Complicated Grief

From: The Mayo Clinic

Definition

Losing a loved one is one of the most distressing and emotional experiences people face. But because death is such a common life experience, virtually everyone deals with grief at some point. Despite the emotional difficulty, most people experiencing normal grief and bereavement endure a period of sorrow, numbness, and even guilt and anger, followed by a gradual fading of these feelings as they accept the loss and move forward.

For some people, though, this normal grief reaction becomes much more complicated, painful and debilitating, or what's known as complicated grief. In complicated grief, painful emotions are so long lasting and severe that you have trouble accepting the death and resuming your own life.

Researchers are beginning to pay more attention to complicated grief because of the serious toll it can exact — possibly leading to depression and thoughts of suicide. Researchers have even developed a new treatment that may help people with complicated grief come to terms with their loss and reclaim a sense of joy and peace.

Symptoms

Mental health experts are still analyzing how complicated grief symptoms differ from those of normal grief or other bereavement reactions. During the first few months after a loss, many signs and symptoms of normal grief are the same as those of complicated grief. However, while normal grief symptoms gradually start to fade within six months or so, those of complicated grief get worse or linger for months or even years. Complicated grief is like being in a chronic, heightened state of mourning.

Signs and symptoms of complicated grief can include:

• Extreme focus on the loss and reminders of the loved one
• Intense longing or pining for the deceased
• Problems accepting the death
• Numbness or detachment
• Preoccupation with your sorrow
• Bitterness about your loss
• Inability to enjoy life
• Depression or deep sadness
• Difficulty moving on with life
• Trouble carrying out normal routines
• Withdrawing from social activities
• Feeling that life holds no meaning or purpose
• Irritability or agitation
• Lack of trust in others

Causes

It's not known what causes complicated grief. As with many mental health disorders, it may involve a complex interaction between your genes, environment, your body's natural chemical makeup and your personality.

Some researchers believe in the five stages of grief theory, attributed to the late psychiatrist Elizabeth Kubler-Ross, M.D. Although she intended this process for people at the end of their lives, some researchers said that bereaved survivors also went through these stages in an orderly fashion:

1. Denial, shock or isolation
2. Anger
3. Bargaining
4. Depression or sadness
5. Acceptance of the loss

People who didn't follow the steps in order or who became stuck at one of these stages were thought to be in an unhealthy grieving pattern. Today, though, most grief experts don't embrace this theory, instead believing that while grief is an evolution, most people don't go through organized stages.

Risk factors

Complicated grief is considered relatively uncommon. Because research about complicated grief is evolving, it's difficult to know how many people are affected. Some estimates suggest that as few as 6 percent or as many as 20 percent of bereaved people develop complicated grief.

While it's not known specifically what causes complicated grief, researchers continue to learn more about the factors that may increase the risk of developing it. These risk factors may include:

• An unexpected or violent death
• Suicide of a loved one
• Lack of a support system or friendships
• Traumatic childhood experiences, such as abuse or neglect
• Childhood separation anxiety
• Close or dependent relationship to the deceased person
• Being unprepared for the death
• In the case of a child's death, the number of remaining children
• Lack of resilience or adaptability to life changes

When to seek medical advice

It's normal to experience grief after a significant loss. Most people who experience normal or uncomplicated grief can move forward eventually with support from family and friends. But if it's been several months or more since your loss and your emotions remain so intense or debilitating that you have trouble going about your normal routine, consider talking to your health care provider.

Specifically, you may benefit from professional help if you:

• Can focus on little else but your loved one's death
• Have persistent pining or longing for the deceased person
• Have thoughts of guilt or self-blame
• Believe that you did something wrong or could have prevented the death
• Feel as if life isn't worth living
• Have lost your sense of purpose in life
• Wish you had died along with your loved one

At times, people with complicated grief may consider suicide. If you're considering suicide, reach out to someone as soon as possible. The best choice is to call 911 or your local emergency services number.

Tests and diagnosis

Complicated grief isn't yet recognized by mental health providers as an actual disorder. However, there's growing consensus that it should be. And even though it's not an official disorder, you may still be diagnosed with complicated grief.

To help diagnose complicated grief, mental health providers perform a thorough psychological evaluation. They ask many questions about the events surrounding the loss of your loved one, your mood, thoughts and behavior, your lifestyle and social situation, and sleeping and eating patterns, for example. You may also fill out psychological questionnaires. And you may have a physical exam to check for any other health problems that may be causing or contributing to your symptoms.

Because bereavement also can lead to other disorders, such as depression or post-traumatic stress disorder, you may be evaluated for those conditions.

