasant interactions.

Social isolation: can happen because of social withdrawal and a lack of trust in
others. This often leads to loss of support, friendship, and intimacy, and grows
fears and worries.

Problems with identity: can happen when PTSD symptoms change important things in
a person's life, like relationships or whether a person can do your work well.
It can also happen when other things that happened at the time of trauma make a
person confused about their own identity. For instance a person who thinks of
himself as unselfish might think he acted selfishly by saving himself during a
disaster. This might make him question whether he is really who he thought he
was.

Feeling permanently damaged: can happen when trauma symptoms don't go away and a
person doesn't think they will get better.

Problems with self-esteem: can happen because PTSD symptoms make it hard for a
person to feel good about him or herself. Sometimes, because of things they did
or didn't do at the time of trauma, survivors feel that they are bad, worthless,
stupid, incompetent, evil, and so on.

Physical health symptoms and problems: can happen because of long periods of
physical agitation or arousal from anxiety. Trauma survivors may also avoid
medical care because it reminds them of their trauma and causes anxiety, and
this may lead to poorer health. Habits used to cope with post-traumatic stress,
like alcohol use, can also cause health problems. Also, other things that
happened at the time of trauma may cause health problems (for example, an
injury).

Alcohol and/or drug abuse: can happen when a person wants to avoid bad feelings
that come with PTSD symptoms, or when other things that happened at the time of
trauma lead a person to take drugs. This is a common way to cope with upsetting
trauma symptoms, but it actually leads to more problems.

Remember:

Although PTSD symptoms and other trauma-related problems may take up most of a
person's attention when they are suffering, people who have PTSD also have
strengths, interests, commitments, relationships with others, past experiences
that were not traumatic, desires, and hopes for the future.

Treatments are available for individuals with PTSD and associated trauma-related
symptoms.

Understanding the effects of trauma on relationships can also be an important
step for family members or friends the effects of trauma.



A brief history of the PTSD diagnosis

The risk of exposure to trauma has been a part of the human condition since we
evolved as a species. Attacks by saber tooth tigers or twenty-first century
terrorists have probably produced similar psychological sequelae in the
survivors of such violence. Shakespeare's Henry IV appears to meet many, if not
all, of the diagnostic criteria for Posttraumatic Stress Disorder (PTSD), as
have other heroes and heroines throughout the world's literature. The history of
the development of the PTSD concept is described by Trimble (1985).

In 1980, the American Psychiatric Association added PTSD to the third edition of
its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) nosologic
classification scheme. Although controversial when first introduced, the PTSD
diagnosis has filled an important gap in psychiatric theory and practice. From
an historical perspective, the significant change ushered in by the PTSD concept
was the stipulation that the etiological agent was outside the individual (i.e.,
a traumatic event) rather than an inherent individual weakness (i.e., a
traumatic neurosis). The key to understanding the scientific basis and clinical
expression of PTSD is the concept of "trauma."

In its initial DSM-III formulation, a traumatic event was conceptualized as a
catastrophic stressor that was outside the range of usual human experience. The
framers of the original PTSD diagnosis had in mind events such as war, torture,
rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural
disasters (such as earthquakes, hurricanes, and volcano eruptions), and
human-made disasters (such as factory explosions, airplane crashes, and
automobile accidents). They considered traumatic events to be clearly different
from the very painful stressors that constitute the normal vicissitudes of life
such as divorce, failure, rejection, serious illness, financial reverses, and
the like. (By this logic, adverse psychological responses to such "ordinary
stressors" would, in DSM-III terms, be characterized as Adjustment Disorders
rather than PTSD.) This dichotomization between traumatic and other stressors
was based on the assumption that, although most individuals have
the ability to cope with ordinary stress, their adaptive capacities are likely
to be overwhelmed when confronted by a traumatic stressor.

