Understanding PTSD

When in danger, it’s natural for a human being to feel afraid. This fear triggers many split-second changes in the body to prepare to defend against the danger or to avoid it. This “fight-or-flight” response is a healthy reaction meant to protect a person from harm. But in post-traumatic stress disorder (PTSD), this reaction is changed or damaged and an individual experiences an altered reaction instead. When people who have or develop PTSD they feel stressed or frightened even when they’re no longer in danger.

PTSD develops after a terrifying traumatic ordeal occurs that involves physical or mental harm, the threat of either and/or having been a witness to such an event. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a friend, loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers.

Although PTSD was first brought to public attention through media in relation to war veterans and the rising occurrence of suicide, it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes (NIMH, 2015).

PTSD in the Workplace

Many individuals who work on the front lines of dealing with the lives of people and the struggles they endure, are at a high risk of developing PTSD. Individuals who work at war and in war torn areas such as our many war vets who give up daily their own lives for the lives we live and health care practitioners as well, who work up front and personal in saving lives of individuals in vulnerable positions who are struck down with trauma of some form. Health care practitioners in particular include paramedics or emergency response personnel, as well as firefighters, authoritative figures such as FBI agents and special intelligence forces, and police.

You spend 30% of your life at work so if you are subjected to a great deal of trauma and death and you have limited and/or poor coping skills, then you may be at risk for the development of PTSD.

Businesses and organizations can intervene a great deal at no cost to help identify and prevent the development of PTSD for many of its workers.

The Etiology of PTSD

            There are various causes of PTSD. Knowing and understanding the causes of PTSD helps health care providers to better identify and care for individuals who may be at risk of developing PTSD. One can develop post-traumatic stress disorder when they go through, witness or learn about an event involving actual or threatened death and/or serious injury or sexual violation (Mayo Clinic, 2015). Although physical, biological, psychological, environmental and spiritual sources can all either precipitate and/or exacerbate the initiation and development of PTSD, it is important to remember that the extent to which an individual develops or experiences PTSD is often dependent on the duration and intensity of the traumatic experience as was previously discussed.

PTSD can occur at any age, including childhood.  Although anyone can get PTSD at any age it is important to remember that not everyone who lives through a dangerous event gets PTSD. In fact, most will not get the disorder. This includes war veterans and survivors of physical and sexual assault, abuse, accidents, disasters, and many other serious events. Although women are more likely to develop PTSD than men, and there is some evidence that susceptibility to the disorder may run in families.

PTSD can also occur as a result of a variety of circumstances and/or experiences with some being more traumatic than others.  Some people get PTSD after a friend or family member experiences danger or is harmed. The sudden, unexpected death of a loved one can also cause PTSD (NIMH, 2015).

Some of these risk or causative factors are present before the trauma and others become important during and after a traumatic event. However, some factors may make you more likely to develop PTSD after a traumatic event (Mayo Clinic, 2015a): The following are just some of these risk factors:

• Experiencing intense or long-lasting trauma
• Having experienced other trauma earlier in life, including childhood abuse or neglect
• Having a job that increases your risk of being exposed to traumatic events, such as military personnel and first responders
• Having other mental health problems, such as anxiety or depression
• Lacking a good support system of family and friends
• Having biological (blood) relatives with mental health problems, including PTSD or depression  (Mayo Clinic, 2015a).

Who is at risk?

Survivors of prior trauma, violence or violent crime (such as physical and sexual assaults, sexual abuse, bombings, riots)  (NIMH, 2015; Ozer et al., 2003). It is important to be cognizant of the fact that intentional acts of interpersonal violence, in particular sexual assault, and combat are more likely to lead to PTSD than accidents or disasters (Creamer et al., 2001; Kessler et al., 1995).

Survivors of accidents and disasters (NIMH, 2015)

Prior adjustment (Ozer et al., 2003)

Family history of psychopathology (Ozer et al., 2003)

Personal history of mental illness (NIMH, 2015)

Perceived life threat (Ozer et al., 2003; Mayou et al., 2002)

Perceived lack of support (NIMH,  2015; Ozer et al., 2003)

Peri-traumatic emotions (Ozer et al., 2003)

Peri-traumatic dissociation (Mayou et al., 2002; Ozer et al., 2003)

Lower income (Mayou et al., 2002)

Younger age (Mayou et al., 2002)

Living through dangerous events and traumas (NIMH, 2015)

Witnessing people getting hurt or killed (NIMH, 2015)

Feeling horror, helplessness, or extreme fear (NIMH, 2015)

Dealing with extra stress after the event, such as loss of a loved one, pain and                                   injury, or loss of a job or home (NIMH, 2015)

Victims of war, torture, state-sanctioned violence or terrorism, and refugees                          (NIMH, 2015).

