Post-Traumatic Stress Disorder and Traumatic Brain Injury
Post-traumatic stress disorder (PTSD) has rightfully earned a reputation as one of the most serious and debilitating of psychiatric conditions. Since its emergence to public prominence in the aftermath of the Vietnam War, to the recognition that millions of victims of sexual and physical abuse suffer from the disorder, Americans and in particular the U.S. military have never been more aware of PTSD. The American Psychiatric Association has defined it as a disorder typified by emotional and anxiety issues suffered in the aftermath of some stressful experience, in which sufferers experience such symptoms as depression, loss of emotional response, anxiety, loss of memory, and loss of interest in the normal activities of life (Bentley, 2005). It is moreover typified by patients undergoing a process of re-experiencing the traumatic events which initiated the disorder. So individuals with PTSD are prone to having flashbacks, disturbing dreams, and periodic recollections of their traumatic experiences (Blanchard et al., 1996). As a result, people with PTSD will exhibit an active avoidance of the thoughts and reminders which stir these distressing flashbacks (Bentley, 2005).
The DSM-IV divides these characteristic symptoms of PTSD into 6 criteria, from Criterion A to Criterion F. Criterion A refers to the traumatic experience itself, which involves both the stressful event and the sense of helplessness and fear that the individual experienced as a result (Breslau, 2002). Criteria B and C refer to the pattern of having flashbacks and to the emotional numbness that patients feel, respectively. Criterion D is defined by the individual showing signs of “excessive arousal”, such as hypervigilence and exaggerated startle (Breslau, 2002). The DSM-IV further describes Criterion E in terms of
the length of time in which these symptoms have been exhibited, and that for the purposes of diagnosing PTSD, they should last at least one month (Breslau, 2002). Finally, Criterion F states that the symptoms and level of impairment the patient suffers must be of clinical significance for the disorder to be diagnosed (Breslau, 2002).
Of course, underlying the symptoms of PTSD is a neurological basis for the disorder. As Liberzon et al. (1999) argue, the limbic regions of the brain, which includes the amygdala, hypothalamus, thalamus, and hippocampal formation, are particularly pertinent in explaining the development of PTSD. This is because these regions of the brain are linked with memory formation as well as the regulation of emotions (Liberzon et al., 1999). Thus, brain imaging research on individuals with PTSD has shown that when exposed to stimuli related to their traumatic experiences, these limbic regions such as the amygdala were activated (Liberzon et al., 1999). That is, precisely those parts of the brain connected to memory and emotion were active during exposure to trauma-related stimuli. Other research has shown that another limbic region, the anterior cingulated cortex, which is involved in both emotion and impulse regulation as well as with autonomic functions like heart rate and blood pressure experiences decreased activity during exposure to traumatic stimuli in PTSD patients (Hopper et al., 2007). This decreased activity may be implicated in the failure of the anterior cingulated cortex to regulate both the emotions and the physiological response characteristic of a flashback episode.
These neuropsychological processes, and hence the onset of PTSD, occur in the aftermath of traumatic experiences. But the precise nature of the precipitating trauma can vary enormously, depending upon the individual, their personal history, and their co morbidity of other psychiatric disorders (Breslau, 2002). Interestingly, there are gender differences in the propensity for developing PTSD. Women are twice more likely to develop this psychiatric condition after experiencing a trauma than men (Breslau, 2002). This is even the case when rape is excluded as a precipitating trauma for the condition. At the same time, while women are more likely than men to develop PTSD after a traumatic experience, men are more likely to experience the types of violence that are known to cause this disorder (Breslau, 2002). In addition, because of the concentration of violence among civilians in inner-cities and among the young, minority and younger demographics are at heightened risk.
Of course, PTSD first came to be recognized by the psychiatric community as a high percentage of Vietnam War veterans showed symptoms of the disease in the 70’s and 80’s. In fact, according to one estimate, perhaps at least 500,000 of the returning soldiers from Vietnam suffered from PTSD (Bentley, 2005). Soldiers in subsequent conflicts, including the Persian Gulf War, Afghan War, and Iraq War have also suffered from high rates of this disorder and there are perhaps another 300,000 veterans of these conflicts with diagnosed or undiagnosed PTSD (Kors, 2008). Members of the military, particularly those who have served in combat, can develop the condition in response to specific incidents such as a mortar attack, IED explosion, or the death of a comrade, but they can also manifest PTSD in response to the prolonged stress and exposure characteristic of duty in a warzone (Kors, 2008).
