Understanding PTSD: A helpful guide for health professionals

Approximately 6% of US adults develop Post-Traumatic Stress Disorder (PTSD) during their lifetime. A sometimes debilitating mental health condition that develops after someone has experienced or witnessed a terrifying, dangerous, or shocking event, PTSD symptoms generally persist for more than one month and include reliving the traumatic event, avoidance of reminders of the experience, and with changes in arousal, mood, and cognition. Let's take a moment to learn what to look for, treatment options, and support for people living with PTSD. 

With PTSD so common, it's essential for health professionals to learn about it and recognize that trauma exposure is a prominent risk factor not only for PTSD but for other mental and physical conditions. For example, African Americans, US Latinos, and Native groups are disproportionately affected by PTSD. Veterans are more likely to experience PTSD than non-veterans, and women are twice as likely than men to develop PTSD due to the unique and often compounded stressors and traumas these groups face, such as combat experiences, systemic discrimination, and gender-based violence. Understanding Post-Traumatic Stress Disorder, recognizing commonly affected groups, and understanding how to treat the condition will empower you to provide exceptional care for your current and future patients. 

The Causes and Risk Factors of PTSD 

There are a variety of traumatic events that can trigger PTSD, along with risk factors that increase the likelihood of developing it.

Causes: 

• Sexual assault 
• Violent assault  
• Intimate partner violence 
• Mass violence (shootings, bombings, terrorism) 
• Racial trauma 
• War and being in combat 
• Natural disasters 
• Childbirth experiences 
• Serious health issues 
• Road accidents 

Risk factors:  

• Feeling intense fear, horror, or helplessness 
• Little or complete lack of social support after a traumatic event 
• Getting injured  
• Seeing others get hurt or killed 
• Previous traumatic experiences, especially as a child 
• Additional stressors after the event, such as the death of a loved one, injury, or loss of a home or job 
• Personal or family history of substance use or mental illness  

Signs and Symptoms of PTSD  

Post-Traumatic Stress Disorder symptoms fall into four main symptom categories: re-experiencing/intrusion, avoidance, hyperarousal, and negative changes in mood and cognition. When patients relive their traumatic experiences, they often re-experience symptoms, including emotional distress, distressing thoughts, nightmares, flashbacks, or recurring memories or dreams of the event. Patients are transported back to their trauma and relive it vividly through these intrusive memories. 

If you're reliving a traumatic event, you'd more than likely want to avoid all reminders of it. Likewise, patients with PTSD often do their best to avoid the places, people, activities, things, events, thoughts, and feelings that trigger their memories of the event.  

Changes in arousal and reactivity symptoms are common and include irritability, angry outbursts, engaging in reckless or self-destructive behavior, being easily startled, having difficulty concentrating and sleeping, being hypervigilant, and being suspicious of surroundings. 

Alterations in mood and cognition define the last category of symptoms. Patients often find it difficult to recall important details of the traumatic event. They may have negative emotions and thoughts about it, leading to self-blame, blaming others, and trust issues. Feelings such as shame, anger, guilt, detachment, and fear may also manifest, along with a reduced interest in previously enjoyed activities and an inability to feel positive emotions.  

Aside from those four main categories of symptoms, there are additional physical symptoms that patients with PTSD often experience, such as a rapid heart rate, increased blood pressure, joint pain, nausea, muscle tension, and bodily pain. Your patient may not even realize their pain is related to the traumatic event they experienced. For those with chronic pain, the pain itself can be a constant reminder of the traumatic event, which can lead to their PTSD symptoms intensifying.  

Diagnostic Criteria and Assessment  

Now that you know how PTSD presents, let's take a look at how to diagnose it. According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), the diagnostic criteria are: 

Exposure to actual or threatened death, sexual violence, or serious injury in one or more of the following ways: 

• Experiencing a traumatic event firsthand 
• Witnessing an event in person as it happened to others 
• Finding out that a traumatic event happened to a close friend or family member 
• Indirect exposure to unpleasant details through professional duties (medics, first responders) 
• One or more episodes of re-experiencing symptoms and recurrent intrusions of the event, accompanied by intense distress and physical symptoms  
• One or more avoidance symptoms 
• Two or more arousal and reactivity symptoms 
• Two or more negative mood and cognition symptoms 
• Persists for more than one month 
• Creates functional impairment in social or work settings, or causes distress 
• Must not be attributable to an underlying medical condition, medication, or substance use 

There are also two specifications for PTSD: Dissociative Specification and Delayed Specification. For Dissociative Specification, patients meet the criteria for PTSD diagnosis and experience high levels of depersonalization or derealization in response to trauma-related stimuli. 