Refugees (NIMH, 2015)

 

Traumatic health event- women following traumatic childbirth, individuals diagnosed with a life-threatening illness (Gaskell, 2005). People who have experienced threat to their own life or the life of others while in medical care, such as during anaesthesia, complications during childbirth or as a result of medical negligence, are also at risk.

The female gender, in particular, is considered a higher risk category (Mayou et al., 2002; Van Loey et al., 2003). Women are twice as likely to develop posttraumatic stress disorder as men, and children can also develop it (Anxiety and Depression Assoc. of America, 2015). Men tend to experience more traumatic events than women, but women experience higher impact events (i.e. those that are more likely to lead to PTSD (Kessler et al., 1995; Stein et al., 1997). Further, women are more likely to develop PTSD in response to a traumatic event than men; this enhanced risk is not explained by differences in the type of traumatic event (Kessler et al., 1995).

Physical

There are various kinds of physical trauma that can lead to the development of PTSD. This includes individuals who have either been involved in the event themselves, had a friend or loved one in an event, have been witness to the event or have learned about the event. Those of natural origin include events such as hurricanes, fires, tornadoes; volcano eruption and other weather related events as well as the diagnosis of a life-threatening illness and a pandemic of disease that permeates throughout a population. Those of manmade origin often include muggings, robbery, kidnapping, torture, plane crash, violence such as abuse, neglect and crime, childhood neglect and abuse, sexual assault, being threatened with a weapon, combat exposure, motor vehicle accidents and the threat of terrorism or terrorist attacks (Mayo Clinic, 2015; NIMH, 2015). The most common events leading to the development of PTSD are often physical in nature (Mayo Clinic, 2015a). Whether the physical event is naturally occurring or man-made, the result is still devastating to the individual experiencing it.

Psychological

            Psychological trauma and/or harassment are an insidious form of trauma that can lead to the development of PTSD. Being bullied at work or school is also a source of PTSD that can be psychologically rooted. Amongst children it can take the form of bullying that occurs in schools or playgrounds. For adults, it can occur in social circles or at work. At work it is often phrased as horizontal hostility, lateral violence or workplace bullying.

In the school yard or playground setting bullying amongst children is a well recognized issue. Each year millions of children and youth experience the humiliation and devastating effects of bullying. Bullying damages the physical, social, and emotional well-being of its victims. It also hurts the children who bully, as well as those who watch it happen. In fact, bullying creates a climate of fear, callousness, and disrespect for everyone involved. Bullying begins in the preschool years, peaks in early adolescence, and continues, but with less frequency, into the high school years. Although bullying does NOT have to be a part of growing up, its impact can alter how a child grows and develops, mentally and psychologically.

Bullying is a form of emotional or physical abuse that has three defining characteristics as follows” Deliberate—a bully’s intention is to hurt someone; Repeated—a bully often targets the same victim again and again; Power Imbalanced—a bully chooses victims he or she perceives as vulnerable. Bullying occurs in many different forms, with varying levels of severity. It may involve Physical Bullying—poking, pushing, hitting, kicking, beating up, Verbal Bullying—yelling, teasing, name-calling, insulting, threatening to harm and Relational Bullying—ignoring, excluding, spreading rumors, telling lies, getting others to hurt someone (Eyes on Bullying, 2015). All of these forms of bullying are meant to undermine the integrity of one’s own abilities, knowledge, actions, behaviors and intent; as a means to deflate one’s confidence, self-esteem, self-concept and one’s overall sense of mental well-being which creates a great deal of stress for the person experiencing it.

Into adulthood and one’s place of work, bullying sometimes continues. Defined, workplace bullying is the on-going health- or career endangering mistreatment of an employee, by one or more of their peers or higher-ups (Canada Safety Council, 2010). It can be the misuse of power or position that undermines a person’s ability, or leaves them feeling hurt, frightened, angry or powerless. Further, it is the engaging in a course of vexatious comment or conduct against a worker in a workplace that is known or ought reasonably to be known to be unwelcome and the repeated, unreasonable or inappropriate behaviour directed towards a worker, or group of workers, that creates a risk to health and safety (Workplace Mental health promotion, 2013).

