Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD), like acute stress disorder, is characterized by the appearance of symptoms immediately after a traumatic event. Therefore, in patients with posttraumatic stress disorder, there are always new symptoms or changes in symptoms that reflect the specific trauma.

Although patients with posttraumatic stress disorder give a different level of significance to the event, they all have symptoms related to trauma. A psychotraumatic event leading to the development of post-traumatic stress disorder usually involves experiencing a threat of own death (or trauma) or the presence of death or injury to others. Experiencing a traumatic event, people who develop post-traumatic stress disorder should experience intense fear or horror. Such experiences can be both with a witness, and with a victim of an accident, a crime, a battle battle, an attack, theft of children, a natural disaster. Also, post-traumatic stress disorder can develop in a person who has learned that he is suffering from a fatal disease, or experiencing systematic physical or sexual abuse. There is a direct correlation between the severity of psychological trauma, which in turn depends on the degree of threat to life or health, and the likelihood of developing post-traumatic stress disorder.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

What causes post-traumatic stress disorder?

It is believed that sometimes post-traumatic stress disorder occurs after an acute reaction to stress. However, posttraumatic stress disorder can also develop in individuals who, after an ES, have not detected any mental disorders (in these cases, posttraumatic stress disorder is considered a delayed response to an event). Somewhat less often, post-traumatic stress disorder occurs in people who have previously experienced an ES. Due to a repeated minor trauma. At the part of the persons who have transferred acute reaction to stress, posttraumatic stress disorder develops after the transitional period. In this case, the victims after the disaster often formed an idea of the inferiority of human life.

Scientific research of post-traumatic stress disorder is a relatively new trend and, most likely, its significance in forensic psychiatry will increase. There have already been references to post-traumatic stress disorder as psychological harm in cases of stalking. Injuries in childhood, physical abuse and, especially, sexual abuse of children are closely linked to the transformation of the victim into a criminal and an abuser in adulthood. The model of a borderline personality disorder presupposes its immediate causal relationship with a long-term and recurring trauma from the persons performing the basic care of the child in childhood. Such a prolonged and recurrent trauma can strongly affect normal personal development. In adult life, acquired personality disorder may be associated with repeated manifestations of maladaptive or violent behavior, which "re-lose" the elements of trauma experienced in childhood. Such persons can often be found in prison populations.

Some characteristics of post-traumatic stress disorder are correlated with the commission of crimes. Thus, crime is associated with the search for thrills ("addiction to trauma"), the search for punishment in order to alleviate feelings of guilt and the development of co-morbid abuse of psychoactive substances. During "flashbacks" (intrusive repetitive experiences), a person can react very violently to environmental stimuli reminiscent of the original traumatic event. This phenomenon was noted among participants in the Vietnam War and among policemen who can react with violence to some kind of stimulus that reflects the situation "on the battlefield".

How does post-traumatic stress disorder develop?

Because posttraumatic stress disorder, a behavioral disorder resulting from the direct impact of trauma, one must turn to numerous studies of traumatic stress in experimental animals and humans in order to understand its pathogenesis.

Hypothalamic-pituitary-adrenal axis

One of the most frequently detected changes in posttraumatic stress disorder is a disturbance in the regulation of cortisol secretion. The role of the hypothalamic-pituitary-adrenal axis (GGNO) in acute stress has been studied for many years. A lot of information has been accumulated on the effect of acute and chronic stress on the functioning of this system. For example, it was found that although corticotropin releasing factor (CRF), adrenocorticotropic hormone (ACTH) and cortisol increase in acute stress, cortisol release decreases with time, despite the increase in CRF levels.

In contrast to the large depression, characterized by a disturbance of the regulating function of HHNO, posttraumatic stress disorder reveals an increase in feedback in this system.