• Depersonalization is the feeling of being detached from oneself. Patients may feel as if the experience is not happening to them. Instead, they may feel they're in a dream or outside their bodies observing what's happening. 
• Derealization is the feeling of detachment from one's environment. Patients may feel that their surroundings are distorted, unreal, or distant from them. 

The full diagnostic criteria for PTSD aren't met until six months after the trauma in the Delayed Specification, although symptoms may begin immediately.  

Complex PTSD (C-PTSD or CPTSD) is not a diagnosis recognized in the DSM, but there are discussions about whether it should be a newly added diagnosis. The difference between PTSD and C-PTSD is related to how long a patient is exposed to trauma. C-PTSD is due to prolonged trauma such as long-term child physical or sexual abuse, domestic violence, human or sex trafficking, war, slavery, or constant community violence. In addition to PTSD symptoms, patients may also experience severe issues with their identity, sense of self, emotional regulation, and relationships. 

A thorough assessment is essential for accurately diagnosing PTSD in order to distinguish it from other trauma and stressor-related disorders, such as Acute Stress Disorder, which resolves in less than one month.

There are a variety of assessment tools and techniques useful in diagnosing PTSD. Some are used by clinicians while interviewing patients, and others are self-reporting instruments. They're used not only when initially diagnosing the condition but throughout treatment to gauge progress and guide treatment decisions. If you'd like to learn more about the specific assessment measures and techniques available, check them out here. 

Treatment Options for PTSD  

There are specific therapy techniques, medications, and alternative options available to treat PTSD, whose goal is to help patients regain a sense of control over their lives and find healthy coping mechanisms. These approaches include: 

• CBT (Cognitive Behavioral Therapy) aims to help patients reframe thoughts and feelings and change behavioral patterns that cause functional difficulties. 
• EMDR (Eye Movement Desensitization and Reprocessing) patients view their traumatic memories less negatively by recounting their experiences and answering questions while moving their eyes in a pattern similar to that of REM sleep. 
• Prolonged Exposure Therapy repeatedly exposes patients to their triggers in a safe and monitored way, helping patients confront their fears, learn to control their fears, and acquire coping strategies. 
• Cognitive Processing Therapy is specifically for PTSD treatment and focuses on altering negative emotions and beliefs caused by trauma. Therapists help patients confront difficult feelings and memories.
• Group Therapy brings together survivors of similar traumatic situations to share their emotions and experiences, demonstrating to patients that others may have reacted similarly and helping patients to feel less isolated.

Other PTSD treatment options include medications such as antidepressants and anti-anxiety medications, which help treat depression and anxiety, which may coexist with PTSD. Prazosin is also used to reduce nightmares in people with PTSD. Complementary and alternative techniques include acupuncture, animal-assisted therapy, and yoga. 

Supporting Individuals with PTSD  

Leading with empathy and understanding when treating a patient with PTSD is crucial. The human being in your care is dealing with distress due to one or many traumatic experiences. Creating a safe space with support for people living with PTSD is a critical part of cultivating a solid therapeutic relationship. 

Trauma-informed care is an integral part of ensuring that people who have PTSD feel safe and supported. The principles of this approach to care include safety, trustworthiness, patient empowerment, choice, and collaboration.  

• Safety: Ensure the emotional/physical safety of the patient and demonstrate that you are a safe person for them to seek help from by respecting their privacy, listening, and being empathetic. 
• Trustworthiness: Be transparent about how care will be provided, offer details about treatment, answer questions, and obtain consent for each part of care.
• Patient empowerment/choice: Provide clear information about treatment options to empower patients to make decisions regarding their care.
• Collaboration: Maximize collaboration between the patient, staff, and their support systems (family, friends, partners) so there's a greater sense of security.

As a health professional working with people who have experienced trauma, you also have to provide yourself with self-care, recognize the symptoms of burnout, maintain a work-life balance, be mindful of your triggers, and seek professional help if you need it. Remember, caregivers deserve care too! 

PTSD in Special Populations  

There are specific populations to keep at the forefront of your mind when working with trauma survivors. PTSD in veterans and those currently serving in the military, children and adolescents, and survivors of sexual assault or domestic violence require unique considerations and can present with treatment challenges. 