As added by Dunn (2003) workplace bullying occurs when there is sabotage directed towards co-workers and/or colleagues who are on the same level or lower level within an organization’s hierarchy. It is behavior that humiliates, degrades or indicates a lack of respect for the dignity and worth of an individual (Rowell, 2008).

Each individual incident of workplace bullying may seem inconsequential but over a period of time, it erodes the self-confidence and self-esteem of the employee (Workplace Mental Health Promotion, 2013).  Bullying also increases the prevalence of various mental disorders amongst nurses who either witnessed or was targeted by it. As Quine (2001) found, significantly higher levels of depression and anxiety occur. McKenna et al. (2003) add that the effects of workplace bullying closely resemble those of post-traumatic stress disorder.

Spiritual

            Spiritually, one can be increasingly predisposed to the development of PTSD as a result of a negative event under some religious or spiritual demise. What often occurs in religious cults is one example. A cult is a group or movement that, to a significant degree, 1. exhibits great or excessive devotion or dedication to some person, idea, or thing; 2. uses a thought-reform program to persuade, control, and socialize members (i.e., to integrate them into the group’s unique pattern of relationships, beliefs, values, and practices); 3. systematically induces states of psychological dependency in members; 4. exploits members to advance the leadership’s goals, and 5. causes psychological harm to members, their families, and the community (Langone, 1993, p. 5). In the fulfillment of their mission or mandate, religious cults are often dangerous and have been well known to allow traumatic events to happen to its membership without any recourse. From rape, incest, seduction, mind-control (Graziano, 1992), members of cults have experienced all sorts of violence under the guise of spiritual guidance.

Another example is what happened to the children who were left in the ‘trustful’ hands of the Roman Catholic Priests and Christian Brothers in Canada and the U.S. in the 1980s and 1990s. Families who instilled much faith in the religious figureheads of Priests and Christian Brothers and the orphanages they ran under “God’s” rule, to care for children when families were unable to so themselves. No one knew anything of the physical, sexual and emotional abuse and neglect that would later befall their children who fell victim to such horrific events and have suffered to this very day as a result of that trauma and the PTSD it left behind.

Biological/genetic

The biological and genetic implications of developing PTSD have been discussed at some length. While many suggest that it can occur as a result of hereditary endowment in the form of personality characteristics (Mayo Clinic, 2015) or as an increased disposition for the development of other mental illnesses such as anxiety and depression (Mayo Clinic, 2015) with one’s own or family history of mental illness increasing the risk of developing PTSD (Anxiety and Depression Association of America, 2015; NIMH, 2015), much discussion on genetics is currently ongoing. At present, many scientists are focusing on genes that play a role in creating fear memories. Understanding how fear memories are created may help to refine or find new interventions for reducing the symptoms of PTSD.

Biologically, there are many measures that can determine the risk with which one can be predisposed or susceptible to the development of PTSD after being involved in, learning about or witnessing a traumatic event. The brain itself holds much power in this regard, as it is our cognitive processing center and houses numerous chemicals in the form of neurotransmitters that are responsible for the development of mental illnesses, such as PTSD.

As indicated in Unit 1, the brain is what regulates the chemicals and hormones released as the body responds to stress (Mayo Clinic, 2015). Studying parts of the brain involved in dealing with fear and stress helps researchers better understand possible causes of PTSD. One such brain structure is the amygdala, known for its role in emotion, learning, and memory. The amygdala appears to be active in fear acquisition, or learning to fear an event (such as touching a hot stove), as well as in the early stages of fear extinction, or learning not to fear (NIMH, 2015). Storing extinction memories and dampening the original fear response appears to involve the prefrontal cortex (PFC) area of the brain, involved in tasks such as decision-making, problem-solving, and judgment. Therefore, our brain not only learns and stores the feared event, but it also triggers how we should best respond given past experiences. Certain areas of the PFC play slightly different roles. For example, when it deems a source of stress controllable, the medial PFC suppresses the amygdala an alarm center deep in the brainstem and controls the stress response. The ventromedial PFC helps sustain long-term extinction of fearful memories, and the size of this brain area may affect its ability to do so (NIMH, 2015). Hence, individual differences in these genes or brain areas may only set the stage for PTSD without actually causing symptoms.

