ABSTRACT: The Post-Traumatic Stress Disorder is an illness of high significance nowadays, for the potential risk to affect any individual, in view of the exposure to a considerable amount of stressful events during daily lifestyle and the complexity of factors involved in its genesis and development, demanding an interdisciplinary approach of psychologists, psychiatrists, neurologists, clinicians and other healthcare professionals.
This work reviews the concept of PTSD, according to the DSM-IV, the etiology and neurophysiology of this disorder, the specific signs and symptoms for its diagnostic and the current therapeutic approach to this disease. It also analyzes special cases of PTSD: the incidence of the disorder among police officers after the September 11th attack in the United States and PTSD in children.
INTRODUCTION
The stressor event triggering the Post-Traumatic Stress Disorder must hold such magnitude that enhances the development of a set of intense neurophysiologic reactions. When these reactions fall into the group of signals and symptoms corresponding to the syndrome described in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition), it characterizes the Post-Traumatic Stress Disorder.
Despite the high prevalence of PSTD based in the DSM-IV new diagnostic criteria, there is still much to be studied about this syndrome. Currently, the prevalence rate of PTSD is estimated as 1-3%, in average, reaching the figure of 5-15% in some studies. The present work aims to perform a revision of the concept, diagnostic and treatment of PTSD, and to study the neurobiological basis and practical applications of the current scientific knowledge about it.
I – DEFINITION
The Post-Traumatic Stress Disorder, previously called irritable heart syndrome, combat neurosis or operational fatigue, is classified by the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 1984) as an anxiety disorder specific to the development of symptoms that happen after the exposition to a critical and traumatic incident. These events are related to death, death threat, damage to physical or mental integrity, or traumatic injuries, and include experiences of combat, natural catastrophes, physical aggression, rape and serious accidents (such as traffic accidents and fire on buildings).
PTSD consists in a syndrome comprised of the triad:
1. Trauma revival through dreams and thoughts during the vigil state;
2. Persistent avoidance of stimulus associated to the trauma and blunted response to these indicators;
3. Persistent hyperarousal.
Associated symptoms include: fatigue, aggressiveness, anger, hypervigilance, depression, anxiety and cognitive impairment (such as lack of concentration). PTSD can weaken an individual in such a case that stimulus linked to the incident may trigger symptoms as intense fear, abandonment and avoidance. Associated physical symptoms express as Autonomic Nervous System responses, such as hyperactivity of sweat glands, and somatic symptoms, like depression.
The beginning of the occurrence of symptoms varies from the first three months of exposition to the critical incident to many years after the occurrence. DSM-IV considers the minimal period as one month.
PTSD is diagnosed as acute if the duration of the symptoms is over a month and less than three months; chronic, if it lasts over three months, and late if the beginning of the symptoms occur over six months after the stressor event. The occurrence of PTSD can be related with the severity of the stressing agent. More severe stress leads to a bigger prevalence. For example, concentration camps resulted in the emergence of Post-Traumatic Stress Disorder in over 75% of the victims. Studies after World War Two with the use of pneumoencephalography (the injection of air in the cerebrospinal space) in concentration camp survivors, showed varied levels of cerebral atrophy and diffuse encephalopathy in 81% of cases. (THYGESEN, 1970)
The diagnosis is based on the DSM-IV criteria, dividing it in Post-Traumatic Stress Disorder or Acute Stress Disorder. The Acute Stress Disorder is conceptualized as occurring around four weeks after the traumatic event, with a duration period from two days to four weeks.
For the diagnostic the described classical triage and affiliated symptoms are observed, such as avoidance, emotional dullness and hyperexcitability. Furthermore, the patient displays feelings of guilt, rejection, and humiliation, and may also report dissociative states, panic attacks, illusions, and hallucinations. He can also have impairment related to memory and concentration. The patient can also show aggression, violence, deficiency of the control of impulses, depression, and substance use. The Rorschach test can evidence aggression and violence.
