Nightmares are dreams that are threatening and scary. Nearly everyone has had a nightmare from time to time. For trauma survivors, though, nightmares are a common problem. Along with flashbacks and unwanted memories, nightmares are one of the ways in which a trauma survivor may relive the trauma for months or years after the event.
Post-traumatic stress disorder (PTSD) is an emotional illness classified as a trauma- and stressor-related disorder as of the most recent edition of the diagnostic reference for mental health disorders, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 or DSM-V). Prior to this most recent edition, PTSD was classified as an anxiety disorder in the DSM-4 (DSM-IV). This condition usually develops because of a terribly frightening, life-threatening, or otherwise highly unsafe experience. PTSD sufferers re-experience the traumatic event or events in some way, tend to avoid places, people, or other things that remind them of the event (avoidance), and are exquisitely sensitive to normal life experiences (hyperarousal). Although this condition has likely existed since human beings have endured trauma, PTSD has only been recognized as a formal diagnosis since 1980. However, it was called by different names as early as the American Civil War, when combat veterans were referred to as suffering from "soldier's heart." In World War I, the military referred to symptoms that were generally consistent with this syndrome as "combat fatigue." Soldiers who developed such symptoms in World War II were said to be suffering from "gross stress reaction," and many troops in Vietnam who had symptoms of what is now called PTSD were assessed as having "post-Vietnam syndrome." "Battle fatigue" and "shell shock" are other names for PTSD.
Although not specifically described in the DSM-5, complex post-traumatic stress disorder (C-PTSD) is recognized in the international manual for diseases, called the International Statistical Classification of Diseases and Related Health Problems (ICD-10). It usually results from prolonged exposure to a traumatic event or series thereof and is characterized by long-lasting problems with many aspects of emotional and social functioning. Compared to people who suffer from PTSD, those who have C-PTSD are at higher risk of engaging in self-harm, including suicide attempts and completion.
Statistics regarding this illness indicate that a low percentage of people in the United States will likely develop PTSD in their lifetime. Combat veterans and rape victims have a lifetime prevalence of PTSD. Somewhat higher rates of this disorder occur in African Americans, Hispanics, and Native Americans compared to Caucasians in the United States. Some of those differences are thought to be due to higher rates of dissociation soon before and after the traumatic event (peritraumatic), a tendency for individuals from minority ethnic groups to blame themselves, have less social support, and an increased exposure to racism for those ethnic groups, as well as differences between how ethnic groups may express distress. In military populations, many of the differences have been found to be the result of increased exposure to combat at younger ages for minority groups. Other important facts about PTSD include the estimate of 8 million people who suffer from PTSD at any one time in the United States and the fact that women are twice as likely as men to develop PTSD.
Almost half of individuals who use outpatient mental health services suffer from PTSD. As evidenced by the occurrence of stress in many individuals in the United States in the days following the 2001 terrorist attacks, not being physically present at a traumatic event does not guarantee that one will not suffer from traumatic stress that can lead to the development of PTSD.
PTSD statistics in children and teens reveal that up to 40% have endured at least one traumatic event, resulting in the development of PTSD in up to 15% of girls and 6% of boys. On average, 3%-6% of high school students in the United States and as many as 30%-60% of children who have survived specific disasters have PTSD. Most children who have seen a parent killed or endured sexual assault or abuse tend to develop PTSD, and more than one-third of youths who are exposed to community violence (for example, a shooting, stabbing, or other assault) will suffer from the disorder.
Although not all traumatized individuals develop PTSD, there can be significant physical consequences of being traumatized. For example, research indicates that people who have been exposed to an extreme stressor sometimes have a smaller hippocampus (a region of the brain that plays a role in memory) than people who have not been exposed to trauma. This is significant in understanding the effects of trauma in general and the impact of PTSD, specifically since the hippocampus is the part of the brain thought to have an important role in developing new memories about life events. Also, whether or not a traumatized person goes on to develop PTSD, they seem to be at risk for higher use of cigarettes, alcohol, and marijuana. Conversely, people whose PTSD is treated also tend to have better success at overcoming a substance-abuse problem.