Further, Stathmin, a protein needed to form fear memories is also believed to play a significant role. In one study, mice that did not make Stathmin were less likely than normal mice to “freeze,” a natural, protective response to danger, after being exposed to a fearful experience. They also showed less innate fear by exploring open spaces more willingly than normal mice (NIMH, 2015). Second, GRP (gastrin-releasing peptide), a signalling chemical in the brain released during emotional events, seems to help control the fear response, and lack of GRP may lead to the creation of greater and more lasting memories of fear as what often occurs in PTSD (NIMH, 2015). Third, a version of the 5-HTTLPR gene, which controls levels of serotonin — a brain chemical related to mood- appears to fuel the fear response (NIMH, 2015). Hence, like many other mental illnesses, it is likely that many genes with small effects are at work in PTSD.

Environmental

Everything we do as humans always seems to involve some aspect of environment. As humans, we are often referred to as ‘products of our environment’ where the environment impacts every aspect of our existence and makes us who we are today as living, social beings. There are several aspects of environment that can play a crucial role in causing or increasing our risk to developing PTSD.  These aspects of environment may include our childhood upbringing, our risk taking behaviours that may predispose us to a higher risk of accidents/injury and our occupation or chosen career.

As a child we are all highly vulnerable not only to the environment in which we are raised, but to the adults raising us as well. As children, we lack the cognitive and intellectual capacity to make safe decisions for ourselves; at such a young age we rely upon our environment and caregivers to do what is right to keep us safe and healthy. Hence, we depend on the trust we have in others to do what is right and to keep us out of harm’s way. Physical abuse, neglect and sexual exploitation and/or assault that occurs to children has long reaching effects that significantly impact the normal development of the child in terms of relationships established, trust, boundaries and respect.

Other than parenting, childhood also creates an environment conducive to the development of PTSD, merely as the existence of normal development. Children are playful and physically active, perhaps more so than any other age cohort, which is needed as a normal part of their developmental milestones. Hence, this increased activity and involvement to explore the world places them at an increased risk to incur traumatic injuries to their head or otherwise that can impact the normal development of the child’s brain and therefore, full capacity to ward off stressors in a normal manner (NIMH, 2015).

The job or occupation you hold and the environment in which you employ that role or task can also be responsible for the development of PTSD. For example, the job you perform as a front line responder in the role as military personnel, and emergency responders such as paramedics, police and firefighters and even emergency based nurses places you as a witness in the middle of an accident, natural disaster, violence, and/or criminal activity. Because you are often the first one on the scene when disaster strikes, you see firsthand accounts of natural or man-made disastrous outcomes that can be characterized by death, dismemberment, life-threatening circumstances and obvious human suffering.  Although seen and perceived as heroes in the public eye, even the strongest among us suffer from mental health problems. Firefighters, paramedics and police are asked to respond to the most traumatic situations –accidents, fires, murders. The sights they deal with on a continuous basis would leave most people in shock (Butko, 2014). Whether it is the retrieval of earthquake victims (Sakuma et al., 2015), working as emergency services personnel such as paramedics (Gillespie, Bresler, Gates, & Succop, 2013), or deployment in military combat (Wheeler & Puskar, 2015), the effect of trauma persists. Further, members of the armed forces, police, journalists and prison service, including those no longer in services are also at an increased risk for PTSD (NIMH, 2015).

The Symptamotology of PTSD

PTSD can impact all age groups from children, to adolescents, to adults, and to older adults. There are some common underlying features associated with PTSD that are found across all ages. It is important, however, to remain cognizant of the fact that symptoms may not occur immediately post-event, and could in fact be quite delayed in onset, occurring months or even years after the event occurred. These symptoms generally include anxiety, depression, anger, insomnia, numbing and medically unexplained complaints (WHO, 2013, p.12).

If the event occurred less than a month ago, assess for symptoms of acute stress with onset after the event. These symptoms may include insomnia, avoidance, re-experiencing, heightened current threat, any disturbing emotions or thoughts, changes in behaviour that trouble the person or others around them (e.g. aggressiveness, social isolation/withdrawal and (in adolescents) risk-taking behaviour), regressive behaviours, including bedwetting (in children), medically unexplained physical complaints including hyperventilation and dissociative disorders of movement and sensation (e.g. paralysis, inability to speak or see) (WHO, 2013, p.8). In adolescents with PTSD, risk-taking behaviour is a common feature. Substance use and abuse in the form of alcohol and drug use problems are common in adults and adolescents with PTSD (WHO, 2013, p. 12).