In the act of diagnosis, it is important to consider associated diseases, such as the occurrence of cranial injury during the trauma, epilepsy, alcohol abuse disorder or other analogous substances, acute intoxication, abstinence syndrome, and other mental disorders, such as borderline personality disorder, that may coexist and is related with PTSD. It must also be considered the differential diagnostic with factual disorder and simulation.
II – ETIOLOGY AND NEUROBIOLOGICAL BASIS
The etiological factors of Post-Traumatic Stress Disorder would be the stress factor, psychological factors and biological factors. The stress factor is the triggering traumatic stress of the syndrome. However, it is known that other factors must be involved for such to occur, since not all individuals that suffer a traumatic event develop PTSD.
According to Kaplan, recent researches about PTSD have shown the greater importance of the “subjective tools” of the individual to deal with the trauma, which would be more important than the severity of the stress event (KAPLAN, 2003). The development of the syndrome has much to do with the subjective significance of the event to the individual.
Therefore, together with the stressor event, important primary factors for the occurrence of Post-Traumatic Stress Disorder include: the presence of a childhood trauma; traits of personality disorders; inappropriate support system; genetic-individual predispositions to psychiatric disorders; recent and stressful life changes; consciousness of an external control site instead of an internal one; excessive alcohol consumption; alexithymia (inability to identify or to verbalize emotional states); etc.
The neurobiological finds associated to PTSD concern the phenomenon of “biological (or neurobiological) scar”. Scar is the mark existent in a tissue or organ, produced by a traumatic lesion, as a result of a re-composition and cellular repair process, with consequent tissue fibrosis. The neurobiological scar refers to the molecular and neurobiological effects induced by a psychological trauma, especially on childhood, which alters in an irreversible way the neuronal development. Interestingly this concept, initially a conclusion from psychological and behavioral studies, has been confirmed by neuroscience and neuroimaging.
Two brain areas primarily affected on PTSD are the brain amygdala and the hippocampus. The amygdala seems to hold special role on perception, recognition and creation of memory, especially the one related to stimulus of emotional nature, generating association through brain connections.
The hippocampus possesses as main function the declarative (or explicit) memory, of persons, places, objects and facts. The procedural or implicit memory, which relates to habits and mechanic (or conditioned) learning is linked to the subcortical and cerebellar circuits. Hippocampus memory is the work and learning memory, and the evocation of short and long term memories. PTSD is marked by symptoms involving the construction and evocation of memories.
Studies with functional magnetic resonance (fMRI) and positron emission tomography (PET) have shown alterations of volume decrease of the right hippocampus (related to spatial tasks) and damage on short term verbal memory. Those studies correlate PTSD symptoms with the reduction of the hippocampus’ volume, even in the absence of alcohol abuse (which also leads to brain atrophy).
Dr. Douglas Brenner, psychiatrist and professor at Emore University, performed many studies on the neurological alterations of PTSD, and declares that there are sufficient evidences to conclude that traumatized patients present hippocampal atrophy specific for the diagnostic of PTSD, and also that patients with PTSD resulted from early trauma on childhood present greater reduction in the left hippocampus (related to verbal stimulus), and patients that develop PTSD as adults present bilateral atrophy or in the right hippocampus (BREMNER, 1993).
The findings from neuroimaging have also shown an exaggerated response pattern in the cerebral amygdala. It is believed that the amygdala has participation in the mnemonic activity related to emotional stimuli, of which the content and perception in Post-Traumatic Stress Disorder are prompters of higher alert, anxiety, and fear. The more emotionally intense stimulus, the harder it is to forget it, although paradoxically the hyperactivation from stress can produce lacunar amnesias.
According to the neurologist Antonio Damasio, the images recreated by evocation walk in parallel with those fashioned by exterior stimuli (perceptive images) (DAMASIO, 2004). Although less vivid than perceptive ones, they still are images, and can be relived at any moment.