Generally, to be diagnosed with a certain mental health disorder, someone must meet specific criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Because complicated grief isn't yet considered an actual disorder, it's not listed in the current DSM and has no official diagnostic criteria. However, some researchers have proposed adding complicated grief as a specific disorder in the next version of the DSM, scheduled for publication in 2011. Different diagnostic criteria have been proposed. One proposal that has gotten support includes these criteria:

• Intense pining or longing for the deceased that occurs daily or is distressing or disruptive
• Trouble accepting the death
• Inability to trust others after the death
• Difficulty moving forward with life
• Excessive bitterness or anger related to the death
• Feeling emotionally numb or detached from others
• A feeling that life is now meaningless
• A belief that the future won't be fulfilling
• Increased agitation or jumpiness

For diagnosis of complicated grief, these symptoms must last at least six months and cause impairment or disruption in your ability to function in daily life, such as at work or in social engagements.

Complications

Complicated grief can affect you physically, mentally and socially. Without appropriate treatment, these complications can include:

• Depression
• Suicidal thoughts or behaviors
• Increased risk of heart disease, cancer and high blood pressure
• Anxiety
• Long-term impairment in daily living
• Post-traumatic stress disorder
• Substance abuse
• Smoking or nicotine use

Treatments and drugs

Complicated grief treatment hasn't been standardized because mental health providers are still learning about the condition. Research studies testing various types of treatment have had mixed results. That isn't to say that treatment isn't helpful, though. More study is needed to help determine which treatment options may be best for complicated grief.

Psychotherapy
Some studies have shown big benefits from treating complicated grief with a newly developed type of psychotherapy called complicated grief treatment, also called complicated grief therapy. This form of psychotherapy, which borrows from cognitive behavior therapy and trauma therapy, is comprehensive and sometimes intense. You may learn about such topics as grief reactions, complicated grief symptoms, adjusting to your loss and redefining your life's goals.

This therapy also includes holding imagined conversations with your loved one and retelling the circumstances of the death, perhaps several times to help you become less distressed by images and thoughts of your loved one. Although some people find this therapy painful, others find it ultimately rewarding and freeing after what may have been years of chronic mourning.

Other forms of therapy, such as interpersonal therapy or psychodynamic psychotherapy, also may be effective. Therapy can help you explore and process emotions, improve coping skills and reduce feelings of blame and guilt.

Medications
There's little solid research on the use of psychiatric medications to treat complicated grief. However, some research has shown benefits from using antidepressants in the class of selective serotonin reuptake inhibitors (SSRIs) to reduce complicated grief symptoms.

Prevention

It's not clear how to prevent complicated grief with any certainty. Some studies suggest that participating in a brief course of counseling or psychotherapy soon after a loss may help, especially for those at increased risk of developing complicated grief. In addition, caregivers providing end-of-life care for a loved one may benefit from counseling and support to help prepare for death and its emotional aftermath.

Through early counseling, you can explore emotions surrounding your loss and learn healthy coping skills. This may help prevent negative beliefs about your loss from gaining such a strong hold that they're difficult to overcome. People who themselves may be at risk of suicide following a loved one's suicide may especially benefit from grief counseling or other treatment.

Finding support from family, friendships, group therapy or social support groups after a loss can promote healthy grieving. You can also take steps to improve your resilience skills to help cope with hardships and loss.

Coping and support

Although it's important to get professional treatment for complicated grief, you can take steps on your own to cope, including:

• Stick to your treatment plan. Take medications as directed and attend therapy appointments as scheduled.
• Exercise regularly. Physical exercise helps relieve depression, stress and anxiety and can redirect your mind to the activity at hand.
• Take care of yourself. Get enough rest, eat a balanced diet and take time to relax. Don't turn to alcohol or unprescribed drugs for relief.
• Reach out to your faith community. If you follow religious practices or traditions, you may gain comfort from rituals or guidance from a spiritual leader.
• Practice stress management. Learn how to better manage stress. Unmanaged stress can lead to depression, overeating, or other unhealthy thoughts and behaviors.
• Socialize. Stay connected with people you enjoy being around. They can offer support, a shoulder to cry on or a joke to give you a little boost.
• Plan ahead for special dates or anniversaries. Holidays, anniversaries and special occasions can trigger painful reminders of your loved one. Find new ways to celebrate or acknowledge your loved one that provide you comfort and hope.
• Learn new skills. If you were highly dependent on your loved one, perhaps to handle the cooking or finances, for example, try to master these tasks yourself. Ask family, friends or professionals for guidance, if necessary. Seek out community classes and resources, too.
• Join a support group. You may not be ready to join a support group immediately after your loss, but over time you may find shared experiences comforting and you may form meaningful new relationships.

Complex PTSD

From: http://www.ncptsd.va.gov

by
Julia M. Whealin, Ph.D. and Laurie Slone, Ph.D.

Differences between the effects of short-term trauma and the effects of chronic trauma?

