Thread by @drjanaway

#PTSD: explanation thread.

Trigger Warning: PTSD/trauma/symptoms/discussion of threat/sexual abuse

Omitted: complex PTSD, adjustment reactions, panic disorder, depression.

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This thread is an attempt to explain the cause, symptoms and treatment of post-traumatic stress disorder. As always, some understandings are subjective and may not represent everybody’s experience. I do my best here, but disagreement is helpful.

Definition: We have to be careful how we define #trauma and thus #ptsd. It is a word that has a specific meaning in medicine, but outside of it can be used for many reasons.

Trauma can be waiting in a queue (in this case frustrating, annoying, unnerving) or a near-death experience (traumatic, life-threatening, existential.) In the latter case, we draw our line in medicine (for the most part.)

Trauma itself is widely accepted to be something linked to a significantly stressful event, where the reaction is intense, prolonged and sometimes delayed. This does not mean that the event must be equally significant for everybody, nor excludes event some may find less severe.

For example, people on the neurodivergent spectrum or learning difficulties make experience trauma in situations where others would not. This may also mean that genetic factors and early life experience may prime someone to be at greater risk.

We can think of trauma as psychological (the classical medical sense,) or physical. It may be due to a one-off event, or multiple. It is the person who defines the reaction, and pre-disposition is not always predictive to what or who may react.

The medical definition of psychic trauma, which is the focus of this thread, is:

'psychologically upsetting experience that produces an emotional or mental disorder or otherwise has lasting negative effects on a person's thoughts, feelings, or behaviour.'

Within these terms, we can begin to see difficulties in where we would draw the line on what is traumatic. However, when we consider the syndrome of PTSD, we can see what has been traumatic in its later symptoms.

Causes: The causes of trauma are many, but can be simply defined as ‘those of life or existence-threatening significance’ with a defined set of physical or psychological reactions which ‘meet the criteria’ for PTSD later..

or are severe enough to meet another diagnosis of depression, acute stress reaction of adjustment disorder. Each is a reaction to trauma, with depression more linked to loss. Trauma does not mean PTSD.

As such we can omit, quite quickly, the tiktokification of the term used widely over minimal things, which trivialises a serious set of conditions and does not meet criteria for a disorder, but distress which may be transient or moderate at worst.

The DSM V and ICD11 suggest(abridged)

Exposure to actual or threatened death, serious injury or sexual violence either directly experiencing the event, witnessing the event, learning of the event happening to those of significant personal relationship, ....'

experiencing repeated or extrema exposure to aversive details of an event.
- ‘exposure to an extremely threatening or horrific event or series of events.’

Examples would thus range from an animal attack, sexual abuse, loss of a partner, learning of a family member being harmed, or occupational exposure to repeated awful material (covid 19 staff etc.) Essentially, if something is horrible enough, it can cause trauma and PTSD

Other factors: there has been some evidence suggesting that genetics play a role in susceptibility to PTSD, and that defined social factors (personal history of depressive/anxiety disorder ....

previous traumatic history, female gender, overthinking, lower intelligence or lack of social support) may increase the risk.

Imaging studies suggest changes inmemory processing and emotional overreaction, with psychological theories suggest an overwhelming of defenses where unconscious memories persist and intrude into conscious awareness

Negative appraisal (judgment) of the event may increase this risk. Psychodynamic theories are complex and beyond the direct scope of this thread, but in general focus on problems in self-esteem, trust, attachment and relating to others, and paranoid/schizoid thinking.

Symptoms

Diagnosing PTSD, and thus defining what may have been traumatic, can be made easier by looking for evidence of a traumatic psychological reaction and its long-term effects. PTSD can occur almost immediately, or after a delay of months, and may differ by person.

The DSM defines the following as indicative (abridged, one or more of associated with event)

-Recurrent, intrusive and distressing memory or sensations of the event. In children, this may present as role-playing the event again.

-Recurrent distressing dreams of the event or symbolic of it.
-Dissociative experiences (flashbacks) where the person may lose complete touch with their surroundings, or experiences subtotal elements of the initial experience again

-Intense or prolonged psychological distress at exposure to internal or external cues of the event (triggers)
-Marked physiological reactions to the same (panic attacks, fight of flight response.)

-Avoidance or efforts to avoid memories, cues, or associations with the event (avoiding the area, person, words.)
-Negative changes in cognition around the event (i.e loss of memory.)

-Persistent negative beliefs about the self or others, paranoid in nature at times
-Distortions in the memory of the cause of events and subsequent links to present and self.

-Persistently negative emotional state, diminished interest in activties, detachment and estrangement from others, inability to experience positive emotions and relationships.

Already we can see a large number of interacting symptoms that can represent PTSD, but also with hallmarks of depression and other disorders. Once again, it is the history and the syndrome that leads to the diagnosis.

However, we must also be aware that the source of trauma may not be evident, and that we must be careful not to create one by suggestion.

The ICD 11, and work comparing it with the DSM, denotes 3 core symptoms:

1)Intrusions and re-experiencing of events
2)Avoidance of association
3)Arousal, hyper-reactivity or sense of threat

As you can see, all DSM points above can be categorised below these headings.