The psychologist Daniel Schacter explains the evocation phenomena, or persistence, as strongly related with the emotional life of the individual, with the relation between emotion and memory, showing that incidents with high emotional burden are better remembered than non-emotive incidents (SCHACTER, 2001). The strap emotion/memory has a beginning the moment the memory is created, when the attention and elaboration will determine if the lived experience is going to be remembered posteriorly or not. In performed studies, words with emotional content automatically attract the attention, fixing them better in the memory.
Dr. Daniel Schacter studied the relation between PTSD and depression, of which it is found to be highly associated. Studies comparing intrusive memories in traumatized patients and in depressed patients who had not experienced a specific trauma showed a higher frequency of intrusive memories and flashbacks in patients with PTSD, who displayed even higher amounts of uncommon dissociative experiences, where they would feel as if they were observing a personal event happening with another person, as distant spectators.
In PTSD, there is a relation between the stressor event and memory, leading to an ulterior reminder of such (evocation). Different stimuli from the event, but somehow related to it, which remembers the environment or the experiences of the individual in the moment of the trauma, initiate in the organism a neurophysiological reaction, as if they were going through the trauma again. This relates with the role of the amygdala in the emotional background memory. It records better events with higher emotional content.
III – THERAPEUTIC APPROACH
The current treatment of Post-Traumatic Stress Disorder covers the pharmacological treatment, psychotherapy, and cognitive therapy.
The pharmacological treatment of PTSD includes the use of tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitor, second generation antidepressants, anti-adrenergic, benzodiazepines, anticonvulsants, antipsychotics, opioids, and other medications.
The first choice medication is the selective serotonin reuptake inhibitor. The recommended time of treatment is of a minimal period of five weeks in order to receive a therapeutic response. Presently, with neuroscience studies, there is a pursuit to develop extra-hypothalamic corticotropin releasing hormones receptor antagonists, which leads to hyperactivity of the defense system on PTSD.
PTSD psychotherapy is based in the fact that this is a physiologic response produced by the organism, as a stage of elaboration and reorganization in the homeostasis break. According to Kaplan, psychotherapy in some cases may be therapeutic, on leading to the reconstruction of the traumatic events. However in other cases it may not be useful, for some patients are highly vulnerable to be able to relive the trauma suffered.
Other approach techniques include the cognitive-behavioral therapy and hypnosis. Cognitive-behavioral therapy aims to a cognitive restructuring regarding the traumatic situation, with reorganization and modification of trauma-related memories. In order that this technique must be applied, it is essential the cessation of exposition to the stressor event. It is also important to involve the patient’s social support network together with him, such as family and friends.
IV – SPECIAL CASES
1. Post-Traumatic Stress Disorder After September 11th Among Police Officers in the United States.
A work performed with Arlington County police officers who first responded to the emergency situation in Pentagon on September 11th 2001, helping in the rescue of victims of the attack, showed that more than 1/3 of them (36%) presented Post-Traumatic Stress Disorder, correlating the amount of time spent in the work in Pentagon with the severity of PTSD presentation.
In common situations, 1/3 of police officers present PTSD in some life period, due to work conditions and frequent exposition to potentially stressor events in daily life. PTSD in police officers holds as peculiar characteristic the hardship for the patient to get help and treatment for the disorder, due to the fact that police officers are trained to help, not to ask for help. This conditioning overburdens them with the notion of self-control and self-sufficiency. Seeking help for stress treatment is not well seen in police environment.
Those who search for psychological counseling are usually branded by their colleagues as weak and untrustworthy as coworkers.
In the stated study, it has been proved the association between PTSD and sleep disorders between police officers. In another study performed among 1000 officers of the New Zealand Police Force, it was proved the significance of a good social relationship as a source of emotional support. An important finding was the evidence that those with a bigger supporting social grid and those who better expressed their emotions showed lower incidents of PTSD after being exposed to traumatic events.