The diagnosis of PTSD accurately describes the symptoms that result when a person experiences a short-lived trauma. For example, car accidents, natural disasters, and rape are considered traumatic events of time-limited duration. However, chronic traumas continue or repeat for months or years at a time. Clinicians and researchers have found that the current PTSD diagnosis often does not capture the severe psychological harm that occurs with such prolonged, repeated trauma. For example, ordinary, healthy people who experience chronic trauma can experience changes in their self-concept and the way they adapt to stressful events. Dr. Judith Herman of Harvard University suggests that a new diagnosis, called Complex PTSD, is needed to describe the symptoms of long-term trauma. Another name sometimes used to describe this cluster of symptoms is: Disorders of Extreme Stress Not Otherwise Specified (DESNOS).

Because results from the DSM-IV Field Trials indicated that 92% of individuals with Complex PTSD/DESNOS also met criteria for PTSD, Complex PTSD was not added as a separate diagnosis. Complex PTSD may indicate a need for special treatment considerations.

What are examples of types of captivity that are associated with chronic trauma?

Judith Herman notes that during long-term traumas, the victim is generally held in a state of captivity, physically or emotionally. In these situations the victim is under the control of the perpetrator and unable to flee.

Examples of captivity include:

• Concentration camps
• Prisoner of War camps
• Prostitution brothels
• Long-term domestic violence
• Long-term, severe physical abuse
• Child sexual abuse
• Organized child exploitation rings

What are the symptoms of Complex PTSD?

The first requirement for the diagnosis is that the individual experienced a prolonged period (months to years) of total control by another. The other criteria are symptoms that tend to result from chronic victimization. Those symptoms include:

Alterations in emotional regulation

This may include symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger

Alterations in consciousness

This includes things such as as forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body

Changes in self-perception

This may include a sense of helplessness, shame, guilt, stigma, and a sense of being completely different than other human beings

Alterations in the perception of the perpetrator

For example; attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge

Alterations in relations with others

Variations in personal relations including isolation, distrust, or a repeated search for a rescuer

Changes in one's system of meanings

This may include a loss of sustaining faith or a sense of hopelessness and despair

What other difficulties do those with Complex PTSD tend to experience?

• Survivors may avoid thinking and talking about trauma-related topics because the feelings associated with the trauma are often overwhelming.
• Survivors may use alcohol and substance abuse as a way to avoid and numb feelings and thoughts related to the trauma.
• Survivors may also engage in self-mutilation and other forms of self-harm.

There is a tendency to blame the victim.

A person who has been abused repeatedly is sometimes mistaken as someone who has a "weak character."

Because of their chronic victimization, in the past, survivors have been misdiagnosed by mental-health providers as having Borderline, Dependent, or Masochistic Personality Disorder. When survivors are faulted for the symptoms they experience as a result of victimization, they are being unjustly blamed.

Researchers hope that a new diagnosis will prevent clinicians, the public, and those who suffer from trauma from mistakenly blaming survivors for their symptoms.

Summary

The current PTSD diagnosis often does not capture the severe psychological harm that occurs with prolonged, repeated trauma. For example, long-term trauma may impact a healthy person's self-concept and adaptation. The symptoms of such prolonged trauma have been mistaken for character weakness. Research is currently underway to determine if the Complex PTSD diagnosis is the best way to categorize the symptoms of patients who have suffered prolonged trauma.

Recommended Reading

Trauma and Recovery: The Aftermath of Violence from Domestic Abuse to Political Terror, by Judith Herman, M.D. (1997). Basic Books; ISBN 0465087302

References

Ford, J. D. (1999). Disorders of extreme stress following war-zone military trauma: Associated features of Posttraumatic Stress Disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67, 3-12.

Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books.

Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV field trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-555.

Complex post-traumatic stress disorder

From: Wikipedia

Complex post-traumatic stress disorder (C-PTSD) is a clinically recognized condition that results from extended exposure to extremes of social and/or interpersonal trauma, including sexual abuse (especially child sexual abuse), physical abuse, emotional abuse, domestic violence, and torture. A differentiation between the diagnostic categorizations of C-PTSD and that of Post traumatic stress disorder (PTSD) has been suggested, as C-PTSD better describes the pervasive negative impact of chronic trauma than does PTSD alone.[1][2] As a descriptor, PTSD fails to capture some of the core characteristics of C-PTSD. These elements include psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized, and, most importantly, the loss of a coherent sense of self. It is this loss of a coherent sense of self, and the ensuing symptom profile, that most pointedly differentiates C-PTSD from PTSD.[3]

Symptom profile

C-PTSD is characterized by chronic difficulties in many areas of emotional and interpersonal functioning. Symptoms may include:^[3][2]

• Difficulties regulating emotions, including symptoms such as persistent sadness, suicidal thoughts, explosive anger, or covert anger, which is characteristic of passive-aggressive behavior