PTSD is unique among psychiatric diagnoses because of the great importance
placed upon the etiological agent, the traumatic stressor. In fact, one cannot
make a PTSD diagnosis unless the patient has actually met the "stressor
criterion," which means that he or she has been exposed to an historical event
that is considered traumatic. Clinical experience with the PTSD diagnosis has
shown, however, that there are individual differences regarding the capacity to
cope with catastrophic stress. Therefore, while some people exposed to traumatic
events do not develop PTSD, others go on to develop the full-blown syndrome.
Such observations have prompted the recognition that trauma, like pain, is not
an external phenomenon that can be completely objectified. Like pain, the
traumatic experience is filtered through cognitive and emotional processes
before it can be appraised as an extreme threat. Because of individual
differences in this appraisal process, different people appear to have
different trauma thresholds, some more protected from and some more vulnerable
to developing clinical symptoms after exposure to extremely stressful
situations. Although there is currently a renewed interest in subjective aspects
of traumatic exposure, it must be emphasized that events such as rape, torture,
genocide, and severe war zone stress are experienced as traumatic events by
nearly everyone.

The DSM-III diagnostic criteria for PTSD were revised in DSM-III-R (1987),
DSM-IV (1994), and DSM-IV-TR (2000). A very similar syndrome is classified in
ICD-10 (The ICD-10 Classification of Mental and Behavioural Disorders: Clinical
Descriptions and Diagnostic Guidelines). Diagnostic criteria for PTSD include a
history of exposure to a traumatic event and symptoms from each of three symptom
clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal
symptoms. A fifth criterion concerns duration of symptoms. One important
finding, which was not apparent when PTSD was first proposed as a diagnosis in
1980, is that it is relatively common. Recent data from the national comorbidity
survey indicates PTSD prevalence rates are 5% and 10% respectively among
American men and women (Kessler et al., 1996). Rates of PTSD are much higher in
postconflict settings such as Algeria (37%), Cambodia (28%), Ethiopia (16%), and
Gaza (18%) (de Jong et al., 2001).

Criteria for a PTSD diagnosis

As noted above, the "A" stressor criterion specifies that a person has been
exposed to a catastrophic event involving actual or threatened death or injury,
or a threat to the physical integrity of him/herself or others. During this
traumatic exposure, the survivor's subjective response was marked by intense
fear, helplessness, or horror.

The "B", or intrusive recollection, criterion includes symptoms that are perhaps
the most distinctive and readily identifiable symptoms of PTSD. For individuals
with PTSD, the traumatic event remains, sometimes for decades or a lifetime, a
dominating psychological experience that retains its power to evoke panic,
terror, dread, grief, or despair. These emotions manifest in daytime fantasies,
traumatic nightmares, and psychotic reenactments known as PTSD flashbacks.
Furthermore, trauma-related stimuli that trigger recollections of the original
event have the power to evoke mental images, emotional responses, and
psychological reactions associated with the trauma. Researchers can use this
phenomenon to reproduce PTSD symptoms in the laboratory by exposing affected
individuals to auditory or visual trauma-related stimuli (Keane et. al., 1987).

The "C", or avoidant/numbing, criterion consists of symptoms that reflect
behavioral, cognitive, or emotional strategies PTSD patients use in an attempt
to reduce the likelihood that they will expose themselves to trauma-related
stimuli. PTSD patients also use these strategies in an attempt to minimize the
intensity of their psychological response if they are exposed to such stimuli.
Behavioral strategies include avoiding any situation in which they perceive a
risk of confronting trauma-related stimuli. In its extreme manifestation,
avoidant behavior may superficially resemble agoraphobia because the PTSD
individual is afraid to leave the house for fear of confronting reminders of the
traumatic event(s). Dissociation and psychogenic amnesia are included among the
avoidant/numbing symptoms and involve the individuals cutting off the conscious
experience of trauma-based memories and feelings. Finally, since individuals
with PTSD cannot tolerate strong emotions, especially those
associated with the traumatic experience, they separate the cognitive from the
emotional aspects of psychological experience and perceive only the former. Such
"psychic numbing" is an emotional anesthesia that makes it extremely difficult
for people with PTSD to participate in meaningful interpersonal relationships.