In the case of the officers who helped on the Pentagon rescue, a distinguished data regards the educational level of the officers. Results showed that the lower the educational level of the policeman, the more PTSD symptoms he would show. The policemen with higher secondary level showed less characteristic symptoms of PTSD.
The final result of the study was that the single most important factor in the development of PTSD on policemen who assisted after the September 11 attacks was the number of hours that each officer spent on the Pentagon. Many kept their work there for various weeks. The higher the time spent on that place, the greater the amount of characteristic symptoms of PTSD was shown. The motive reported by the police officers for the long stay in the military complex was the sense of duty and the need of offering a significant contribution to the restoration of the Pentagon.
2. Post-Traumatic Stress Disorder in Children
Post-Traumatic Stress Disorder on children tends to interfere in all areas of personality, due to a special adaptation and vulnerability on the development phase. The prevalence of PTSD on children varies from 30% to 100% after the exposure to a traumatic stress event, depending on the duration, intensity, and proximity of the event.
The course of PTSD on children becomes chronic when they are submitted to multiple injuries, feelings of guilt related emerge and it leads to their participation on juridical, penal, or civil processes. Approximately 50% of children recover in the first three months. 30-50% of them lead to a chronic course of PTSD
Regarding symptomatology, PTSD on childhood introduces a greater variety of reactions to trauma, such as recessive demeanor (enuresis, encopresis, and recession of linguistic skills), anxiety, fear, somatization, depression, behavior problems, isolation, concentration disorder, dissociations and sleep disorders. Some become aggressive, others become passive.
As anxiety disorders, they display phobias, recalling of the stressor event and anxiety on separation. In teenagers, it is related to substance consumption and depression. It was also discovered that girls are more symptomatic than boys. The response of the child to the stressor event is related to the response of the parents to the issue. There is an association between the symptomatology of parents and children. There is no significant difference regarding transcultural studies or socio-economic levels.
In the long run, there are effects in the child development, with the establishment of risk behavior. The psychological effects include chronic PTSD, borderline, antisocial and narcissist personality disorders, multiple personality disorder (especially when the trauma happens in pre-school age), self-mutilations and suicide attempts, drug abuse and alcoholism.
When the exposition to the childhood trauma is continued, it characterizes the chronicity of PTSD. As a response to the chronic stressor, children display fear or absence of feelings regarding the trauma, and develop defense strategies and management of the chronic stressor, such as negation, repression, dissociation, self-anesthesia, self-hypnosis, identification with the aggressor and self-destructive behavior. These factors will alter the functioning and the development of personality.
We emphasize the importance of the diagnostic and early detection of PTSD in children, in order to prevent greater disorders in medium or long term and development disorders in the exposed individual.
CONCLUSION
The importance of the Post-Traumatic Stress Disorder as a primary health issue needs to be recognized and emphasized, and professionals in the field should be prepared to early diagnostic, because many times it can be mistaken with hyperactivity, behavior disorders, mood or anxiety disorders.
In children, the earlier the diagnostic and treatment, the lower the development of personality disorders and anxiety presented in the long term. The early intervention and treatment prevent the chronicity of PTSD, especially in the presence of the chronic stressor event, that can lead to affective deregulation, conscience alterations, self-perception disorders and disorders of interpersonal relationship and the system of values, with permanent and serious damage to the entire personality in formation of the child. The higher the time of exposition to the traumatic event, greater the potential damage to the child.
Currently, the multidisciplinary approach is of great importance to the appropriate management of the individual presenting Post-Traumatic Stress Disorder, including psychiatrists, psychologists, neurologists, and other healthcare specialists, aiming the appropriate recognition of the pathology and the effective treatment for the specific case. Present life style leads to an exposition of the individual to innumerable trigger situations to PTSD that if not diagnosed in the proper time will lead from a low complexity treatment to an increasingly higher level of professional involvement, time and absence from work, decreasing the productive capacity of the individual.
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