In some cases the severity of distress can lead to a detachment from reality where paranoia or depressive ideas become delusional.

These are not psychotic illnesses, but psychotic symptoms, where the person believes a self-referential idea that is not true, often of people hunting them or wishing to kill them. The definition of this and its diagnoses are complicated and beyond the scope of this thread.

Here I will take some time to explain a little more of the terms described above, and here I would much appreciate your input in the comments:

Intrusive experiences: these could be memories, images, sounds or any sensory experience occurring created by the person but in relation to the event. It may be distressing images, but the crucial element of these experiences are that they are not hallucinations.

Distressing dreams: essentially this means ‘nightmares’ This is the classical way in which PTSD is portrayed in films, with the character reliving the event in their dreams, associated with a feeling of doom or fear, and waking sweaty, confused and panicked.

Dissociative experiences: these are a wide range of experiences that capture a majorly transient detachment from reality, which can include elements of intrusive experiences, but the person may feel unattached....

Derealisation (the world is not real) and or depersonalisation (I am not real,) may both exist, but once again this does not form hallucination or delusion as it is within the mind. PTSD may present without this.

Internal and external cues: classically (and unfortunately tiktokingly) understood as ‘triggers’, these are sensations, thoughts or stimuli that, internally or externally created, are associated either directly, or indirectly but significantly, with the event...

Once again we must remind ourselves that a ‘trigger’ is an overused term, so for it to be a significant trigger here it must link to a traumatic event and resultant symptoms.

Avoidance: this is a direct protective measure to avoid the recurrence of the event or cues associated with it. It extends to avoiding situations where triggers of the event may exist, for example avoiding the city where it happened, or a certain person, or memories of them.

For a diagnosis to be made we need, ideally, to be able to link the symptoms to an event (often) and the symptoms meet the criteria of PTSD alone, not fulfill the criteria for complex PTSD or another diagnosis, or represent an extension of normal human experience.

As per the last thread, I will also discuss some of the psychological defenses associated with PTSD and explain them.

Repression: the exclusion of memory from conscious awareness to prevent distress. This can include childhood sexual abuse. The repressed may be inferred psychodynamically from actions, words or symbolic content via defenses.

Denial: the person will deny any knowledge of the event (knowingly, as neurotic protection) or unconsciously (psychotic.) It can be adaptive in the short term but can lead to people avoiding treatment.

Displacement: moving the target of unexpressed emotion to a safer target, or one more in tune with ones own prejudices to allow more catharsis. I.E, blaming a vaccine for the death of a family member.

Projection: attributing one’s own thoughts, experiences and emotions on to another (more in the EUPD thread)

Regression: this is complex, but essentially means dropping back to a place of earlier psychological and social development. I.e becoming more dependent on others, requiring extensive help. This makes sense as a way of bringing in protection, but can be harmful.

Reaction formation: acting on fear or intolerance by engaging extensively with it. For example, hypersexuality after sexual trauma is a way of mastering the fear around it.

Isolation: removing the emotion to make something more tolerable.

repression to internal cues, and projection to fear and paranoia. The detailed examination of this in an individual requires extensive assessment.

Last, in this section, we will discuss hyperarousal and physical symptoms, which can be summarized as those present in the fight or flight response. In essence, this is a shortcut created by evolution for survival and relies on adrenaline to pump the body into action.

If not used, it becomes increasingly uncomfortable. Changes include increased heart rate, sweating, increased breathing rate, numbness in fingers and around mouth, intense fear/panic, stomach troubles, a feeling of needing to act, anger, bravery and changes in thought.

In PTSD this reaction can be driven easily by internal or external cues, and is often inappropriate to what most of us would imagine. It is also recurrent, intense and a baseline hypervigilance (always on edge, angry, startled) may exist as a further protection against threats.

Treatment:

Treatment for PTSD is variable and first line relies on talking therapies such as Cognitive behavioural therapy and EMDR. Both are very effective. SSRI antidepressants, used more as an anxiolytic, have been shown to be effective.

Combinations are much better. The use of adjunctive antipsychotics can be helpful in a mood mediating function, also to reduce adrenaline through secondary chemical effects. If there are psychotic or near psychotic features, this may be more important.

Psychodynamic therapy, especially during active illness, can be dangerous if not performed safely and is strictly ruled out in severe illness or psychotic symptoms.

Hopefully this thread has been helpful. As always, this is a docsplanation, but elements of this are personally relevant to me having been through several experiences that fit definition, so I can speak with some insight.

Below I have included help sources and my reference list. As always, we must be careful not to trivialise disorder.

If this has been helpful, or you think could be educational to others, please share. Your comments are always welcome.

nhs.uk/mental-health/…
rcpsych.ac.uk/mental-health/…

Sources:

…ical-dictionary.thefreedictionary.com/trauma
mind.org.uk/information-su…

traumadissociation.com/complexptsd#:~….

ICD 10/11
DSM V
Oxford Shorter Textbook of Psychiatry
Sims Symptoms in the Mind
My clinical experience.