• Variations in consciousness, such as forgetting traumatic events, reliving traumatic events, or having episodes of dissociation (during which one feels detached from one's mental processes or body)

• Changes in self-perception, such as a sense of helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings

• Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge

• Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer

• Loss of, or changes in, one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair

Treatment

Treatment for C-PTSD tends to require a multi-modal approach.^[4] It has been suggested that treatment for C-PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems.^[5] Six suggested core components of complex trauma treatment include:^[4]

1. Safety
2. Self-regulation
3. Self-reflective information processing
4. Traumatic experiences integration
5. Relational engagement
6. Positive affect enhancement

Multiple treatments have been suggested for C-PTSD. Among these treatments are group therapy, cognitive behavioral therapy, eye movement desensitizations and reprocessing, and psychodrama. As C-PTSD is a fairly new concept, therapeutic protocols are just being developed.^[6] Current medical care includes the use of SSRIs^{[citation needed]}, and sometimes the atypical antipsychotics^{[citation needed]}.

Since C-PTSD shares symptoms with both PTSD and borderline personality disorder,^[7] it is likely that a combination of treatments utilized for these conditions would be helpful for an individual with C-PTSD, such as dialectic behavior therapy and exposure therapy.^{[citation needed]}

See also

• Dissociation

Footnotes

1. ^ van der Kolk BA, Courtois CA (2005). "Editorial comments: Complex developmental trauma". J Trauma Stress 18 (5): 385–8. doi:10.1002/jts.20046. PMID 16281236.
2. ^ ^{a b} Julia M. Whealin, Ph.D. and Laurie Slone, Ph.D.. "Complex PTSD". National Center for Posttraumatic Stress Disorder. United States Department of Veteran Affairs.
3. ^ ^{a b} Herman, Judith Lewis (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. Basic Books. pp. 119–122. ISBN 0465087302.
4. ^ ^{a b} Cook, A.; Blaustein, M.; Spinazzola, J.; Van Der Kolk, B. (2005). "Complex trauma in children and adolescents". Psychiatric Annals 35 (5): 390–398. http://doi.apa.org/?uid=2005-05449-004. Retrieved on 29 March 2008.
5. ^ van der Kolk BA, Roth S, Pelcovitz D, Sunday S, Spinazzola J (2005). "Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma". J Trauma Stress 18 (5): 389–99. doi:10.1002/jts.20047. PMID 16281237.
6. ^ Treating Complex PTSD http://www.cavalcadeproductions.com/ptsd-treatment.html
7. ^ Taylor S, Asmundson GJ, Carleton RN (2006). "Simple versus complex PTSD: a cluster analytic investigation". J Anxiety Disord 20 (4): 459–72. doi:10.1016/j.janxdis.2005.04.003. PMID 15979838.

References

• Appleyard, K.; Osofsky, J.D. (2003). "Parenting after trauma: Supporting parents and caregivers in the treatment of children impacted by violence". Infant Mental Health Journal 24 (2): 111–125. doi:10.1002/imhj.10050.
• Cook, A.; Blaustein, M.;Spinazzola, J.; and van der Kolk, B., (2003) Complex trauma in children and adolescents. White paper from the National Child Traumatic Stress Newtork Complex Trauma Task Force.
• Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et al., (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35, 390-398.
• Herman, JL (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books.
• Scott, Catherine V.; Briere, John (2006). Principles of Trauma Therapy : A Guide to Symptoms, Evaluation, and Treatment. Thousand Oaks: Sage Publications. ISBN 0-7619-2921-5.
• Ford JD (1999). "Disorders of extreme stress following war-zone military trauma: associated features of posttraumatic stress disorder or comorbid but distinct syndromes?". J Consult Clin Psychol 67 (1): 3–12. PMID 10028203.
• Roth S, Newman E, Pelcovitz D, van der Kolk B, Mandel FS (1997). "Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM-IV Field Trial for Posttraumatic Stress Disorder". J Trauma Stress 10 (4): 539–55. PMID 9391940.
• van der Kolk, B.A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). "Disorders of extreme stress: the empirical foundation of a complex adaptation to trauma". Journal of Traumatic Stress 18, 389-399.

External links

• Complex post-traumatic stress disorder at the Open Directory Project
• U.S. Department of Veterans Affairs
• Recommended DSM criteria
• Carrot of Hope PTSD group
• Sidran Institute traumatic stress information

PTSD and Physical Health

From: Veterans Affairs Canada

A National Center for PTSD Fact Sheet
By Kay Jankowsi, Ph.D.