Thus, in patients with posttraumatic stress disorder there is a lower cortisol level with its usual daily fluctuations and a higher sensitivity of corticosteroid lymphocyte receptors than in patients with depression and mentally healthy individuals. Moreover, neuro endocrinology tests show that in posttraumatic stress disorder there is an increased secretion of ACTH in the administration of CRF and an increased reactivity of cortisol in the dexamethasone test. It is believed that such changes are due to a violation of the regulation of HHGO at the level of the hypothalamus or hippocampus. For example, Sapolsky (1997) argues that traumatic stress through the effect on the secretion of cortisol over time induces hippocampal pathology, and MRI morphometry shows that a decrease in hippocampal volume is observed with posttraumatic stress disorder.

The autonomic nervous system

Since hyperactivation of the autonomic nervous system is one of the key manifestations of posttraumatic stress disorder, studies of the noradrenergic system have been undertaken in this state. With the introduction of yohimbine (alpha2-adrenergic blocker) in patients with posttraumatic stress disorder, immersion in painful experiences ("flashbacks") and panic-like reactions occurred. Positron emission tomography indicates that these effects can be associated with an increase in the sensitivity of the noradrenergic system. These changes can be related to the data on the dysfunction of GnOH, taking into account the interaction of the GGNO and the noradrenergic system.

Serotonin

The most obvious evidence of the role of serotonin in posttraumatic stress disorder is obtained with pharmacological studies in humans. There are also data obtained on models of stress in animals, which also suggest the involvement of this neurotransmitter in the development of post-traumatic stress disorder. It is shown that environmental factors can have a significant effect on the serotonergic system of rodents and anthropoid apes. Moreover, the preliminary data show that there is a connection between the external conditions of the upbringing of children and the activity of their serotonergic system. At the same time, the condition of the serotonergic system with posttraumatic stress disorder remains poorly understood. More research is needed using neuroendocrinology tests, neuroimaging, molecular genetic methods.

Condition-reflex theory

It is shown that posttraumatic stress disorder can be explained on the basis of a conditioned reflex alarm model. With posttraumatic stress disorder, a deep trauma can serve as an unconditional stimulus and can theoretically affect the functional state of the amygdala and associated neuronal circles generating a sense of fear. The hyperactivity of this system can explain the presence of "flashbacks" and a general increase in anxiety. External manifestations associated with trauma (for example, sounds of battle) can serve as conditional stimuli. Therefore, similar sounds by the mechanism of the conditioned reflex can cause activation of the amygdala, which will lead to "flashback" and increased anxiety. Through the ties of the amygdala and the temporal lobe, the activation of the neuron circle generating fear can "revive" the memory traces of a psychotraumatic event even in the absence of appropriate external stimuli.

Among the most promising were studies that studied the intensification of the startle reflex under the influence of fear. As a conditional stimulus, a flash of light or sound was made, they were turned on after an unconditional stimulus was given-an electric shock. An increase in the amplitude of the startle reflex upon presentation of a conditioned stimulus made it possible to assess the degree of influence of fear on the reflex. This reaction seems to involve a neural circle generating fear and described by LeDoux (1996). Although there is some discrepancy in the data obtained, they indicate a possible link between post-traumatic stress disorder and a potentiated fear of a start-reflex. Neuroimaging methods also indicate the involvement of post-traumatic stress disorder disorders related to the generation of anxiety and fear, primarily the amygdala, the hippocampus and other temporal lobe structures.

[10], [11], [12], [13], [14], [15], [16]

Symptoms of Post Traumatic Stress Disorder

Post-traumatic stress disorder is characterized by three groups of symptoms: a constant experience of a traumatic event; the desire to avoid incentives reminiscent of psychological trauma; increased autonomic activation, including an intensified reaction of fright (startle reflex). Sudden painful immersions in the past, when the patient again and again experiences the event as if it happened only now (the so-called "flashbacks") - a classic manifestation of post-traumatic stress disorder. Constant experiences can also be expressed in unpleasant memories, heavy dreams, intensification of physiological and psychological reactions to stimuli, somehow related to psycho-traumatic events. To diagnose posttraumatic stress disorder, the patient must identify at least one of these symptoms, reflecting the constant experience of a traumatic event. Other symptoms of post-traumatic stress disorder include trying to avoid thoughts and actions related to trauma, anhedonia, memory loss to events related to trauma, dulling of affect, feelings of alienation or derealization, feelings of hopelessness.