Untreated PTSD can have devastating, far-reaching consequences for sufferers' functioning and relationships, their families, and for society. Complications of PTSD in women who are pregnant include having other emotional problems, poor health behaviors, and memory problems. Women who suffered sexual abuse at earlier ages are more likely to develop complex PTSD and borderline personality disorder. Babies who are born to mothers who suffer from this illness during pregnancy are more likely to experience a change in at least one chemical in their body that makes it more likely (predisposes) the baby to develop PTSD later in life. Individuals who suffer from this illness are at risk of having more health problems, as well as trouble reproducing. Examples of the physical health problems that PTSD sufferers are at higher risk of developing include arthritis, heart disease, and respiratory, as well as digestive problems.
Emotionally, PTSD sufferers may struggle more to achieve as good an outcome from mental health treatment as that of people with other emotional problems. In children and teens, PTSD can have significantly negative effects on their social and emotional development, as well as on their ability to learn.
Economically, PTSD can have significant consequences, as well. As of 2017, more than 900,000 veterans were receiving disability compensation for this illness, at a cost of $15 billion. This represents a 400% increase in the number of military people receiving disability benefits for PTSD since 2005.
Virtually any trauma, defined as an event that is life threatening or that severely compromises the physical or emotional well-being of an individual or causes intense fear, may cause PTSD. Such events often include either experiencing or witnessing a severe accident or physical injury, receiving a life-threatening medical diagnosis, being the victim of kidnapping or torture, exposure to community violence, war combat, or to a natural disaster, exposure to other disaster (for example, plane crash) or terrorist attack, being the victim of rape, mugging, robbery, or assault, enduring physical, sexual, emotional, or other forms of abuse, as well as involvement in civil conflict. Although the diagnosis of PTSD currently requires that the sufferer has a history of experiencing a traumatic event as defined here, people may develop PTSD in reaction to events that may not qualify as traumatic but can be devastating life events like divorce or unemployment.
Issues that tend to put people at higher risk for developing PTSD include increased duration of a traumatic event, higher number of traumatic events endured, higher severity of the trauma experienced, having an emotional condition prior to the event, or having little social support in the form of family or friends. In addition to those risk factors, children and adolescents, females, minority groups and people with learning disabilities or violence in the home seem to have a greater risk of developing PTSD after a traumatic event.
According to the DSM-5, the following three groups of symptom criteria are required to assign the diagnosis of PTSD in the context of an individual who has a history of being exposed to an actual or perceived threat of death, serious injury, or sexual violence to self or others that does not involve exposure through media unless that is work related:
The emotional numbing of PTSD may present as a lack of interest in activities that used to be enjoyed (anhedonia), emotional deadness, distancing oneself from people, and/or a sense of a foreshortened future (for example, not being able to think about the future or make future plans, not believing one will live much longer). At least one re-experiencing symptom, one avoidance symptom, two negative changes in mood or thinking, and two hyperarousal (fight or flight) symptoms must be present for at least one month and must cause significant distress or impairment in functioning in order for the diagnosis of PTSD to be assigned.
A similar disorder in terms of symptom repertoire is acute stress disorder. The major differences between the two disorders are that acute stress disorder symptoms persist from three days to one month after the trauma exposure, and a fewer number of traumatic symptoms are required to make the diagnosis as compared to PTSD.
In children, re-experiencing the trauma may occur through repeated play that has trauma-related themes instead of or in addition to memories, and distressing dreams may have more general content rather than of the traumatic event itself. As in adults, at least one re-experiencing symptom, one avoidance/numbing symptom, and two hyperarousal symptoms must be present for at least one month and must cause significant distress or functional impairment in order for the diagnosis of PTSD to be assigned. When symptoms have been present for three days to one month, a health care provider can then make a diagnosis of acute stress disorder (ASD).
Symptoms of PTSD that tend to be associated with C-PTSD include problems regulating feelings, which can result in suicidal thoughts, explosive anger, or passive aggressive behaviors, a tendency to forget the trauma or feel detached from one's life (dissociation) or body (depersonalization), persistent feelings of helplessness, shame, guilt, or being completely different from others, feeling the perpetrator of trauma is all powerful, and preoccupation with either revenge against or allegiance with the perpetrator, and severe change in those things that give the sufferer meaning, like a loss of spiritual faith or an ongoing sense of helplessness, hopelessness, or despair.