Exposure to traumatic events such as military combat, physical and sexual abuse, and natural disaster, can be related to poor physical health. Posttraumatic Stress Disorder (PTSD) is also related to health problems. This fact sheet provides information on the relationships between trauma, PTSD, and physical health; specific health problems associated with PTSD; health-risk behaviors and PTSD; mechanisms that help explain how PTSD and physical health could be related; and a clinical agenda to address PTSD and health.

Before addressing these topics, it is necessary to provide some basic information about how existing studies have measured physical health. The most common way to measure physical health is by having people report about their own health conditions, symptoms, and overall physical health. Self-report measures of physical health can be valid indicators of actual illness, but they should be interpreted with caution because they may be influenced by psychological health. The most reliable measure of physical health involves a physician's diagnosis or laboratory tests.

Is psychological trauma related to physical health?

A considerable amount of research has found that trauma has negative effects on physical health. The relationship is clearest when examining self-report of physical health problems and trauma experienced as a result of time in the military, sexual assault, childhood abuse, and motor vehicle accidents. Greater self-report of military trauma, sexual assault, childhood abuse, and motor vehicle accidents is related to greater self-report of health problems. However, when health status is measured by physician diagnosis, associations are not as consistent for military trauma and sexual assault in adulthood. There is, however, a probable association for survivors of natural disaster. Two recent studies found that reports of childhood abuse and neglect were related to an increase in physician diagnosed disorders including cancer, ischemic heart disease, and chronic lung disease. It is also likely that a relationship exists between the experience of a trauma and an increase in utilization of medical services for physical health problems. In addition, health care costs have been found to be higher among women who report a history of childhood abuse or neglect than among women who report no history of maltreatment as a child.

What is the relationship between physical health and PTSD?

A growing body of literature has found a link between PTSD and physical health. Some studies have found that PTSD explains the association between exposure to trauma and poor physical health. In other words, trauma may lead to poor health outcomes because of PTSD. When health problems are measured by self-report, there is a clear association with PTSD for veterans and active duty personnel, civilian men and women, firefighters, and adolescents. Those who report that they have PTSD symptoms are more likely to have a greater number of physical health problems than those who do not have PTSD. Similar results are found when physical health is measured by physician report or by laboratory tests. PTSD also has been found to be associated with greater medical service utilization for physical health problems. At present, however, an association between PTSD and illness via physician diagnosis and medical service utilization has only been examined in veteran populations. Further research is indicated to examine PTSD, physical illness, and medical service utilization in both veteran and other traumatized populations.

Existing research has not been able to determine conclusively that PTSD causes poor health. Thus, caution is warranted in making a causal interpretation of what is presented here. It may be the case that something associated with PTSD is actually the cause of greater health problems. For example, it could be that a factor associated with PTSD, such as smoking, is the actual cause of the increased health problems. This is not likely, however, given that we know that PTSD is associated with poor physical health even when behavioral factors such as smoking are controlled.

PTSD may promote poor health through a complex interaction between biological and psychological mechanisms. The National Center for PTSD and other laboratories around the world are studying these mechanisms. Current thinking is that the experience of trauma brings about neurochemical changes in the brain. These changes may have biological, as well as psychological and behavioral, effects on one's health. For example, these neurochemical changes may create a vulnerability to hypertension and atherosclerotic heart disease that could explain in part the association with cardiovascular disorders. Research also shows that these neurochemical changes may relate to abnormalities in thyroid and other hormone functions, and to increased susceptibility to infections and immunologic disorders associated with PTSD.

The psychological and behavioral effects of PTSD on health may be accounted for in part by comorbid depressive and anxiety disorders. Many people with PTSD also experience depressive disorders or other disorders. Depressed individuals report a greater number of physical symptoms and use more medical treatment than do individuals who are not depressed. Depression also has been linked to cardiovascular disease in previously healthy populations and to additional illness and mortality among patients with serious medical illness. PTSD also may be related to poor health through symptoms of comorbid anxiety or panic. The evidence linking anxiety to cardiovascular morbidity and mortality is quite strong, but the mechanisms are largely unknown.

Hostility, or anger, is another possible mediator of the relationship between PTSD and physical health. It is commonly associated with PTSD and decades of research on the health risks associated with the Type A behavior pattern have isolated hostility as a crucial factor in cardiovascular disease. PTSD and poor health also may be mediated in part by behavioral risk factors for disease such as smoking, substance abuse, diet, and lack of exercise.

Little is known about how coping and social support relate to health in PTSD, but it is likely that both play important roles. Further research is needed to better understand these potential protective factors.

What specific health problems are related to PTSD?

There is not a lot of information about what specific health problems are associated with PTSD. Many studies have not looked at specific health problems but instead report only the number of overall health problems associated with PTSD. Some studies have examined specific health problems, but these problems have been primarily self-reported. However, there is some evidence to indicate PTSD is related to cardiovascular, gastrointestinal, and musculoskeletal disorders. There is also one study with similar findings that evaluated physician diagnosed disorders and PTSD in relation to specific body systems.