PTSD is characterized by an aggravation of the instinct of self-preservation, for which the increase and persistence of constantly increased internal psychoemotional stress (excitation) is typical for the purpose of maintaining a constantly functioning mechanism for comparing (incoming) external stimuli with stimuli imprinted in consciousness as signs of ES.

In these cases, an increase in internal psychoemotional stress is noted - hypervigilance (excessive vigilance), concentration of attention, increase in resistance (noise immunity), attention to situations that the individual regards as threatening. There is a narrowing of the amount of attention (a decrease in the ability to keep a large number of ideas in the circle of arbitrary purposeful activity and the difficulty of freely operating them). An excessive increase in attention to external stimuli (the structure of the external field) occurs due to the reduction of attention to the structure of the subject's internal field with the difficulty of switching attention.

One of the significant signs of posttraumatic stress disorder is a disorder that is subjectively perceived as a variety of memory impairments (difficulties in remembering. Holding in memory of one or another information and reproduction). These disorders are not related to the true violations of various memory functions, but are caused primarily by the difficulty of concentrating on facts that are not directly related to the traumatic event and the threat of its recurrence. At the same time, the victims can not recall the important aspects of the traumatic event, which is due to violations that occurred during the acute reaction to stress.

Constantly increased internal psychoemotional stress (excitement) supports a person's readiness to react not only to a real emergency, but also to manifestations that are more or less similar to a traumatic event. Clinically, this manifests itself in an overreaction of fright. Events that symbolize and / or reminiscent of ES (visiting the grave of the deceased on the 9th and 40th day after the death, etc.), there is a subjective deterioration of the condition and a pronounced vasovegetative reaction.

Simultaneously with the above disorders, there are involuntary (without feeling of being made) memories of the most striking events related to ES. In most cases, they are unpleasant, but some people themselves (by effort of will) "evoke memories of ES", which, in their opinion, helps to survive this situation: the events associated with it become less terrible (more common).

Some people with PTSD at times may experience flashbacks, a disorder that manifests itself as involuntary, very vivid ideas about the psnhotravmiruyuschey situation. Sometimes they are difficult to distinguish from reality (these states are close to the syndrome of obscuration of consciousness), and a person at the moment of experiencing a flashback can manifest aggression.

In the course of posttraumatic stress disorder, sleep disorders are almost always detected. The difficulty of falling asleep, as the victims note, is associated with an influx of unpleasant memories of emergencies. There are frequent nocturnal and early wakes with a sense of unreasonable anxiety "probably something has happened." There are dreams that directly reflect a traumatic event (sometimes dreams are so bright and unpleasant that the victims prefer not to fall asleep at night and wait for the morning "to fall asleep calmly").

The constant internal tension in which the victim is located (due to the aggravation of the instinct of self-preservation) makes it difficult to modulate the affect: sometimes the victims can not restrain outbursts of anger even for a minor cause. Although outbreaks of anger can be associated with other disorders: difficulty (inability) to adequately perceive the emotional mood and emotional gestures of others. The victims are also observed alexithymia (inability to translate into the verbal plan experienced by himself and others the emotions). At the same time, there is a difficulty in understanding and expressing emotional halftones (polite, soft refusal, alert sympathy, etc.).

In persons suffering from post-traumatic stress disorder, emotional indifference, lethargy, apathy, lack of interest in the surrounding reality, a desire to have fun (anhedonia), a desire to learn new, unexplored, and a decrease in interest in previously significant activity can occur. The victims, as a rule, are reluctant to talk about their future and most often perceive it pessimistically, without seeing the prospects. They are irritated by big companies (except for those who suffered the same stress as the patient himself), they prefer to remain alone. However, after a while they become oppressed by loneliness, and they begin to express dissatisfaction with their loved ones, reproaching them for their inattention and frailty. At the same time, a feeling of alienation and distance from other people arises.