Symptoms included in the "D", or hyper-arousal, criterion most closely resemble
those seen in panic and generalized anxiety disorders. While symptoms such as
insomnia and irritability are generic anxiety symptoms, hyper-vigilance and
startle are more characteristic of PTSD. The hyper-vigilance in PTSD may
sometimes become so intense as to appear like frank paranoia. The startle
response has a unique neurobiological substrate and may actually be the most
pathognomonic PTSD symptom.

The "E", or duration, criterion specifies how long symptoms must persist in
order to qualify for the (chronic or delayed) PTSD diagnosis. In DSM-III, the
mandatory duration was six months. In DSM-III-R, the duration was shortened to
one month, which it has remained.

The "F", or functional significance, criterion specifies that the survivor must
experience significant social, occupational, or other distress as a result of
these symptoms.

Assessing PTSD

Since 1980, there has been a great deal of attention devoted to the development
of instruments for assessing PTSD. Keane and associates (1987) working, with
Vietnam war-zone veterans, have developed both psychometric and
psychophysiologic assessment techniques that have proven to be both valid and
reliable. Other investigators have modified such assessment instruments and used
them with natural disaster victims, rape/incest survivors, and other traumatized
individuals. These assessment techniques have been used in the epidemiological
studies mentioned above and in other research protocols.

Neurobiological research indicates that PTSD may be associated with stable
neurobiologicalalterations in both the central and autonomic nervous systems.
Psychophysiological alterations associated with PTSD include hyper-arousal of
the sympathetic nervous system, increased sensitivity and augmentation of the
acoustic-startle eye blink reflex, a reducer pattern of auditory evoked cortical
potentials, and sleep abnormalities. Neuropharmacologic and neuroendocrine
abnormalities have been detected in most brain mechanisms that have evolved for
coping, adaptation, and preservation of the species. These include the
noradrenergic, hypothalamic-pituitary-adrenocortical, serotonergic,
glutamatergic, thyroid, endogenous opioid, and other systems. This information
is reviewed extensively elsewhere (Friedman, Charney & Deutch, 1995; Friedman,
in press).

Longitudinal research has shown that PTSD can become a chronic psychiatric
disorder and can persist for decades and sometimes for a lifetime. Patients with
chronic PTSD often exhibit a longitudinal course marked by remissions and
relapses. There is also a delayed variant of PTSD in which individuals exposed
to a traumatic event do not exhibit the PTSD syndrome until months or years
afterward. Usually, the immediate precipitant is a situation that resembles the
original trauma in a significant way (for example, a war veteran whose child is
deployed to a war zone or a rape survivor who is sexually harassed or assaulted
years later).

If an individual meets diagnostic criteria for PTSD, it is likely that he or she
will meet DSM-IV-TR criteria for one or more additional diagnoses (Kulka et.
al., 1990; Davidson & Foa, 1993). Most often, these comorbid diagnoses include
major affective disorders, dysthymia, alcohol or substance abuse disorders,
anxiety disorders, or personality disorders. There is a legitimate question
whether the high rate of diagnostic comorbidity seen with PTSD is an artifact of
our current decision-making rules for the PTSD diagnosis since there are not
exclusionary criteria in DSM-III-R. In any case, high rates of comorbidity
complicate treatment decisions concerning patients with PTSD since the clinician
must decide whether to treat the comorbid disorders concurrently or
sequentially.