A number of studies have found an association between PTSD and poor cardiovascular health. These studies found that self-report of circulatory disorders and symptoms of cardiovascular trouble were each associated with PTSD in veteran populations, civilian men and women, and male firefighters. Among studies that have examined PTSD in relation to cardiovascular illness via physician diagnosis or laboratory findings, PTSD has been consistently associated with a greater likelihood of cardiovascular morbidity. In a recent study, researchers used electrocardiogram (ECG) findings to compare the cardiovascular function of Vietnam veterans with PTSD to the cardiovascular function of veterans without PTSD. After controlling for risk factors such as alcohol consumption, weight, current substance abuse, and smoking, in addition to controlling for current medication use, PTSD was found to be associated with nonspecific ECG abnormalities, atrioventricular conduction defects, and infarctions. Because the PTSD group in this study included only those veterans with severe PTSD, it is important to interpret this study with caution. It is unknown whether men with less severe PTSD would show the same ECG abnormalities. It is also important to be cautious about generalizing the findings in this study since there have been no studies specifically evaluating cardiovascular morbidity and PTSD in women.

The gastrointestinal and musculoskeletal systems have also been shown to be associated with PTSD, but the relationship of PTSD to these two systems has not been as extensively researched as the relationship between PTSD and the cardiovascular system. The majority of the studies that have been conducted have gathered information about veterans, but a study of civilian young men and women found that there is a relationship between gastrointestinal symptoms and PTSD. Similarly, researchers found that PTSD was related to musculoskeletal symptoms among male firefighters. Additional research is needed to learn more about how these and other bodily system troubles may be related to PTSD.

What is the agenda for clinical practice?

One agenda for clinical practice is for mental-health workers to increase collaboration with primary and specialty medical care professionals in order to better address this relationship between PTSD and health problems. Medical personnel need to become more aware of the potential harmful effects trauma and PTSD can have on health. Specifically, it is important to screen for PTSD in medical settings. Studies of patients seeking physical-health care show that many have been exposed to trauma and experience posttraumatic stress but have not received appropriate mental-health care. In answer to this problem, it might be useful to integrate PTSD treatment services with medical care services.

The Numbers Count: Mental Disorders in America

From: National Institute of Mental Health

Mental Disorders in America

Mental disorders are common in the United States and internationally. An estimated 26.2 percent of Americans ages 18 and older — about one in four adults — suffer from a diagnosable mental disorder in a given year.¹ When applied to the 2004 U.S. Census residential population estimate for ages 18 and older, this figure translates to 57.7 million people.²Even though mental disorders are widespread in the population, the main burden of illness is concentrated in a much smaller proportion — about 6 percent, or 1 in 17 — who suffer from a serious mental illness.¹ In addition, mental disorders are the leading cause of disability in the U.S. and Canada for ages 15-44.³ Many people suffer from more than one mental disorder at a given time. Nearly half (45 percent) of those with any mental disorder meet criteria for 2 or more disorders, with severity strongly related to comorbidity.¹

In the U.S., mental disorders are diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).⁴

Mood Disorders

Mood disorders include major depressive disorder, dysthymic disorder, and bipolar disorder.

• Approximately 20.9 million American adults, or about 9.5 percent of the U.S. population age 18 and older in a given year, have a mood disorder.¹
• The median age of onset for mood disorders is 30 years.⁵
• Depressive disorders often co-occur with anxiety disorders and substance abuse.⁵

Major Depressive Disorder

• Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15-44.³
• Major depressive disorder affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year.¹
• While major depressive disorder can develop at any age, the median age at onset is 32.⁵
• Major depressive disorder is more prevalent in women than in men.⁶

Dysthymic Disorder

• Symptoms of dysthymic disorder (chronic, mild depression) must persist for at least two years in adults (one year in children) to meet criteria for the diagnosis. Dysthymic disorder affects approximately 1.5 percent of the U.S. population age 18 and older in a given year.¹ This figure translates to about 3.3 million American adults.²
• The median age of onset of dysthymic disorder is 31.¹

Bipolar Disorder

• Bipolar disorder affects approximately 5.7 million American adults, or about 2.6 percent of the U.S. population age 18 and older in a given year.¹
• The median age of onset for bipolar disorders is 25 years.⁵

Suicide

• In 2004, 32,439 (approximately 11 per 100,000) people died by suicide in the U.S.⁷
• More than 90 percent of people who kill themselves have a diagnosable mental disorder, most commonly a depressive disorder or a substance abuse disorder.⁸
• The highest suicide rates in the U.S. are found in white men over age 85.⁹
• Four times as many men as women die by suicide⁹; however, women attempt suicide two to three times as often as men.¹⁰

Schizophrenia

• Approximately 2.4 million American adults, or about 1.1 percent of the population age 18 and older in a given year,¹¹ have schizophrenia.
• Schizophrenia affects men and women with equal frequency.¹²
• Schizophrenia often first appears in men in their late teens or early twenties. In contrast, women are generally affected in their twenties or early thirties.¹²

Anxiety Disorders

Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and phobias (social phobia, agoraphobia, and specific phobia).