Special mention should be made of the increased suggestibility of the victims. They are easily persuaded to try their luck in gambling. In some cases, the game captures so much that the victims often lose everything up to the allowance allocated by the authorities to purchase new housing.

As already mentioned, with post-traumatic stress disorder a person is constantly in a state of internal tension, which, in turn, reduces the fatigue threshold. Along with other disorders (decreased mood, impaired concentration, subjective memory impairment), this leads to a decrease in efficiency. In particular, when solving certain problems, the victims find it difficult to identify the main one, when they receive the next assignment they can not grasp its basic meaning, they are trying to shift to others responsible decisions, etc.

It should be specially emphasized that in most cases, the victims realize ("feel") their professional decline and for whatever reasons refuse the proposed work (not interesting, does not correspond to the level and the previous social situation, pays little), preferring to receive only unemployment benefits , which is much lower than the proposed salary.

The aggravation of the instinct of self-preservation leads to a change in everyday behavior. The basis of these changes are behavioral acts, on the one hand, aimed at early detection of emergencies, on the other, representing precautions in the eventual re-deployment of a traumatic situation. The precautions taken by the person determine the nature of the transferred stress.

Persons who survive the earthquake tend to sit close to the door or window, so that if necessary, quickly leave the room. They often look at a chandelier or aquarium to determine if an earthquake does not start. Simultaneously, they choose a stiff chair, since the soft seats soften the push and thus make it difficult to capture the moment the earthquake starts.

Victims who suffered a bombing, entered the room, immediately open the windows, examine the room, look under the bed, trying to determine whether it is possible to hide there during the bombing. People who took part in hostilities, entering the room, tend not to sit with their backs to the door and choose a place from which to watch all those present. Former hostages, if they were captured on the street, try not to go out alone and, on the contrary, if the capture occurred at home, not to be left alone at home.

In persons who have been exposed to ES, the so-called acquired helplessness can develop: the thoughts of the victims are constantly busy with the anxious expectation of a repetition of the ES. The experiences associated with the time, and the sense of helplessness that they have experienced in this. This feeling of helplessness usually makes it difficult to modulate the depth of personal involvement in contact with others. Different sounds, smells or situations can easily stimulate the memory of events related to trauma. And this leads to memories of his helplessness.

Thus, in people affected by ES, there is a decrease in the overall level of functioning of the individual. However, a person who survives an emergency situation, in most cases, does not perceive his deviations and complaints as a whole, believing that they do not go beyond the norm and do not require treatment to the doctors. Moreover, the majority of victims consider the existing deviations and complaints as a natural reaction to everyday life and do not connect with the occurred emergency.

An interesting assessment of the victims of the role played in their lives ES. In the overwhelming majority of cases (even if none of the relatives were injured during the emergency, material damage was fully compensated, and housing conditions became better), they believe that the emergency situation had a negative impact on their fate ("the emergency situation crossed out prospects"). Simultaneously, an original idealization of the past (underestimated abilities and missed opportunities) takes place. Usually, in the case of natural disasters (earthquakes, mudflows, landslides), the victims do not look for the guilty ("God's will"), while in anthropogenic disasters, they seek to "find and punish the perpetrators". Although if the microsocial environment (including the victim) refers to "the will of the Almighty" "everything that happens under the moon," both natural and man-made emergencies, a gradual disaggregation of the desire to find the guilty occurs.

However, some of the victims (even if they were injured) indicate that the emergency situation in their lives has played a positive role. They note that they had a reassessment of values and they began to "truly appreciate the life of a person". Their lives after the disaster are characterized as more open, in which a great place is to help other affected and sick people. These people often emphasize that after the disaster, the authorities and the micro-social environment showed concern for them and provided great help, which prompted them to start "social philanthropic activity."

