Post traumatic stress disorder

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]

Early cases of the disorder were recognized after World War I, including individuals treated by Sigmund Freud. The diagnosis was removed from DSM-II, which resulted in the inability of Vietnam veterans to receive benefits for this condition. In part through the efforts of Chaim F. Shatan, who coined the term post-Vietnam Syndrome, the condition was added to the DSM-III as post traumatic stress disorder.^[1]

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…”^[2]

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.^[3] A psychiatry professor recounts an interview with a veteran who reported to a VA medical center after he had received a leaflet listing PTSD symptoms and encouraging affected veterans to apply for compensation. During the interview, the veteran complained to the psychiatrist of “survivor quilt.” Asked what that was, he replied, “I don’t know, Doc, but I’ve got it bad.” It transpired that the leaflet had misprinted “survivor guilt” as “survivor quilt” and the veteran had quoted that symptom in his campaign to win PTSD compensation.^[4]

The matter of malingering is addressed by Brunet et al.,^[5] who conclude that “All mental disorders are prone to malingering when there are secondary gains, and PTSD is no exception. However, in the case of PTSD, the reverse is also true”: PTSD is often under-reported due to fear of associated stigma, a fear that is particularly high among emergency service workers and military personnel, and in societies where the traumatic event (e.g., sexual assault) may be associated with stigma.

While PTSD-like symptoms have been recognized in combat veterans of many military conflicts, the modern understanding of PTSD dates from the 1980s. Reported cases of combat-related PTSD from Operation Enduring Freedom and Operation Iraqi Freedom are being compiled in ePluribus Media’s PTSD Timeline.

Veterans Affairs Canada (VAC) is a new program including rehabilitation, financial benefits, job placement, health benefits program, disability awards and family support.^[6]

If an individual suffering from PTSD commits a crime, there may be uncertainty about whether the individual can be held responsible for that act. In extreme cases, the defense of automatism, where the defendant was unable to control his actions, may be available. PTSD may produce an internal defect of reason within the meaning of the M’Naghten Rules (which defines the mental disorder defence in some criminal jurisdictions). The difference is that whereas defenses that rely on automatism result in an acquittal, since no guilt can be assigned to a party unable to control their actions; insanity or mental disorder leaves the “offender” available for sentencing by the court. In the event that a death has resulted, diminished responsibility may be available as an alternative to insanity. This defense reduces what would otherwise have been murder to manslaughter. In the specific instance of spousal abuse, this is often called battered woman syndrome and, more generally, the abuse defense in the U.S.

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 begun to engage the issue in their work. An important breakthrough in this was the publication of Maus: A Survivor’s Tale (1972) by Art Spiegelman. There is now a genre of art that focuses on, exposes, and comments on survivors and survivor-tales. Some want to see art as part of a process of healing, and in this they work in a manner akin to art therapy or the older twentieth century notion of art psychology. There are others who resist the implicit mandate that art should be put into the service of psychological repair. These artists tend to work in a direction that links trauma to questions of memory, identity and politics.

Many movies 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.

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.^[7] 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.^[8]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• PTSD can follow a natural disaster such as a flood or fire, or events such as:

• Assault
• Domestic abuse
• Prison stay
• Rape
• Terrorism
• War

• For example, the terrorist attacks of September 11, 2001 may have caused PTSD in some people who were involved, in people who saw the disaster, and in people who lost relatives and friends.

• Veterans returning home from a war often have PTSD.

• The cause of PTSD is unknown. Psychological, genetic, physical, and social factors are involved. PTSD changes the body’s response to stress. It affects the stress hormones and chemicals that carry information between the nerves (neurotransmitters).

• It is not known why traumatic events cause PTSD in some people but not others. Having a history of trauma may increase your risk for getting PTSD after a recent traumatic event.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Post traumatic stress disorder must be differentiated from other diseases such as acute stress disorder, anxiety disorder, major depressive disorder, and personality disorders.^[1]

• Acute stress disorder
• Adjustment disorders
• Anxiety disorders
• Conversion disorder
• Dissociative disorders
• Major depressive disorder
• Obsessive-compulsive disorder
• Personality disorders
• Psychotic disorders
• Traumatic brain injury^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.^[1]

PTSD may be experienced following any traumatic experience, or series of experiences which satisfy the criteria and that do not allow the victim to readily recuperate from the detrimental effects of stress. The National Comorbidity Survey Report provided the following information about PTSD in the general adult population: The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.^[2]

In recent history, the Indian Ocean Tsunami Disaster, which took place December 26, 2004 and took hundreds of thousands of lives, the September 11, 2001 attacks on the World Trade Center and The Pentagon, and the impact and effects of Hurricane Katrina 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.

Other agencies, such as the National Meditation Center for World Peace, have created similar special programs. The NMC trains agencies such as crisis centers NGOs and works with international agencies to prevent trauma to children.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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• Alcohol abuse or other drug abuse
• Depression
• Panic attacks

There are chances of a good outcome with:

• Early diagnosis
• Prompt treatment
• Strong social support

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