Soldiers who suffer from PTSD quite often also have undergone traumatic brain injuries (TBI) as well. Veterans from Operation Iraqi Freedom and Operation Enduring Freedom were subject to unconventional weapons like IED’s and hence suffered from high rates (ranging from 5-23% in clinical studies) of TBI injuries (Vasterling et al., 2009). Screening conducted of soldiers with traumatic brain injuries has shown that they suffer disproportionately from PTSD. Studies have shown that approximately 10% of all soldiers with even mild brain injuries or MTBI tested positive for the psychiatric disorder. Moreover, when only soldiers who suffered from loss of consciousness from their brain injuries were screened, fully 44% were diagnosed with PTSD (Vasterling et al., 2009). Traumatic brain injuries may contribute to the development of PTSD by weakening the brain’s executive ability to regulate memories and emotions. In neuropsychological terms, to the extent that the limbic regions of the brain are implicated in the psychiatric disorder, it may be that damage to another cerebral region, the medial prefrontal cortex, may help exacerbate PTSD (Vasterling et al., 2009). This is because the medial prefrontal cortex has been found to play a role of counterbalancing and inhibiting the activity of the limbic system (Vasterling et al., 2009). So, damage to this part of the brain responsible for controlling the limbic regions may worsen an individual’s ability to regulate mood and recollections and hence exacerbate their PTSD.
In addition, TBI causes other neurological defects, and can cause impaired working memory, a loss of fine motor skills, and reduced intellectual capacity and problem solving ability (Vasterling et al., 2009). The more severe the TBI is the longer-lasting these cognitive effects will be. So, while most soldiers as well as civilians who experience traumatic brain injuries will require relatively quickly, up to 20% of those who suffered even mild injuries will still suffer mental effects a year afterwards (Vasterling et al., 2009). Commonly soldiers will have memory loss in the immediate hours after their TBI. Evidence suggests that if this loss of memory function lasts long enough, such as more than a day, after their injury that this may prevent the development of a clear recollection of their experience. This in turn can impact the likelihood of them developing PTSD (Vasterling et al., 2009).
But members of the U.S. military are not the only demographic group susceptible to developing PTSD. PTSD can also be triggered as a result of physical assault and criminal violence, such as that which is most common in the inner-city. For example, one study of PTSD among residents of Detroit found that the precipitating traumas including shootings, stabbings, muggings, and witnessing someone else being victimized (Breslau et al., 1998). Of the various stressors studied, assaultive violence was most likely to lead to PTSD. But even the death of family and friends can precipitate the disorder, as can simply learning about a trauma that a loved one has undergone (Breslau et al., 1998). In addition, childhood traumas, including cumulative traumas over many years, are also common causes of PTSD. Children who experience physical or sexual abuse or even simply neglect and parental abandonment may experience this psychiatric disorder (Cloitre et al, 2009).
Some researchers and practitioners in psychiatry and social work also argue for broader definitions of PTSD. Specifically, while the previous traumas described as causing the condition are potentially life-threatening in nature, these researchers suggest that less dangerous incidents, when experienced repeatedly can also cause PTSD (Seides, 2010). The principle underlying this theoretical approach is that different people have distinct cognitive resources to draw upon. Under the cognitive theory of stress and coping, some patients may simply not have sufficient coping skills to handle, for example, such stressors as repeated verbal abuse (Seides, 2010). If this view is correct, it may well be that PTSD is most commonly the product of the inability to cope with long-term social stressors like abuse by family members and co-workers than it is the consequence of life-threatening acts of violence (Seides, 2010).
Regardless of the origin of an individual’s PTSD, social workers, psychiatric professionals, and other mental health practitioners have developed several treatment methods to ameliorate the disorder. The first and perhaps most popular of these treatment alternatives is exposure therapy (Taylor et al., 2003). Exposure therapy was developed in recognition of the fact that individuals with PTSD are characterized by an avoidance of the stimuli and thoughts related to their trauma. So, this type of therapy provides patients with imaginal exposure, in which they are guided through active recollection of their traumatic experiences (Taylor et al., 2003). The intention is to have the patient emotionally process their pathological memories (Jaycox et al., 1998). In addition, by exposing patients to thoughts as well as to stimulus cues to the trauma, they will be able to become habituated to them (Taylor et al., 2003). For example, patients who suffered through an assault at a particular environment may be taken either to that location or to a similar location in order to both emotionally process their pathological memories and to become habituated to what these environmental stimuli (Taylor et al., 2003).