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For individuals who may be wondering if they should seek evaluation for PTSD by their medical or mental health professional, self-tests may be useful. The National Institute of Mental Health offers a self-test for PTSD. The assessment of PTSD can be difficult for practitioners to make since sufferers often come to the professional's office complaining of symptoms other than anxiety associated with a traumatic experience. Those symptoms tend to include body symptoms (somatization), depression, or drug addiction. Studies of Iraq war veterans indicate that these individuals tend to show more physical symptoms of PTSD as opposed to describing the associated emotional problems.
Many people with PTSD may present with a history of making suicide attempts. In addition to depression and substance-use disorders, the diagnosis of PTSD often co-occurs (is comorbid) with bipolar disorder (manic depression), eating disorders, and other anxiety disorders like obsessive compulsive disorder (OCD), panic disorder, social anxiety disorder, and generalized anxiety disorder.
Most health care professionals who examine a child or teenager for PTSD will interview both the parent and the child, usually separately, in order to allow each party to speak freely. Interviewing the child in addition to the adults in his or her life is quite important given that while the child or adolescent's parent or guardian may have a unique perspective, there are naturally things the young person may be thinking, feeling, or doing that the adult is not aware of. Another challenge for diagnosing PTSD in children, particularly in younger children, is that they may express their symptoms differently from adults. For example, symptoms in children may include the child going backward or regressing in their development, becoming accident prone, engaging in risky behaviors, becoming clingy, or suffering from more physical complaints as compared to adults with PTSD. Traumatized younger children may also have trouble sitting still, focusing, or managing their impulses and therefore be mistaken as suffering from attention deficit hyperactivity disorder (ADHD).
Sometimes, professionals will use a rating scale or a structured psychiatric interview for children in its entirety or just the portion that assesses PTSD in order to test for PTSD. Examples of such tools include the Diagnostic Interview for Children and Adolescents-Revised (DICA-R), the Diagnostic Interview Schedule for Children-Version IV (DISC-IV), and the Schedule for Affective Disorders and Schizophrenia for School Age Children (K-SADS). There are also some PTSD-specific structured interviews, like the Clinician-Administered PTSD Scale-Child and Adolescent Version, the Child PTSD Checklist, and the Child PTSD Symptom Scale. For the assessment of the severity of PTSD symptoms in children, structured interviews like the Child Post-traumatic Stress Reaction Index, the Child and Adolescent Trauma Survey, and the Trauma Symptom Checklist for Children are sometimes used. Some professionals find the Child Trauma Screening Questionnaire useful in predicting which children who endure a traumatic event will go on to develop PTSD.
Treatments for PTSD usually include trauma-focused psychological and medical interventions. Providing information about the illness, helping the individual manage the trauma by talking about it directly, teaching the person ways to manage symptoms of PTSD, and exploration and modification of inaccurate ways of thinking about the trauma are the usual techniques used in psychotherapy for this illness. Education of PTSD sufferers usually involves teaching individuals about what PTSD is, how many others suffer from the same illness, that extraordinary stress causes PTSD rather than personal weakness, how it is treated, and what to expect in treatment. This education thereby increases the likelihood that inaccurate ideas the person may have about the illness are dispelled, and any shame they may feel about having it is minimized. This may be particularly important in populations like military personnel that may feel particularly stigmatized by the idea of seeing a mental health professional and therefore avoid doing so.
