Post-traumatic stress syndrome

According to the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, by the American Psychiatric Association), posttraumatic stress syndrome (also posttraumatic stress disorder, PTSD, German: posttraumatische Belastungsstörung ) is defined as:


 * a mental disorder that arises after sudden events that threaten life or personal integrity.

A shocking event can be experienced directly by the patient himself or someone close to him (relatives or friends), or he may only be present as a witness.

We currently view PTSD in simple terms as:


 * a condition where the integration of a traumatic experience into other everyday experiences fails.

A Brief History
Post-traumatic stress disorder was dealt with in a certain sense already in the last century by Sigmund Freud, when he investigated the circumstances that caused the disability of approximately 20% of the Austro-Hungarian soldiers during the First World War.


 * This group of soldiers had both mental and physical problems, none of them were seriously injured.

Freud rejected claims at the time that this could be the result of minor central nervous bleeding and that it could also be a reactivation of childhood neurosis. He considered the cause of soldiers' disability to be a reaction to the immediate threat to life in war.

PTSD was classified as a separate diagnosis by American psychiatrists after research into the changes in the psyche of soldiers in the Korean and Vietnam wars. During this time, attention focused on elucidating the biological (physiological, genetic, and neuropsychological) circumstances of PTSD and developing and testing new treatments such as the use of somatics, psychodynamics, and cognitive behavioral therapy.

Symptoms
Post-traumatic stress disorder most often arises as a delayed reaction to an exceptionally strong stressful event (war, traffic accident, rape or other criminal act, floods). After such an event, an acute reaction to stress may first develop, characterized by restlessness, disorientation, reduced attention, and at a later stage, apathy or, on the contrary, hyperactivity. This reaction can often be easily overcome within a few days. PTSD can then follow.

PTSD develops in only a fraction of people exposed to a stressor (20-40% of victims are said to be). It manifests itself by reliving the event in thoughts, fantasies or dreams ("flashbacks"). The patient often avoids the place or situation reminiscent of the accident. He does not remember some details or even entire periods, has difficulty falling asleep and staying asleep, is irritable, has outbursts of anger, difficulty concentrating and suffers from excessive startle reactivity. The development of these symptoms occurs no later than 6 months after the event and the symptoms last for at least one month.

It was found that the probability of developing PTSD does not depend much on the gender or age of the affected person. There are traumas after which the disorder almost always develops (e.g. torture, kidnapping), in some cases it only arises under certain circumstances (e.g. traffic accidents).

Diagnostics
A system of criteria is used to diagnose PTSD, which a patient suffering from this disorder meets at least in five points :


 * The individual was exposed to a traumatic event.
 * The traumatic event is re-experienced in the form of distressing memories, flashbacks, thoughts, dreams, feelings, hallucinations, or illusions . After the patient is exposed to trauma-like stimuli, significant psychological problems appear.
 * The person avoids stimuli, thoughts, places or activities reminiscent of the event. He has difficulty remembering some moments from the period of trauma and sometimes feels alienated from the surrounding society.
 * We observe increased irritability in the patient, which was not present before the trauma. These include, for example, restless sleep or difficulty falling asleep, increased startle reactivity (at a sudden noise, flash of light or touch). There are difficulties with concentration, hidden aggression with occasional outbursts of anger.
 * All symptoms last longer than one month.
 * A mental disorder is reflected in the work, social and family life of the patient. Interest in hobbies and favorite activities decreases, and self-esteem disorders and emotional rigidity may appear.

Post-traumatic stress syndrome can also be associated with other psychological disorders, such as depression, panic disorder , phobias and generalized anxiety disorder. Sometimes PTSD can be confused with these diseases, but with differential diagnosis we can distinguish them from each other.

PTSD can also be diagnosed biochemically by determining the blood level of the hormone cortisol from the adrenal cortex. Cortisolemia paradoxically decreases in PTSD patients, although the response to stress should be an increase in the level of cortisol in the blood.

Patient care and treatment
Psychotherapy and pharmacotherapy are currently used to treat PTSD. As far as drugs are concerned, SSRI antidepressants (Selective Serotonin Reuptake Inhibitors) and monoamine oxidase inhibitors (MAOIs) are mainly prescribed. Administration of anxiolytics has been shown to be less successful, although they can also be used in acute cases. Benzodiazepines can be given as first aid. Placebo also plays an important role in the treatment of post-traumatic stress syndrome. What is undoubtedly interesting is that the administration of ineffective substances is practically as successful as the administration of commonly used drugs with guanfacine or clonidine.

However, the most important thing is the psychotherapy process, because the patient has to come to terms with the unfortunate event and reintegrate into normal life. Here, the approach to children and the approach to adults are somewhat different. Children often suffer because adults do not talk about their misfortune, so that the child forgets more easily. Suppressed emotions, however, cause tensions with which the child must cope on his own. Internally, he understands that his parents or other adults do not want to talk to him about the events he experienced. Therefore, the psychotherapist must analyze the situation well and choose the right course of treatment.

The psychotherapeutic approach is based on empathic conversation. For children, the interview consists of these three parts:


 * 1) opening – the child expresses the essence of the trauma through play or drawing; especially in preschool and younger school age, artistic expressions are easy to read, so to speak, transparent.
 * 2) trauma - gradually turns into a conversation about the event.
 * 3) closure – represents a summary of the entire therapy, coming to terms with the event; the therapist reassures the child of his safety and that his feelings are understandable and only temporary.

The interview with adults has a somewhat different structure, although it is again divided into three phases:


 * 1) assessment of the current state – with a focus on depression, anxiety, re-experiencing trauma, panic reactions, etc.
 * 2) the period before the trauma - with questions about possible psychological disorders in the family.
 * 3) discussion of the trauma itself.

A psychotherapist should try to be empathetic, calm, pleasant. With occasional and appropriately chosen questions, he gets to the details and discusses them together with the patient. In no case should he impose his own opinions on the patient - on the contrary, the patient will come to his own conclusions. The patient should not resist emotions (anger, helplessness, crying), it is advisable to support him in the expression of feelings, as this is an excellent way to get rid of tension and internally clarify his attitude towards the trauma, or later formulate goals for the next life.

A psychotherapist usually has long-term practice and rich experience in conducting similar interviews. A more complicated situation arises if, for example, a general practitioner or other doctor is to treat a patient with this disorder as part of outpatient treatment in a place where psychotherapeutic care is not available. It is not unusual that all therapy ends with the mere administration of antidepressants. However, such care is insufficient, and it is not uncommon for the personality to be marked for life after a traumatic event, the nature of the patient and his personal life change, and long-term psychosomatic problems often develop. In the case of mass disasters (e.g. terrorist attacks on September 11, 2001 in the USA, floods in the Czech Republic in 1997 and 2002, the tragic train accident near Studénka on August 8, 2008), it is to our credit that various organizations try to assemble teams of psychologists who are available to victims,