It’s natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. However, when the symptoms last more than a few weeks and become an ongoing problem, they might be PTSD and further assessment and monitoring by a health care provider is needed. Also, as previously discussed, some people with PTSD don’t show any symptoms for weeks or months so even for a significant period of time after the traumatic event, individuals should still be monitored closely (NIMH, 2015).

It is also important to remember that PTSD symptoms can vary in intensity over time. You may have more PTSD symptoms when you’re stressed in general, or when you run into reminders of what you went through. For example, you may hear a car backfire and relive combat experiences. Or you may see a report on the news about a sexual assault and feel overcome by memories of your own assault. (Mayo Clinic, 2015b). It is believed, however, that the intensity of these symptoms will decrease over time and through the duration of recovery.

Categories of Symptoms

In addition to the common symptomology that occurs with PTSD, these symptoms may be categorized into one of three groups. These three groups reflect the re-experiencing of symptoms, avoidance symptoms and hyper-arousal symptoms (NIMH, 2015).

The re-experiencing of symptoms is what first occurs when someone is experiencing PTSD. These symptoms can often occur as flashbacks or reliving the trauma over and over again where the person experiences physical symptoms such as a racing heart and sweating. Bad dreams and frightening thoughts can also symbolize that a person has re-experiencing symptoms. A flashback is an episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks lose touch with reality, usually for a few seconds or minutes (NIMH, 2015).

Intrusive memories also occur. An intrusive memory is unwanted, usually vivid and causes intense fear or horror (WHO, 2013). These kinds of symptoms can significantly impact one’s life and daily routines.  They can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing of the event; as can images, sounds (e.g. sound of a gun) and smells (e.g. odour of assailant). Slight differences may occur in children, where symptoms of re-experiencing may also be displayed through frightening dreams without clear content, night terrors or trauma-specific re-enactments in repetitive play or drawings  (WHO, 2013). Other forms of intrustive memories that may present themselves are:

• Recurrent, unwanted distressing memories of the traumatic event
• Reliving the traumatic event as if it were happening again (flashbacks)
• Severe emotional distress or physical reactions to something that reminds you of the event (Mayo Clinic, 2015b)

 

The second category of symptoms for PTSD is the avoidance symptoms.  Symptoms or behaviours from this category may be manifested by individuals as staying away or trying to avoid thinking or talking about places, events, objects, thoughts and memories that are reminders of the experience, as well as feeling emotionally numb, feeling strong guilt, depression, or worry, losing interest in activities that were enjoyable in the past and having trouble remembering the dangerous event. Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car. While people usually use these strategies as a way to avoid re-experiencing symptoms that cause them significant distress, paradoxically, such avoidance strategies tend to increase the occurrence of re-experiencing symptoms (WHO, 2013).

The third and final category of PTSD symptomology is that of hyper-arousal. These symptoms include being easily startled, feeling ‘tense’ or ‘on edge’ and having difficulty sleeping and/or having angry outbursts for no obvious reason (WHO, 2013). For example, affected persons may still feel a sense of impending doom and that they are in acute danger. This experience of heightened current threat or perceived threat can make the person hyper-vigilant and prone to experiencing exaggerated startle responses.  While hyper-vigilance means an exaggerated concern and alertness to danger and increasingly watchful in public places, an exaggerated startle response means simply being easily startled symptoms such as unexpected sudden movements or loud noises. These reactions are considered excessive when the person reacts much more strongly than others and takes considerable time to calm down. These symptoms are usually constant, instead of being triggered by things that remind one of the traumatic event (WHO, 2013). Further, they can make the person feel stressed and angry and may make daily tasks such as eating, or concentrating difficult. Others include (Mayo Clinic, 2015b):

Irritability, angry outbursts or aggressive behavior

Always being on guard for danger

Overwhelming guilt or shame

Self-destructive behavior, such as drinking too much or driving too fast

Trouble concentrating

Trouble sleeping

Being easily startled or frightened

 

The Mayo Clinic (2015b) believes there is a fourth category of symptoms, that being negative changes in thinking and mood. This cluster of symptoms includes the following:

Negative feelings about yourself or other people

Inability to experience positive emotions

Feeling emotionally numb

Lack of interest in activities you once enjoyed

Hopelessness about the future

Memory problems, including not remembering important aspects of the traumatic event

Difficulty maintaining close relationships