Teaching people with PTSD practical approaches to coping with what can be very intense and disturbing symptoms is a useful way to treat the illness. Specifically, helping sufferers learn how to manage their anger and anxiety, improve their communication skills, and use breathing and other relaxation techniques can help individuals with PTSD gain a sense of mastery over their emotional and physical symptoms. The health care professional might also use exposure-based cognitive behavioral therapy by having the person with PTSD recall their traumatic experiences using images or verbal recall while using the coping mechanisms they learned. Individual or group cognitive behavioral psychotherapy can help people with PTSD recognize and adjust trauma-related thoughts and beliefs by educating sufferers about the relationships between thoughts and feelings, exploring common negative thoughts held by traumatized individuals, developing alternative interpretations, and by practicing new ways of looking at things. This treatment also involves practicing learned techniques in real-life situations. Intensive exposure therapy, which often involves multiple extensive sessions over several days followed by several weekly sessions over six months or more, is an evidence-based treatment that has been found to help people who have chronic PTSD. The Veterans Administration has invested in expanding the availability of this treatment to the people it serves.
Eye-movement desensitization and reprocessing (EMDR) is a form of cognitive therapy in which the health care professional guides the person with PTSD in talking about the trauma suffered and the negative feelings associated with the events, while focusing on the professional's rapidly moving finger during one-on-one treatment sessions. While some research indicates this treatment may be effective, it is unclear if this is any more effective than cognitive therapy done without the use of rapid eye movement.
Helping PTSD sufferers maintain their employment and other tasks of their daily lives is an important part of treatment. Occupational therapy (OT) is an important treatment modality in that regard, in that it focuses on rehabilitation and recovery through participation in activities. This can range from assisting helping people with PTSD regain independence in basic self-care to helping them reintegrate into previously held work and community roles. Another potentially powerfully positive activity-based intervention for individuals with PTSD can be the use of a service dog. Particularly toward the completion of more conventional treatments, service dogs have been found to be effective in improving PTSD suffers' sense of safety, responsibility, optimism, and self-awareness.
Families of PTSD individuals, as well as the sufferer, may benefit from family counseling, couples counseling, parenting classes, and conflict-resolution education. Family members may also be able to provide relevant history about their loved one (for example, about emotions and behaviors, drug abuse, sleeping habits, and socialization) that people with the illness are unable or unwilling to share.
Directly addressing the sleep problems that can be part of PTSD not only helps alleviate those problems but thereby helps decrease the symptoms of PTSD in general. Specifically, rehearsing adaptive ways of coping with nightmares (imagery rehearsal therapy), training in relaxation techniques, positive self-talk, and screening for other sleep problems can be helpful in decreasing the sleep problems associated with PTSD.
Medications that help PTSD sufferers include serotonergic antidepressants (SSRIs), like fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), and medicines that help decrease the physical symptoms associated with illness, like prazosin (Minipress), clonidine (Catapres), guanfacine (Tenex), and propranolol. Individuals with PTSD are much less likely to experience a relapse of their illness if the person continues antidepressant treatment for at least a year. SSRIs are the first group of medications that have received approval by the U.S. Food and Drug Administration (FDA) for the treatment of PTSD. Treatment guidelines provided by the American Psychiatric Association describe these medicines as being particularly helpful for people whose PTSD is the result of trauma that is not combat related. SSRIs tend to help PTSD sufferers modify information that is taken in from the environment (stimuli) and to decrease fear. Research also shows that this group of medicines tends to decrease anxiety, depression, and panic. SSRIs may also help reduce aggression, impulsivity, and suicidal thoughts that can be associated with this disorder. For combat-related PTSD, there is more and more evidence that prazosin can be particularly helpful. Although other medications like duloxetine (Cymbalta), bupropion (Wellbutrin), venlafaxine (Effexor), and desvenlafaxine (Pristiq) sometimes treat PTSD, little research has studied their effectiveness in treating this illness.
Other less directly effective but nevertheless potentially helpful medications for managing PTSD include mood stabilizers like lamotrigine (Lamictal), tiagabine (Gabitril), and divalproex sodium (Depakote), as well as mood stabilizers that are also antipsychotics, like risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), asenapine (Saphris), and paliperidone (Invega). Antipsychotic medicines seem to be most useful in the treatment of PTSD in those who suffer from agitation, dissociation, hypervigilance, intense suspiciousness (paranoia), or brief breaks in being in touch with reality (brief psychotic reactions). The antipsychotic medications are helpful treatment options for managing PTSD when used in combination with an SSRI.