Although PTSD continues to be classified as an Anxiety Disorder, areas of
disagreement about its nosology and phenomenology remain. Questions about the
syndrome itself include: what is the clinical course of untreated PTSD; are
there different subtypes of PTSD; what is the distinction between traumatic
simple phobia and PTSD; and what is the clinical phenomenology of prolonged and
repeated trauma? With regard to the latter, Herman (1992) has argued that the
current PTSD formulation fails to characterize the major symptoms of PTSD
commonly seen in victims of prolonged, repeated interpersonal violence such as
domestic or sexual abuse and political torture. She has proposed an alternative
diagnostic formulation that emphasizes multiple symptoms, excessive
somatization, dissociation, changes in affect, pathological changes in
relationships, and pathological changes in identity.

PTSD has also been criticized from the perspective of cross-cultural psychology
and medical anthropology, especially with respect to refugees, asylum seekers,
and political torture victims from non-Western regions. Clinicians and
researchers working with such survivors argue that since PTSD has usually been
diagnosed by clinicians from Western industrialized nations working with
patients from a similar background, the diagnosis does not accurately reflect
the clinical picture of traumatized individuals from non-Western traditional
societies and cultures. Major gaps remain in our understanding of the effects of
ethnicity and culture on the clinical phenomenology of posttraumatic syndromes.
We have only just begun to apply vigorous ethnocultural research strategies to
delineate possible differences between Western and non-Western societies
regarding the psychological impact of traumatic exposure and the clinical
manifestations of such exposure (Marsella et. al., 1996).

Treatment for PTSD

The many therapeutic approaches offered to PTSD patients are presented in Foa,
Keane, and Friedman's (2000) comprehensive book on treatment. The most
successful interventions are cognitive-behavioral therapy (CBT) and medication.
Excellent results have been obtained with some CBT combinations of exposure
therapy and cognitive restructuring, especially with female victims of childhood
or adult sexual trauma. Sertraline (Zoloft) and paroxetine (Paxil) are selective
serotonin reuptake inhibitors (SSRI) that are the first medications to have
received FDA approval as indicated treatments for PTSD. Success has also been
reported with Eye Movement Desensitization and Reprocessing (EMDR), although
rigorous scientific data are lacking and it is unclear whether this approach is
as effective as CBT.

Perhaps the best therapeutic option for mildly to moderately affected PTSD
patients is group therapy. In such a setting, the PTSD patient can discuss
traumatic memories, PTSD symptoms, and functional deficits with others who have
had similar experiences. This approach has been most successful with war
veterans, rape/incest victims, and natural disaster survivors. It is important
that therapeutic goals be realistic because, in some cases, PTSD is a chronic
and severely debilitating psychiatric disorder that is refractory to current
available treatments. The hope remains, however, that our growing knowledge
about PTSD will enable us to design interventions that are more effective for
all patients afflicted with this disorder.

There is great interest in rapid interventions for acutely traumatized
individuals, especially with respect to civilian disasters, military
deployments, and emergency personnel (medical personnel, police, and
firefighters). This has become a major policy and public health issue since the
massive traumatization caused by the September 11 terrorist attacks on the World
Trade Center. Currently, there is controversy about which interventions work
best during the immediate aftermath of a trauma. Research on critical incident
stress debriefing (CISD), an intervention used widely, has brought disappointing
results with respect to its efficacy to attenuate posttraumatic distress or to
forestall the later development of PTSD. Promising results have been shown with
brief cognitive-behavioral therapy.





Coping with PTSD and Recommended Lifestyle Changes for PTSD Patients

A National Center for PTSD Fact Sheet

By Joe Ruzek, Ph.D.

Coping with PTSD

Because PTSD symptoms seldom disappear completely, it is usually a continuing
challenge for survivors of trauma to cope with PTSD symptoms and the problems
they cause. Survivors often learn through treatment how to cope more
effectively.

Recovery from PTSD is an ongoing, daily, gradual process. It doesn't happen
through sudden insight or "cure." Healing doesn't mean that a survivor will
forget war experiences or have no emotional pain when remembering them. Some
level of continuing reaction to memories is normal and reflects a normal body
and mind. Recovery may lead to fewer reactions and reactions that are less
intense. It may also lead to a greater ability to manage trauma-related emotions
and to greater confidence in one's ability to cope.

