Understanding Post-Traumatic Stress Disorder

 

By Jeannie Singleton, MSW, LSW

His eyes flicker back and forth quickly. His mind shoots off rapid questions. What’s that noise? What’s that smell? His heart rate speeds up, his breathing quickens, his eyes pop open as his body prepares to flee the hidden danger it perceives…and then suddenly he realizes he’s safe and sound in his bed in the burn unit.

What is post-traumatic stress disorder?

Startle response, nightmares, sleep problems, hypervigilance, intrusive recollections, and flashbacks are some of the most common signs and symptoms of posttraumatic stress disorder, also commonly known as PTSD. Symptoms of PTSD are often disruptive and make it difficult for individuals, and oftentimes their family members, to get through what used to be normal daily activities.

It has been reported that approximately one third of survivors with a major burn injury experience PTSD after discharge.1 Fortunately, significant advances have been made in the research and treatment of PTSD and it is my hope that this 3-part series will help shed some light on the subject.

In this first article, I would like to share some basic information on PTSD, including its history and how it is diagnosed. The second article will focus on treatment, and the third article will discuss the impact that PTSD has on individuals and families.

As a medical social worker assigned to the only burn center in Hawaii, I am often asked by patients and family members what causes PTSD and what can be done to treat it. When looking back through history, it’s clear that post-traumatic stress disorder has been around for a very long time, although it’s been referred to by a variety of names.

For example, in the American Civil War the term “soldiers heart” was used to describe what soldiers experienced after participating in the Battle at Antietam where 15,000 soldiers were killed in 1 hour. Soldiers suffering from psychiatric breakdown “were put on trains with no supervision, the name of their home town or state pinned to their tunics; others were left to wander about the countryside until they died from exposure or starvation.”2  In World War I soldiers displaying signs of PTSD were often described as suffering from “gas neurosis,” “trench neurosis,” or “shell shock.” World War II, Korea, and Vietnam soldiers who exhibited symptoms of PTSD were told that they were experiencing combat psychosis/neurosis or combat/battle fatigue.

How is it diagnosed?

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)3, in order for an individual to be diagnosed with PTSD that person must meet certain diagnostic criteria. Heres a brief and general overview of the first set of criteria:

  • Directly experiencing the event
  • Witnessing, in person, the event as it occurred to others
  • Learning about a violent or accidental event that occurred to a significant individual
  • Experiencing repeated/extreme exposure to aversive details of traumatic events (does not include electronic media/pictures, unless work related)

There are numerous ways that an individual can be exposed to a traumatic event. For instance traumatic events can be caused by crime victimization (assault, rape, child abuse), natural or manmade disasters (tsunamis, earthquakes, fires), accidents, incarceration (inmates, ex-prisoners of war, Holocaust survivors), and sudden life-threatening illness (myocardial infarction, acute respiratory distress syndrome).

Once it has been established that a person meets criterion A, the next step is to look at criterion B, which is the re-experiencing of symptoms. In order to meet diagnostic criteria, an individual must experience at least 1 of the following:

  • Recurrent, involuntary, intrusive thoughts/memories of the trauma
  • Recurrent distressing dreams of the event
  • Reliving the experience as if it were recurring (flashbacks)
  • Intense emotional distress after exposure to trauma reminders
  • Intense physical reactions to trauma reminders

Assuming that the individual has met criteria A and B, we would move on to check if that person also meets criteria C, D, and E before saying that this individual has PTSD.

Criterion C focuses on the avoidance symptoms, which means that an individual must experience at least 1 of the following:

  • Effortful avoidance of thoughts/feelings associated with the trauma
  • Avoidance of situations, activities, or places that remind one of the trauma

Criterion D addresses negative changes to thoughts/mood and an individual must experience at least 2 of the following:

  • Can’t remember important aspects of the trauma
  • Persistent, exaggerated negative beliefs about the self, others, and the world
  • Persistent, distorted thoughts about the cause of the trauma that leads to self/other blame
  • Persistent negative emotional state
  • Decreased interest in significant activities
  • Feelings of detachment from others
  • Persistent inability to experience positive emotions

Criterion E focuses on increased arousal symptoms, and an individual must experience at least 2 of the following to meet criteria:

  • Irritability or anger outbursts
  • Reckless or self-destructive behavior
  • Hypervigilance—overly alert
  • Exaggerated startle response
  • Difficulty concentrating
  • Problems falling or staying asleep

So what does all of this mean?

It is important that an individual who is concerned that he or she may have PTSD see a provider who is familiar with PTSD and who can complete a good assessment. Some of the important things that a provider should look for when completing an assessment is the ability to link the symptoms directly back to the trauma, particularly the re-experiencing of symptoms.

It is also important that there is an assessment of prior functioning—symptoms that existed at a similar level prior to the trauma. For instance, being angry would not count toward the PTSD diagnosis if the individual has a prior history of anger management problems.

Another thing to keep in mind when undergoing assessment for symptoms of PTSD is the importance of working with a behavioral health provider or clinician who is familiar with PTSD, rather than trying to self-diagnose. This is important because what an individual reports experiencing can be different than the clinical interpretation of the symptom. For example, it is normal to have an occasional nightmare or a bad trigger moment, everyone does even without trauma, but a good assessor will be able to contextualize the symptoms and detect changes in functioning, which is key to diagnosis.

Accurately diagnosing PTSD can be difficult because there is a significant overlap between PTSD and other mental health diagnoses. For example, there is a significant overlap of negative changes in mood/cognition and depression symptoms, and personality disorders can display many of the criteria D and E symptoms.

Although all the reasons listed above are good reasons for having a solid assessment completed, I believe the most important reason is because PTSD treatments will simply not be effective if the individual is not experiencing PTSD. We will explore this topic more in part 2 of this series where we will look into what is being done to successfully treat post-traumatic stress disorder.

 

References
1. Fauerbach JA, McKibben J, Bienvenu OJ, et al. Psychological distress after a major burn injury. Psychosom Med. 2007:69:473–482.
2. Bentley S. A short history of PTSD: From Thermopylae to Hue soldiers have always had a disturbing reaction to war. VVA Veteran. March/April 2005.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association;2013.

 

Jeannie Singleton is a licensed medical social worker currently working in the burn center and ICU unit at Straub Medical Center. Her prior experience includes working in child welfare services, adult mental health and substance abuse, and the Veterans Administration. Jeannie received her certification in cognitive processing therapy for PTSD while working with veterans in the traumatic stress recovery program.

 

This story is an excerpt from The Phoenix Society’s® Burn Support Magazine, Issue 2, 2016.  Burn Support Magazine is a tri-annual publication that contains articles on the emotional, psychological, and social aspects of burn recovery.  All Rights Reserved.
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