Benzodiazepines (tranquilizers) such as diazepam (Valium) and alprazolam (Xanax) have unfortunately been associated with a number of problems, including withdrawal symptoms, and risks of overdose and addiction, and have not been found to be significantly effective for helping individuals with PTSD.
While disaster-preparedness training is a good idea in terms of improving the immediate physical safety and logistical issues involved with a traumatic event, such training may also provide important preventive factors against developing PTSD. That is as evidenced by the fact that those with more professional-level training and experience (for example, police, firefighters, mental health professionals, paramedics, and other medical professionals) tend to develop PTSD less often when coping with disaster than those without the benefit of such training or experience. People who have experienced trauma but are not members of those professions have been found to be less likely to develop PTSD if they receive imaging exposure and therapeutic processing by trained professionals within a day of the trauma and weekly sessions for at least two weeks thereafter.
There are medications that help prevent the development of PTSD. Some medicines that treat depression, decrease the heart rate, or increase the action of other body chemicals are effective tools in the prevention of PTSD when given in the days immediately after an individual experiences a traumatic event.
A number of factors improve the prognosis (outlook) for people with PTSD. They include personal attributes like above-average cognitive abilities, high self-esteem and optimism, interpersonal abilities like good social skills, problem solving, and impulse control, and external factors like secure attachment, sense of safety, and environmental stability.
Some suggested ways for PTSD patients to cope with this illness include learning more about the disorder as well as talking to friends, family, professionals, and PTSD survivors for support. Joining a support group may be helpful. Other tips include reducing stress by using relaxation techniques (for example, breathing exercises, positive imagery), actively participating in treatment as recommended by professionals, increasing positive lifestyle practices (for example, exercise, healthy eating, distracting oneself through keeping a healthy work schedule if employed, volunteering whether employed or not), and minimizing negative lifestyle practices like substance abuse, social isolation, working to excess, and self-destructive or suicidal behaviors.
Air Force Palace HART
Phone: 800-774-1361
Email: [email protected]
American Love and Appreciation Fund (for veterans)
305-673-2856
Army Wounded Warrior Program
Phone: 800-237-1336 or 800-833-6622
DHSD Deployment Helpline
Phone: 800-497-6261
Marine for Life
Phone: 866-645-8762
Email: [email protected]
Military One Source
Phone: 800-342-9647
http://www.militaryonesource.com/
Military Severely Injured Center
Phone: 800-774-1361
Email: [email protected]
National Center for PTSD
http://www.ptsd.va.gov
802-296-6300
National Coalition Against Sexual Assault
Phone: 717-728-9764
National Alliance for Mentally Ill
Phone: 800-950-6264
National Institute of Mental Health
http://www.nimh.nih.gov
Email: [email protected]
866-615-6464
National Mental Health Association
Phone: 800-969-6642
Navy Safe Harbor
Phone: 800-774-1361
Email: [email protected]
Operation Comfort (for veterans and their families)
Phone: 866-632-7868 (1-866-NEAR TO U)
PTSD Alliance
888-436-6306
http://www.ptsdalliance.org
PTSD Information Hotline
Phone: 802-296-6300
PTSD Sanctuary
Phone: 800-THERAPIST
Rape, Abuse and Incest National Network
Phone: 800-656-HOPE
http://www.rainn.org
U.S. Department of Veterans Affairs
Crisis Line: 800-273-8255
http://www.mentalhealth.va.gov
As the use of the Internet continues to expand, so will Internet psychiatry. This is particularly true given that it may be quite useful in specifically providing access to psychotherapy for individuals with PTSD. Other areas that researchers are targeting to improve recovery for PTSD sufferers include expanding research on eye movement desensitization and reprocessing (EMDR), studying how PTSD can be more specifically treated in various ethnic groups, and discovering how to best prevent people from developing the illness. For military personnel, the more access to care that can be made available and the more comfortable active duty and veteran military men and women can be made to seek those services, the better the outcome that can be expected for service individuals with PTSD.
Lack of sleep and insomnia can be caused by medical conditions or diseases, medications, stress, or pain. The treatment for lack of sleep and insomnia depends upon the cause.
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