When a trauma survivor takes direct action to cope with problems, he or she
often gains a sense of personal power and control. Active coping means
recognizing and accepting the impact of traumatic experiences and then taking
concrete action to improve things.

Positive coping actions are those that help to reduce anxiety and lessen other
distressing reactions. Positive coping actions also improve the situation in a
way that does not harm the survivor further and in a way that lasts into the
future. Positive coping methods include:

Learning about trauma and PTSD-It is useful for trauma survivors to learn more
about PTSD and how it affects them. By learning that PTSD is common and that
their problems are shared by hundreds of thousands of others, survivors
recognize that they are not alone, weak, or crazy. When a survivor seeks
treatment and learns to recognize and understand what upsets him or her, he or
she is in a better position to cope with the symptoms of PTSD.

Talking to another person for support-When survivors are able to talk about
their problems with others, something helpful often results. Of course,
survivors must choose their support people carefully and clearly ask for what
they need. With support from others, survivors may feel less alone, feel
supported or understood, or receive concrete help with a problem situation.
Often, it is best to talk to professional counselors about issues related to the
traumatic experience itself; they are more likely than friends or family to
understand trauma and its effects. It is also helpful to seek support from a
support group. Being in a group with others who have PTSD may help reduce one's
sense of isolation, rebuild trust in others, and provide an important
opportunity to contribute to the recovery of other survivors of trauma.

Talking to your doctor about trauma and PTSD-Part of taking care of yourself
means mobilizing the helping resources around you. Your doctor can take care of
your physical health better if he or she knows about your PTSD, and doctors can
often refer you to more specialized and expert help.

Practicing relaxation methods-These can include muscular relaxation exercises,
breathing exercises, meditation, swimming, stretching, yoga, prayer, listening
to quiet music, spending time in nature, and so on. While relaxation techniques
can be helpful, they can sometimes increase distress by focusing attention on
disturbing physical sensations or by reducing contact with the external
environment. Be aware that while uncomfortable physical sensations may become
more apparent when you are relaxed, in the long run, continuing with relaxation
in a way that is tolerable (i.e., interspersed with music, walking, or other
activities) helps reduce negative reactions to thoughts, feelings, and
perceptions.

Increasing positive distracting activities-Positive recreational or work
activities help distract a person from his or her memories and reactions.
Artistic endeavors have also been a way for many trauma survivors to express
their feelings in a positive, creative way. This can improve your mood, limit
the harm caused by PTSD, and help you rebuild your life. It is important to
emphasize that distraction alone is unlikely to facilitate recovery; active,
direct coping with traumatic events and their impact is also important.

Calling a counselor for help-Sometimes PTSD symptoms worsen and ordinary efforts
at coping don't seem to work. Survivors may feel fearful or depressed. At these
times, it is important to reach out and telephone a counselor, who can help turn
things around.

Taking prescribed medications to tackle PTSD-One tool that many with PTSD have
found helpful is medication treatment. By taking medications, some survivors of
trauma are able to improve their sleep, anxiety, irritability, anger, and urges
to drink or use drugs.

Negative coping actions help to perpetuate problems. They may reduce distress
immediately but short-circuit more permanent change. Some actions that may be
immediately effective may also cause later problems, like smoking or drug use.
These habits can become difficult to change. Negative coping methods can include
isolation, use of drugs or alcohol, workaholism, violent behavior, angry
intimidation of others, unhealthy eating, and different types of
self-destructive behavior (e.g., attempting suicide). Before learning more
effective and healthy coping methods, most people with PTSD try to cope with
their distress and other reactions in ways that lead to more problems. The
following are negative coping actions:

Use of alcohol or drugs-This may help wash away memories, increase social
confidence, or induce sleep, but it causes more problems than it cures. Using
alcohol or drugs can create a dependence on alcohol, harm one's judgment, harm
one's mental abilities, cause problems in relationships with family and friends,
and sometimes place a person at risk for suicide, violence, or accidents.