• Approximately 40 million American adults ages 18 and older, or about 18.1 percent of people in this age group in a given year, have an anxiety disorder.¹
• Anxiety disorders frequently co-occur with depressive disorders or substance abuse.¹
• Most people with one anxiety disorder also have another anxiety disorder. Nearly three-quarters of those with an anxiety disorder will have their first episode by age 21.5 ⁵

Panic Disorder

• Approximately 6 million American adults ages 18 and older, or about 2.7 percent of people in this age group in a given year, have panic disorder.¹
• Panic disorder typically develops in early adulthood (median age of onset is 24), but the age of onset extends throughout adulthood.⁵
• About one in three people with panic disorder develops agoraphobia, a condition in which the individual becomes afraid of being in any place or situation where escape might be difficult or help unavailable in the event of a panic attack.¹²

Obsessive-Compulsive Disorder (OCD)

• Approximately 2.2 million American adults age 18 and older, or about 1.0 percent of people in this age group in a given year, have OCD.¹
• The first symptoms of OCD often begin during childhood or adolescence, however, the median age of onset is 19.⁵

Post-Traumatic Stress Disorder (PTSD)

• Approximately 7.7 million American adults age 18 and older, or about 3.5 percent of people in this age group in a given year, have PTSD.¹
• PTSD can develop at any age, including childhood, but research shows that the median age of onset is 23 years.⁵
• About 19 percent of Vietnam veterans experienced PTSD at some point after the war.¹³ The disorder also frequently occurs after violent personal assaults such as rape, mugging, or domestic violence; terrorism; natural or human-caused disasters; and accidents.

Generalized Anxiety Disorder (GAD)

• Approximately 6.8 million American adults, or about 3.1 percent of people age 18 and over, have GAD in a given year.¹
• GAD can begin across the life cycle, though the median age of onset is 31 years old.⁵

Social Phobia

• Approximately 15 million American adults age 18 and over, or about 6.8 percent of people in this age group in a given year, have social phobia.¹
• Social phobia begins in childhood or adolescence, typically around 13 years of age.⁵

Agoraphobia

Agoraphobia involves intense fear and anxiety of any place or situation where escape might be difficult, leading to avoidance of situations such as being alone outside of the home; traveling in a car, bus, or airplane; or being in a crowded area.⁵

• Approximately 1.8 million American adults age 18 and over, or about 0.8 percent of people in this age group in a given year, have agoraphobia without a history of panic disorder.¹
• The median age of onset of agoraphobia is 20 years of age.⁵

Specific Phobia

Specific phobia involves marked and persistent fear and avoidance of a specific object or situation.

• Approximately 19.2 million American adults age 18 and over, or about 8.7 percent of people in this age group in a given year, have some type of specific phobia.¹
• Specific phobia typically begins in childhood; the median age of onset is seven years.⁵

Eating Disorders

The three main types of eating disorders are anorexia nervosa, bulimia nervosa, and binge-eating disorder.

• Females are much more likely than males to develop an eating disorder. Only an estimated 5 to 15 percent of people with anorexia or bulimia¹⁴ and an estimated 35 percent of those with binge-eating disorder¹⁵ are male.
• In their lifetime, an estimated 0.5 percent to 3.7 percent of females suffer from anorexia, and an estimated 1.1 percent to 4.2 percent suffer from bulimia.¹⁶
• Community surveys have estimated that between 2 percent and 5 percent of Americans experience binge-eating disorder in a 6-month period.^15,17
• The mortality rate among people with anorexia has been estimated at 0.56 percent per year, or approximately 5.6 percent per decade, which is about 12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population.¹⁸

Attention Deficit Hyperactivity Disorder (ADHD)

• ADHD, one of the most common mental disorders in children and adolescents, also affects an estimated 4.1 percent of adults, ages 18-44, in a given year.¹
• ADHD usually becomes evident in preschool or early elementary years. The median age of onset of ADHD is seven years, although the disorder can persist into adolescence and occasionally into adulthood.⁵

Autism

Autism is part of a group of disorders called autism spectrum disorders (ASDs), also known as pervasive developmental disorders. ASDs range in severity, with autism being the most debilitating form while other disorders, such as Asperger syndrome, produce milder symptoms.