Another treatment method is to provide relaxation training to patients. Patients are guided through breathing exercises, meditation and muscle relaxation (Bryant, 2006). For example, they are directed to slowly reduce their rate of breathing to ten breaths per minute. One downside of this form of treatment is that the relaxation techniques themselves can induce recollections of the trauma. But the rationale behind relaxation training is that it can reduce the intensity of the symptoms of PTSD (Taylor et al., 2003). In addition, it can help attenuate the degree of hyper-vigilance and arousal that individual’s with the disorder typically exhibit.
PTSD has also been treated using a technique known as eye movement desensitization and reprocessing (EMDR) (Taylor et al., 2003). Like in exposure therapy, patients with PTSD are directed to recollect their trauma (i.e. experience imaginal exposure). They are also encouraged to free associate with respect to their experiences, even as the practitioner uses rhythmic oscillations, such as finger moving from side to side, directly in view of the patient (Taylor et al, 2003). The technique is supposed to reduce the stress response and pathologies associated with the traumatic memories.
Meanwhile, some therapists use cognitive therapy to treat patients with PTSD. Cognitive therapy has been found to be particularly useful with individuals before they have undergone exposure therapy (Bryant, 2006). This is simply because undergoing the imaginal exposure and stimuli involved in the latter form of treatment may be too distressing to some patients. These individuals may benefit from cognitive therapy, in which they discuss their condition with a therapist and are encouraged to recognize that they have control over their thoughts and emotions (Bryant, 2006). Cognitive therapy can help PTSD patients understand that that they can eventually change their beliefs, even if that step is only taken later, such as after exposure or EMDR therapy.
In addition, a more recent treatment alternative for PTSD has been developed known as acceptance and commitment therapy. Acceptance and commitment treatment was developed as part of cognitive behavioral therapeutic tradition (CBT) to specifically tackle the avoidance behaviors that PTSD patients manifest, as they seek to keep away thoughts, memories, and stimuli related to their personal traumas (Twohig, 2008). In addition, this form of therapy is meant to treat the substance abuse problems that many patients develop. Patients are led to be mindful and accepting of their thoughts and emotions instead of seeking to repress and control them (Twohig, 2008). At the same time, PTSD patients are taught that their personal identities (which are referred to as self-as-context) are distinct from their thoughts and emotions. This means that they are then able to detach themselves from and be able to mentally process the pathological behaviors and moods of their disorder, and so able to gradually change them. Acceptance and commitment therapy may be especially valuable for those patients who have tried but failed to improve following traditional methods like exposure therapy (Dewane, 2011).
Finally, beyond these treatment alternatives, veterans and other patients who have had PTSD need to be rehabilitated and reintegrated into society. Psychosocial rehabilitation involves providing patients with the education they need to provide care for themselves and to lead independent lives after undergoing successful treatment for PTSD (Penk et al., 2011). For example, individuals in the VA system are given training, housing, education, and peer-counseling to assist them in redeveloping a sense of personal agency and to become fully functioning in civilian life (Penk et al., 2011). Moreover, psychosocial rehabilitation integrates treatment for other co morbid conditions, including other mental disorders, suicide ideation, and substance addictions, to help individuals overcome their traumas. The development of psychosocial rehabilitation, along with CBT treatments like acceptance and commitment therapy are indicative of the progress that researchers and practitioners alike are making in understanding PTSD and related psychiatric conditions and with treating it. In addition, a better understanding of the relationship between PTSD and TBI is helping veterans from recent conflicts like Operation Iraqi Freedom and Operation Enduring Freedom to recover from their traumas and become independent contributors to society. As society becomes more aware of this psychiatric disorder and more understanding of the difficult course that active-duty soldiers, veterans, and civilians alike may undergo during their recovery, patients with PTSD have better prospects than ever before.
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