PTSD is believed to be caused by psychological trauma. Possible sources of trauma includes experiencing or witnessing childhood or adult physical, emotional or sexual abuse. In addition, experiencing or witnessing an event perceived as life-threatening such as physical assault, adult experiences of sexual assault, accidents, drug addiction, illnesses, medical complications, or the experience of, or employment in occupations exposed to war (such as soldiers) or disaster (such as emergency service workers). Traumatic events that may cause PTSD symptoms to develop include violent assault, kidnapping, torture, being a hostage, prisoner of war or concentration camp victim, experiencing a disaster, bad car accidents or getting a diagnosis of a life-threatening illness. Children may develop PTSD symptoms by experiencing sexually traumatic events like age-inappropriate sexual experiences. Witnessing traumatic experiences or learning about these experiences may also cause the development of PTSD symptoms. The amount of dissociation that follows directly after a trauma predicts PTSD. Individuals who are more likely to dissociate during a traumatic event are considerably more likely to develop chronic PTSD. Many servicemen and women returning from Iraq and Afghanistan have PTSD. The diagnosed cases of PTSD in United States troops sent to either Afghanistan or Iraq rose 46.4 percent in 2007, bringing the five year total to almost 40,000 (from U.S. military data). Members of the Marines and Army are much more likely to develop PTSD than Air Force and Navy personnel, because of greater exposure to combat. A preliminary study found that mutations in a stress-related gene interact with child abuse to increase the risk of PTSD in adults.
Low cortisol levels may predispose individuals to PTSD; following war trauma, Swedish soldiers serving in Bosnia and Herzegovina with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms, following war trauma, than soldiers with normal pre-service levels. Because cortisol is normally important in restoring homeostasis after the stress response, it is thought that trauma survivors with low cortisol experience a poorly contained—that is, longer and more distressing—response, setting the stage for PTSD. However, there is considerable controversy within the medical community regarding the neurobiology of PTSD. A review of existing studies on this subject showed no clear relationship between cortisol levels and PTSD. Only a slight majority have found a decrease in cortisol levels while others have found no effect or even an increase.
In addition to biochemical changes, PTSD also involves changes in brain morphology. In a study by Gurvits et al., Combat veterans of the Vietnam war with PTSD showed an 20% reduction in the volume of their hippocampus compared with veterans who suffered no such symptoms.
In animal research as well as human studies, the amygdala has been shown to be strongly involved in the formation of emotional memories, especially fear-related memories. Neuroimaging studies in humans have revealed both morphological and functional aspects of PTSD. The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and insufficient top-down control by the medial prefrontal cortex and the hippocampus. Further animal and clinical research into the amygdala and fear conditioning may suggest additional treatments for the condition.
Although most people (50-90%) encounter trauma over a lifetime , only about 8% develop full PTSD . Vulnerability to PTSD presumably stems from an interaction of biological diathesis, early childhood developmental experiences, and trauma severity. Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood . This effect of childhood trauma, which is not well understood, may be a marker for both traumatic experiences and attachment problems . Proximity to, duration of, and severity of the trauma also make an impact; and interpersonal traumas cause more problems than impersonal ones .
Schnurr, Lunney, and Sengupta identified risk factors for the development of PTSD in Vietnam veterans. Among those are:
They also identified certain protective factors, such as:
There may also be an attitudinal component e.g. a soldier who believes that they will not sustain injuries may be more likely to develop symptoms of PTSD than one who anticipates the possibility, should either be wounded. Likewise, the later incidence of suicide amongst those injured in home fires above those injured in fires in the workplace suggests this possibility.
Notably, criterion A (the "stressor") consists of two parts, both of which must apply for a diagnosis of PTSD. The first (A1) requires that "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others." The second (A2) requires that "the person’s response involved intense fear, helplessness, or horror." The DSM-IV-TR criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience." Since the introduction of DSM-IV, the number of possible PTSD traumas has increased and one study suggests that the increase is around 50%. Various scales exist to measure the severity and frequency of PTSD symptoms.
Indeed, the success of exposure-based therapies has raised the question of whether exposure is a necessary ingredient in the treatment of PTSD. Some organizations have endorsed the need for exposure ,. Yet other approaches, particularly involving social supports,, may also be important. A recent open trial of interpersonal psychotherapy reported high rates of remission from PTSD symptoms without using exposure. A randomized controlled trial funded by the National Institute of Mental Health is currently comparing exposure-based psychotherapy to interpersonal psychotherapy at the New York State Psychiatric Institute (www.columbiatrauma.org; 212 543-6747).
There are data to support the use of "autonomic medicines" such Propranolol (beta blocker) and Clonidine (alpha-adrenergic agonist) if there are significant symptoms of "over-arousal". These may inhibit the formation of traumatic memories by blocking adrenaline's effects on the amygdala, has been used in an attempt to reduce the impact of traumatic events. or they may simply demonstrate to the patient that the symptoms can be controlled thereby assisting with "self efficacy" and helping the patient remain calmer. There is also data to support the use of mood-stabilizers such lithium carbonate, divalproex sodium and carbemazepine if there is significant uncontrolled mood or aggression. Risperidone is used to help with dissociation, mood and aggression, and benzodiazepines are used for short-term anxiety relief.Food and Drug Administration (FDA) recently approved a clinical protocol that combines the drug MDMA with talk therapy sessions. Funded by the non-profit Multidisciplinary Association for Psychedelic Studies (MAPS), the studies are taking place in South Carolina under the supervision and direction of Dr. Michael Mithoefer. Other PTSD/MDMA research include a pilot study in Switzerland, co-sponsored by MAPS and the Swiss Medical Association for Psycholytic Therapy (SAePT), and another study approved in Israel to investigate MDMA as a tool in the psychotherapeutic treatment of crime and terrorism-related PTSD.