Social isolation-By reducing contact with the outside world, a trauma survivor
may avoid many situations that cause him or her to feel afraid, irritable, or
angry. However, isolation will also cause major problems. It will result in the
loss of social support, friendships, and intimacy. It may breed further
depression and fear. Less participation in positive activities leads to fewer
opportunities for positive emotions and achievements.

Anger-Like isolation, anger can get rid of many upsetting situations by keeping
people away. However, it also keeps away positive connections and help, and it
can gradually drive away the important people in a person's life. It may lead to
job problems, marital or relationship problems, and the loss of friendships.

Continuous avoidance-If you avoid thinking about the trauma or if you avoid
seeking help, you may keep distress at bay, but this behavior also prevents you
from making progress in how you cope with trauma and its consequences.

Recommended Lifestyle Changes – Taking Control

Those with PTSD need to take active steps to deal with their PTSD symptoms.
Often, these steps involve making a series of thoughtful changes in one's
lifestyle to reduce symptoms and improve quality of life. Positive lifestyle
changes include:

Calling about treatment and joining a PTSD support group-It may be difficult to
take the first step and join a PTSD treatment group. Survivors say to
themselves, "What will happen there? Nobody can help me anyway." In addition,
people with PTSD find it hard to meet new people and trust them enough to open
up. However, it can also be a great relief to feel that you have taken positive
action. You may also be able to eventually develop a friendship with another
survivor.

Increasing contact with other survivors of trauma-Other survivors of trauma are
probably the best source of understanding and support. By joining a survivors
organization (e.g., veterans may want to join a veteran's organization) or by
otherwise increasing contact with other survivors, it is possible to reverse the
process of isolation and distrust of others.

Reinvesting in personal relationships with family and friends-Most survivors of
trauma have some kind of a relationship with a son or daughter, a wife or
partner, or an old friend or work acquaintance. If you make the effort to
reestablish or increase contact with that person, it can help you reconnect with
others.

Changing neighborhoods-Survivors with PTSD usually feel that the world is a very
dangerous place and that it is likely that they will be harmed again. It is not
a good idea for people with PTSD to live in a high-crime area because it only
makes those feelings worse and confirms their beliefs. If it is possible to move
to a safer neighborhood, it is likely that fewer things will set off traumatic
memories. This will allow the person to reconsider his or her personal beliefs
about danger.

Refraining from alcohol and drug abuse-Many trauma survivors turn to alcohol and
drugs to help them cope with PTSD. Although these substances may distract a
person from his or her painful feelings and, therefore, may appear to help deal
with symptoms, relying on alcohol and drugs always makes things worse in the
end. These substances often hinder PTSD treatment and recovery. Rather than
trying to beat an addiction by yourself, it is often easier to deal with
addictions by joining a treatment program where you can be around others who are
working on similar issues.

Starting an exercise program-It is important to see a doctor before starting to
exercise. However, if the physician gives the OK, exercise in moderation can
benefit those with PTSD. Walking, jogging, swimming, weight lifting, and other
forms of exercise may reduce physical tension. They may distract the person from
painful memories or worries and give him or her a break from difficult emotions.
Perhaps most important, exercise can improve self-esteem and create feelings of
personal control.

Starting to volunteer in the community-It is important to feel as though you are
contributing to your community. When you are not working, you may not feel you
have anything to offer others. One way survivors can reconnect with their
communities is to volunteer. You can help with youth programs, medical services,
literacy programs, community sporting activities, etc.



---------------------------------
Do you Yahoo!?
Yahoo! SiteBuilder - Free, easy-to-use web site design software

[Non-text portions of this message have been removed]