In the dynamics of the development of disorders in the first stage of SDP, the personality is immersed in a world of experiences associated with ES. The individual lives in the world, the situation, the dimensions that took place before the emergency. He seems to be trying to bring back his past life ("return everything as it was"), trying to figure out what happened, looking for the guilty and seeking to determine the extent of his guilt in what happened. If the individual came to the conclusion that the ES is "this is the will of the Almighty," then in these cases, the formation of feelings of guilt does not occur.

In addition to psychiatric disorders, somatic abnormalities also occur in an ES. Approximately half of the cases marked an increase in both systolic and diastolic pressure (by 20-40 mm Hg). It should be emphasized that the marked hypertension is accompanied only by the rapidity of the pulse without deterioration of the mental or physical state.

After psychosomatic disorders, psychosomatic diseases (duodenal ulcer and stomach, cholecystitis, cholangitis, colitis, constipation, bronchial asthma, etc.) are often aggravated (or diagnosed for the first time). It should be specially noted that in women of childbearing age, premature menstruation is often observed ), miscarriages in the early stages of pregnancy. Among the sexological disorders there is a decrease in libido and erection. Often the victims complain of cold snaps and a feeling of tingling in the palms, feet, fingers and toes. Excessive sweating of the extremities and deterioration of nail growth (delamination and fragility). Deterioration of hair growth is noted.

Over time, if a person manages to "digest" the impact of emergencies, memories of a stressful situation become less relevant. He tries to actively avoid even talking about what he has experienced, so as not to "awaken heavy memories." In these cases, sometimes on the forefront are irritability, conflict and even aggressiveness.

The types of response described above are mainly caused by an ES in which there is a physical threat to life.

Another disorder that develops after the transition period is a generalized anxiety disorder.

In addition to an acute reaction to stress, which is usually resolved within three days after an ES, psychotic level disorders, which in the Russian literature are called reaesthetic psychoses, can develop.

The course of post-traumatic stress disorder

The likelihood of developing symptoms, as well as their severity and stamina, are directly proportional to the reality of the threat, as well as the duration and intensity of the injury (Davidson, Foa, 1991). Thus, in many patients who have sustained a prolonged intensive trauma with a real threat to life or physical integrity, acute stressful reactions develop, against which the posttraumatic stress disorder may develop in the course of time. However, in many patients, post-traumatic stress disorder does not develop after acute stressful manifestations. Moreover, the developed form of post-traumatic stress disorder has a variable course, which also depends on the nature of the trauma. Many patients experience complete remissions, while others have only mild symptoms. Only 10% of patients with post-traumatic stress disorder - probably comfort, who suffered the most severe and long-lasting trauma, - are chronic. Patients often face reminders of trauma, which can trigger exacerbation of chronic symptoms.

Diagnostic criteria for post-traumatic stress disorder

A. A person experienced a psycho-traumatic event, in which both conditions took place.

1. A person was a participant or witness of an event accompanied by a real death or its threat, serious physical damage or a threat to physical integrity with respect to himself or others.
2. The person experienced intense fear, helplessness or horror. Note: in children, inappropriate behavior or agitation may occur instead.

B. The psychotraumatic event is the subject of constant experiences that can take one or more of the following forms.

1. Repetitive obsessive oppressive memories of trauma in the form of images, thoughts, sensations. Note: in young children, there may be permanent games related to the trauma experienced.
2. Repeated tormenting dreams, including scenes from the experience. Note: children can have awesome dreams without a certain content.
3. A person acts or feels this way, as if he is experiencing anew a psycho-traumatic event (in the form of revived experiences, illusions, hallucinations or dissociative episodes like "flashback", including at the time of awakening or intoxication). Note: children can repeat the play of episodes of injury.
4. Intensive psychological discomfort in contact with internal or external stimuli, symbolizing or resembling a psychotraumatic event.
5. Physiological reactions in contact with internal or external stimuli, symbolizing or resembling a psychotraumatic event.

B. Constant avoidance of incentives related to trauma, as well as a number of common manifestations that were not present before injury (at least three of the following symptoms are needed).

