Kurt Fritzsche, Susan H. McDaniel and Michael Wirsching (eds.)Psychosomatic Medicine2014An International Primer for the Primary Care Setting10.1007/978-1-4614-1022-5_14
© Springer Science+Business Media New York 2014
14. Acute and Posttraumatic Stress Disorder (PTSD)
(1)
Department of Psychosomatic Medicine and Psychotherapy, University Medical Center, Hauptstr. 8, 79104 Freiburg, Germany
(2)
Department of Psychiatry, Makerere University College of Health Sciences and Mulago National Referral and Teaching Hospital, 7072 Kampala, Mulago Hill Road, Uganda
(3)
Department of Human Sciences, Federal University of Paraná, R. Gal. Carneiro, 460, 80060-150 Curitiba, PR, Brazil
(4)
Division of Psychosomatic Medicine, Taipei City Psychiatric Center, Taipei City Hospital, No. 309 Song-De Road, 11080 Taipei, Taiwan
Abstract
Symptoms of posttraumatic stress disorder (PTSD) are intrusions, hyperarousal and avoidance behaviour. Early interventions for acute trauma include calming, safety and stabilisation. Treatment of PTSD should be provided by psychotherapists and include trauma exposition.
Keywords
TraumaEarly interventionsPosttraumatic stress disorderPsychoeducationTrauma expositionCase Study
A 45-year-old ENT physician was critically injured by a drunken 52-year-old patient with multiple stab wounds in the abdomen. This followed a verbal dispute from the patient’s perspective, due to unsatisfactory treatment outcome. The doctor was treated at the hospital emergency room and then transferred to a normal ward. In the following days he developed anxiety in enclosed spaces, seemed mostly irritable and complaint of insomnia and restlessness. Upon questioning, he told about very frightening dreams that were directly or indirectly related to his experience of violence. He then woke up drenched in sweat and had trouble to get his bearings. Initially, he avoided to talk about these experiences and his mental condition. Only by careful inquiries of the ward physician it was possible to gather the full extent of the acute trauma.
(continued)
Definition
Psychological trauma is defined as the result of a momentary or prolonged stressful event that is beyond normal human experience and that would be stressful for anyone. The defining characteristic is the large discrepancy between external threats and the available coping skills.
A traumatic event meets the following criteria:
The person was a victim or witness of an event in which one’s own life or the lives of others were threatened or as a result had a serious injury, for example, natural disaster, war, traffic accident, diagnosis of a terminal illness, stay in intensive care, terrorism, rape and violent crime.
The reaction of the person concerned involves feelings of intense fear, helplessness and horror.
Due to the traumatic experience, the confidence in oneself and others is shaken fundamentally.
Another classification is often linked to the duration of the potentially traumatic event. Traumatisation, which was caused by a rather short and single event (e.g. serious accident or sexual abuse in adulthood) is referred to as Type I trauma , and a longer lasting and repeated trauma (repeated physical and sexual abuse in childhood) as Type II trauma. In Type I trauma, usually there are very clear, vivid memories of the event and there is a classic picture of posttraumatic stress disorder (PTSD), whereas, in Type II trauma often there are only diffuse, little clear recollections. Here, very different comorbid mental disorders (e.g. anxiety, depression, physical symptoms and eating disorders) may occur.
Relevance
It is assumed that traumatic experiences which have not been processed to a sufficient extent and integrated are a reason for numerous physical and psychological complaints, which arise in primary care. A traumatisation increases the likelihood of developing other mental illnesses such as depression, anxiety disorders, somatoform disorders and drug and substance abuse. Identifying trauma in time and providing necessary care will shorten the suffering and prevent the chronicity of symptoms.
Theory
Symptoms
One can distinguish three groups of symptoms of PTSD.
Intrusions
Obsessive intrusive images such as nightmares, flashbacks or other sensations such as noise and strong sense of smell that directly emerge from the triggering event (accident, robbery etc.) are difficult to access by the voluntary control of the person concerned (intrusion symptoms).
Hyperarousal
Severe irritability, sleep disturbances, lack of concentration and overall significantly reduced physical and mental stamina.
Avoidance
Places and situations that are mentally and emotionally related to the traumatic experience are avoided. The feelings are superficial.
Other consequential symptoms of PTSD include sense of shame and guilt, identification with the aggressor, dissociation, self-harming and violence against others.
The long-term effects of PTSD are:
Lasting personality changes such as hostility, distrust, withdrawal, chronic emptiness and feelings of alienation (Diagnosis F 62.0)
Muscle or joint pain due to continuous strain of the deep structure of the muscles as a result of the interrupted, quasi-frozen fight or flight reactions in the acute phase of trauma stored in the body memory
Lower abdominal pain after sexual intercourse as a result of sexual trauma
Diagnostic Categories
Acute Stress Disorder (ICD-10: F43.0)
This is a temporary disorder of an otherwise mentally stable person following an extraordinary physical and/or emotional stress, which subsides within 4 weeks after the trauma. The symptoms include a shock reaction, feeling of absence, numbness and disorientation, as well as hyperactivity and autonomic arousal. These are adequate emotional and physical ways of reacting to heavy stress.
Adjustment Disorder (ICD-10: F43.2)
The psychological responses, mostly in the form of depressive or anxious symptoms may last several months up to half a year. There are patients who actively deal with the trauma and related psychological and physical symptoms, and others who try to numb themselves with alcohol or tranquilizers.
Posttraumatic Stress Disorder: PTSD (ICD-10: F43.1)
The symptoms occur within few weeks to 6 months (acute PTSD), or 6 months and later (delayed-onset PTSD) after the traumatic event. The symptoms last for more than a month. The person concerned is affected psychologically and socially.
Lasting Personality Change After Extreme Stress (ICD-10: F62.0)
The disorder is characterized by a hostile or distrustful attitude towards the world, a feeling of alienation, feelings of emptiness or hopelessness and a chronic feeling of tension. Posttraumatic stress disorder may have preceded this type of personality change.
Outlook DSM-V: Complex Trauma
Based on field investigations initiated by the DSM-working group of the APA, a more complex disease pattern has been identified that arises not only in the wake of severe trauma such as physical or sexual abuse experiences, but also of war and torture experiences or abductions and was conceptualized as (‘Disorder of Extreme Stress Not Otherwise Specified’ (DESNOS), Appendix DSM-IV). This category is to be redrafted and incorporated in the next revision of the DSM (Version V) as ‘Complex Post Traumatic Stress Disorder’.
Frequency
Depending on the age of those affected, the lifetime prevalence of PTSD is 1.1 and 2.9 % (Wittchen et al. 2011). Substantially higher is the probability of the occurrence of less pronounced disorders. Women are affected twice as often as men. The occurrence of PTSD depends on the kind of trauma: Trauma due to violation: PTSD prevalence of 50 %, 25 % due to other violent felony, 20 % due to war victims. Trauma due to serious, life-threatening illness, e.g. cancer: PTSD prevalence of 15 %. Trauma due to intensive-medical measures, e.g. polytrauma: PTSD prevalence of 5 %. Trauma due to accident, e.g. traffic accident: PTSD prevalence of 18 % (Kessler et al. 1995).
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