There are several features of MDMA that make it an excellent candidate for treating PTSD in psychotherapy. The effects of MDMA are such that activity in the left amygdala, responsible for fear and anxiety, decreases in rats. This makes it a promising candidate as a tool in psychotherapy, allowing the patient to explore and examine their trauma (and accompanying emotions) without the fear and retraumatization encountered without drug. Ordinarily incapacitated by the resurgence of emotions (fear, shame, anger) attached to the trauma, subjects are rendered capable of approaching their trauma in a new and constructive way. Further helpful in treating PTSD, is the new capacity to experience empathy and compassion for both others and the self.
The National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5 of female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was 30.9 for males and 26.9 for females. In a reanalysis of the NVVRS data, along with analysis of the data from the Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial analysis of the NVVRS data, a large majority of Vietnam veterans suffered from PTSD-symptoms. Four out of five reported recent symptoms when interviewed 20-25 years after Vietnam.
In recent history, catastrophes (by human means or not) such as the Indian Ocean Tsunami Disaster may have caused PTSD in many survivors and rescue workers. Today relief workers from organizations such as the Red Cross and the Salvation Army provide counseling after major disasters as part of their standard procedures to curb severe cases of post-traumatic stress disorder.
There is debate over the rates of PTSD found in populations, but despite changes in diagnosis and the criteria used to define PTSD between 1997 and 2007, epidemiological rates have not changed significantly.
The term post-traumatic stress disorder or PTSD was coined in the mid 1970s. Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders. The term was formally recognised in 1980. (In the DSM-IV, which is considered authoritative, the spelling "posttraumatic stress disorder" is used. Elsewhere, "posttraumatic" is often rendered as two words — "post-traumatic stress disorder" or "post traumatic stress disorder" — especially in less formal writing on the subject.)
In the United States, the provision of compensation to veterans for PTSD is under review by the Department of Veterans Affairs (VA). The review was begun in 2005 after the VA had noted a 30% increase in PTSD claims in recent years. The VA undertook the review because of budget concerns and apparent inconsistencies in the awarding of compensation by different rating offices.
This led to a backlash from veterans'-rights groups, and to some highly-publicized suicides by veterans who feared losing their benefits, which in some cases constituted their only income. In response, on November 10 2005, the Secretary of Veterans Affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans currently receiving disability compensation for post-traumatic stress disorder...
The diagnosis of PTSD has been a subject of some controversy due to uncertainties in objectively diagnosing PTSD in those who may have been exposed to trauma, and due to this diagnosis' association with some incidence of compensation-seeking behavior.
The social stigma of PTSD may result in under-representation of the disorder in military personnel, emergency service workers and in societies where the specific trauma-causing event is stigmatized (e.g. sexual assault).
Many US veterans of the wars in Iraq and Afghanistan returning home have faced significant physical, emotional and relational disruptions. In response the United States Marine Corps has instituted programs to assist them in re-adjusting to civilian life - especially in their relationships with spouses and loved ones - to help them communicate better and understand what the other has gone through. Similarly, Walter Reed Army Institute of Research (WRAIR) developed the Battlemind program to assist servicemembers avoid or ameliorate PTSD and related problems.
Jonathan Shay, a psychiatrist for the Boston Department of Veterans' Affairs Outpatient Clinic was treating soldiers who suffered from PTSD. He was struck by the similarity of their war experiences to Homer's account of Achilles in the Iliad. He also believes Hotspur in William Shakespeares Henry IV, Part 1 is portrayed as a person suffering from PTSD.
In recent decades, with the concept of trauma, and PTSD in particular, becoming just as much a cultural phenomenon as a medical or legal one, artists have engage the issue in their work. Many movies, such as First Blood, Birdy, Coming Home, The Deer Hunter, Born on the Fourth of July, and Heaven & Earth deal with PTSD. It is an especially popular subject amongst "war veteran" films, often portraying Vietnam war veterans suffering from extreme PTSD and having difficulties adjusting to civilian life.
The song "Just Another Day" by 80s new wave group Oingo Boingo ambiguously references posttramaumatic stress disorder.
In more recent work, an example is that of Krzysztof Wodiczko who teaches at MIT and who is known for interviewing people and then projecting these interviews onto large public buildings. Wodiczko aims to bring trauma not merely into public discourse but to have it contest the presumed stability of cherished urban monuments. His work has brought to life issues such as homelessness, rape, and violence. Other artists who engage the issue of trauma are Everlyn Nicodemus of Tanzania and Milica Tomic of Serbia.
George Carlin comments on the various incarnations of PTSD terminology on his 1990 album Parental Advisory: Explicit Lyrics. He traces the progression of what he views as euphemisms, which followed "shell shock" in World War I: "battle fatigue" in World War II, "operational exhaustion" in the Korean War, and finally PTSD, a clinical, hyphenated term, in the Vietnam War. "The pain is completely buried under jargon. Post-traumatic stress disorder. I'll bet you if we'd have still been calling it shell shock, some of those Viet Nam veterans might have gotten the attention they needed at the time."
Some people believe that sufferers of Post Traumatic Stress Disorder have been stereotyped in popular culture. Many dramatic television shows have featured "psycho veteran" characters. Most recently, ABC's three daytime soap operas All My Children, One Life To Live, and General Hospital have each featured an Iraq War veteran who suffers from PTSD, and two of those three characters were written as being antisocial and prone to violence, while the other killed a man in defense (after having subdued him and he was no longer a threat) during a moment of stress.
Also, the Happy Tree Friends character Flippy exhibits some PTSD because of hearing sounds that reminds him of the Vietnam War. This results in the gruesome deaths of the other characters and sometimes even himself.