1. Striving to avoid thoughts, feelings or talk about trauma.
2. Aspiration to avoid actions, places, people capable of recalling trauma.
3. Inability to recall important details of the injury.
4. The expressed restriction of interests and aspirations to participate in any activity.
5. Remoteness, isolation.
6. The weakening of affective reactions (including the inability to experience love feelings).
7. Feeling of hopelessness (absence of any expectations related to career, marriage, children or the duration of the life to come).

D. Permanent signs of increased excitability (absent before trauma), which are manifested by at least two symptoms of the following.

1. Difficulties falling asleep or maintaining sleep.
2. Irritability or outbursts of rage.
3. Violation of concentration of attention.
4. Increased alertness.
5. Reinforced startle reflex.

E. Duration of symptoms specified in criteria B, C, D, not less than one month.

E. The disorder causes clinically pronounced discomfort or disrupts the life of the patient in social, occupational or other important areas.

The disorder is classified as acute if the duration of the symptoms does not exceed three months; chronic - if symptoms persist for more than three months; retarded - if the symptoms manifest no earlier than six months after the traumatic event.

To diagnose post-traumatic stress disorder, it is necessary to identify at least three of the listed symptoms. Of the symptoms of increased activation (insomnia, irritability, increased excitability, reinforced startle reflex), there should be at least two. The diagnosis of post-traumatic stress disorder is made only if the marked symptoms persist for at least a month. Prior to the month, an acute stress disorder is diagnosed. In DSM-IV, there are three types of post-traumatic stress disorder with different course. Acute PTSD lasts less than three months, chronic PTSD lasts longer. Delayed PTSD is diagnosed when its symptoms become apparent six or more months after the injury.

Since severe trauma can cause a whole range of biological and behavioral reactions, the patient who survives it may experience other somatic, neurological or psychiatric disorders. Neurological disorders are especially likely in the case when the trauma implied not only psychological, but also physical impact. The patient who has suffered a trauma often develop affective disorders (including dysthymia or major depression), other anxiety disorders (generalized anxiety or panic disorder), drug addiction. Studies note the relationship of certain mental manifestations of post-traumatic syndromes with premorbid status. For example, post-traumatic symptoms are more likely to occur in persons with premorbid anxiety or affective symptoms than those who have been mentally healthy. Thus, the analysis of premorbid mental status is important for understanding the symptoms that develop after a traumatic event.

[17], [18], [19], [20], [21], [22], [23], [24]

Differential diagnosis

When diagnosing post-traumatic stress disorder, care should be taken - first of all, it is necessary to exclude other syndromes that may appear after trauma. It is especially important to recognize neurologic or somatic diseases that can be treated, which can contribute to the development of symptomatic symptoms. For example, traumatic brain injury, drug addiction or withdrawal symptoms may be the cause of symptoms that occurred immediately after the injury or a few weeks later. The detection of neurological or somatic disorders requires a detailed history, a thorough physical examination, and sometimes a neuropsychological study. With classic uncomplicated posttraumatic stress disorder, the patient's consciousness and orientation do not suffer. If a neuropsychological study reveals a cognitive defect that was not present before the trauma, organic brain damage should be ruled out.

Symptoms of posttraumatic stress disorder can be difficult to distinguish from manifestations of panic disorder or generalized anxiety disorder, since all three states exhibit marked anxiety and increased reactivity of the vegetative system. Important in the diagnosis of posttraumatic stress disorder is the establishment of a temporary link between the development of symptoms and a traumatic event. In addition, with post-traumatic stress disorder, there is a constant experience of traumatic events and the desire to avoid any reminder of them, which is not typical for a panic and generalized anxiety disorder. Post-traumatic stress disorder often has to be differentiated and with great depression. Although these two states can easily be distinguished by their phenomenology, it is important not to miss comorbid depression in patients with PTSD, which may have an important influence on the choice of therapy. Finally, posttraumatic stress disorder should be differentiated with borderline personality disorder, dissociative disorder, or a deliberate imitation of symptoms that may have clinical manifestations similar to PTSD.

[25], [26], [27], [28], [29], [30], [31]