Veterans and active military have a unique set of trauma and risk factors that can lead to PTSD, such as military sexual trauma (sexual assault that occurred while on or off duty). Veterans who were deployed compared to those who weren't during the same service period are three times more likely to have PTSD. Other factors that contribute to PTSD development are the location of the war, the type of enemy fought, politics surrounding the war, as well as military occupation. Veterans often have difficulty receiving treatment due to barriers to access, such as remote treatment locations for care, as well as stigma within the military. Some feel that mental illness is a sign of weakness and refuse care. Increasing access through telehealth and working to destigmatize mental illness among this population has helped get veterans the care they need. 

PTSD in children and adolescents can have its own set of symptoms aside from the ones outlined above. Children under the age of six can act out the traumatic event during playtime, wet the bed even though they are toilet trained, be extremely clingy, or even forget or be unable to talk. Older kids and teens are more likely to show symptoms like those observed in adults, but they may also become disrespectful, disruptive, destructive, feel guilty, or have thoughts of revenge. Medication approaches in children are not as effective as in adults and are generally not recommended as a first-line treatment. Instead, they tend to be reserved for children with severe symptoms or as a treatment option for when children are older. 

PTSD in sexual assault and domestic violence survivors has additional symptoms to consider as well. Aside from primary PTSD symptoms, these patients may also have physical health concerns such as chronic pelvic pain, arthritis, digestive issues, seizures, and intense premenstrual symptoms. They are also statistically at higher risk for contracting a sexually transmitted infection (STI), leading to additional emotional and physical issues. Treatment of PTSD in sexual assault survivors is challenging because patients often reject medication and struggle with blaming themselves for the assault. Early social support and a supportive environment are associated with a successful recovery. 

Aggression and violence between intimate partners can also cause PTSD. Domestic violence includes physical violence, sexual violence, threats of sexual abuse, emotional abuse, and stalking. Getting support for PTSD due to domestic violence can be challenging because it causes feelings of shame and low self-esteem. Violent partners may also keep the person isolated or threaten them if they seek support. A careful approach is recommended so that patients who have experienced domestic violence are willing and able to receive treatment.

Preventing PTSD and Early Intervention  

Not every person who experiences a traumatic event develops PTSD. There are a variety of resilience factors that can reduce the likelihood of developing this disorder, including: 

• Reaching out to family, friends, or support groups for help 
• Talking about the traumatic event with loved ones 
• Accepting one's responses to a traumatic event 
• Developing coping strategies for navigating traumatic experiences 
• Being capable of managing upsetting situations even while feeling fear
• Believing you can heal from the trauma 

Recognizing early signs of trauma and providing timely intervention can help with preventing PTSD. Early signs include denial, anger, fear, sadness, difficulty concentrating, headaches, and fatigue. Aside from recognizing those early signs, education, and PTSD awareness campaigns are important in reducing stigma and providing mental health support.

Conclusion  

Recognizing PTSD and understanding that there are many types of trauma is profoundly important, and experiencing trauma doesn't mean that someone will develop PTSD. However, if they're experiencing intrusive, hyperarousal, reactivity symptoms and changes in mood and cognition for more than a month, seeking help from a health professional is crucial. As you encounter patients with PTSD, make sure to use a trauma-informed approach, be an active, engaged listener, and express empathy. And as a health professional, make sure to stay up to date with new research so you can always provide optimal patient care.

References 

• https://www.ptsd.va.gov/understand/common/common_adults.asp  
• https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd  
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9180718/  
• https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd  
• https://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd  
• https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/overview/   
• https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967
• https://www.ptsd.va.gov/professional/treat/essentials/dsm5_ptsd.asp  
• Ganti, Latha; Kaufman, Matthew S.; and Blitzstein, Sean M. First Aid for the Psychiatry Clerkship, Fifth Edition. New York: McGraw-Hill Education, 2018
• https://www.ncbi.nlm.nih.gov/books/NBK207191/box/part1_ch3.box16/  
• https://my.clevelandclinic.org/health/diseases/24881-cptsd-complex-ptsd  
• https://www.apa.org/ptsd-guideline/assessment  
• https://www.ptsd.va.gov/professional/assessment/list_measures.asp  
• https://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy  
• https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf  
• https://www.ptsd.va.gov/understand/common/common_veterans.asp  
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• https://www.ncbi.nlm.nih.gov/books/NBK559140/  
• https://www.verywellmind.com/symptoms-of-ptsd-after-a-rape-2797203  
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323517/  
• https://www.ptsd.va.gov/understand/types/violence_ipv.asp  
• https://www.cstsonline.org/research/active-research-studies