• Estimating the prevalence of autism is difficult and controversial due to differences in the ways that cases are identified and defined, differences in study methods, and changes in diagnostic criteria. A recent study reported the prevalence of autism in 3-10 year-olds to be about 3.4 cases per 1000 children.¹⁹
• Autism and other ASDs develop in childhood and generally are diagnosed by age three.²⁰
• Autism is about four times more common in boys than girls. Girls with the disorder, however, tend to have more severe symptoms and greater cognitive impairment.^19,20

Alzheimer's Disease

• AD affects an estimated 4.5 million Americans. The number of Americans with AD has more than doubled since 1980.²¹
• AD is the most common cause of dementia among people age 65 and older.²²
• Increasing age is the greatest risk factor for Alzheimer’s. In most people with AD, symptoms first appear after age 65. One in 10 individuals over 65 and nearly half of those over 85 are affected.²³ Rare, inherited forms of Alzheimer’s disease can strike individuals as early as their 30s and 40s.²⁴
• From the time of diagnosis, people with AD survive about half as long as those of similar age without dementia.²⁵

For More Information

Mental Health Information and Organizations from NLM's MedlinePlus (en Español).

References

1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

2. U.S. Census Bureau Population Estimates by Demographic Characteristics. Table 2: Annual Estimates of the Population by Selected Age Groups and Sex for the United States: April 1, 2000 to July 1, 2004 (NC-EST2004-02) Source: Population Division, U.S. Census Bureau Release Date: June 9, 2005. http://www.census.gov/popest/national/asrh/

3. The World Health Organization. The World Health Report 2004: Changing History, Annex Table 3: Burden of disease in DALYs by cause, sex, and mortality stratum in WHO regions, estimates for 2002. Geneva: WHO, 2004.

4. American Psychiatric Association. Diagnostic and Statistical Manual on Mental Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Press, 1994.

5. Kessler RC, Berglund PA, Demler O, Jin R, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry. 2005 Jun;62(6):593-602.

6. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Journal of the American Medical Association, 2003; Jun 18;289(23):3095-105.

7. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (producer). Web-based Injury Statistics Query and Reporting System (WISQARS). Available online from: URL: http://www.cdc.gov/ncipc/wisqars/default.htm accessed December 2006.

8. Conwell Y, Brent D. Suicide and aging I: patterns of psychiatric diagnosis. International Psychogeriatrics, 1995; 7(2): 149-64.

9. Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: final data for 2002. National Vital Statistics Reports. 2004 Oct 12;53 (5):1-115.

10. Weissman MM, Bland RC, Canino GJ, et al. Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, 1999; 29(1): 9-17.

11. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry. 1993 Feb;50(2):85-94.

12. Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.

13. Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koen KC, Marshall R. The psychological risk of Vietnam for U.S. veterans: A revist with new data and methods. Science. 2006; 313(5789):979-982.

14. Andersen AE. Eating disorders in males. In: Brownell KD, Fairburn CG, eds. Eating disorders and obesity: a comprehensive handbook. New York: Guilford Press, 1995;177-87.

15. Spitzer RL, Yanovski S, Wadden T, Wing R, Marcus MD, Stunkard A, Devlin M, Mitchell J, Hasin D, Horne RL. Binge eating disorder: its further validation in a multisite study. International Journal of Eating Disorders. 1993 Mar;13(2):137-53.

16. American Psychiatric Association Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry. 2000 Jan;157(1 Suppl):1-39..

17. Bruce B, Agras WS. Binge eating in females: a population-based investigation. International Journal of Eating Disorders. 1992;12:365-73.

18. Sullivan PF. Mortality in anorexia nervosa. American Journal of Psychiatry. 1995 Jul;152(7):1073-4.

19. Yeargin-Allsopp M, Rice C, Karapurkar T, Doernberg N, Boyle C, Murphy C. Prevalence of Autism in a US Metropolitan Area. The Journal of the American Medical Association.. 2003 Jan 1;289(1):49-55.

20. Fombonne E. Epidemiology of autism and related conditions. In: Volkmar FR, ed. Autism and pervasive developmental disorders. Cambridge, England: Cambridge University Press, 1998; 32-63.

21. Hebert LE, Scherr PA, Bienias JL, Bennett DA, Evans DA. Alzheimer disease in the US population: prevalence estimates using the 2000 census. Archives of Neurology. 2003 Aug;60(8):1119-22.

22. National Institute on Aging, Progress Report on Alzheimer’s disease 2004-2005. NIH Publication No. 05-5724. Bethesda, MD: National Institute on Aging, 2005. Available from http://www.alzheimers.org/pr04-05/index.asp

23. Evans DA, Funkenstein HH, Albert MS, Scherr PA, Cook NR, Chown MJ, Hebert LE, Hennekens CH, Taylor JO. Prevalence of Alzheimer's disease in a community population of older persons: Higher than previously reported. The Journal of the American Medical Association. 1989 Nov 10;262(18):2551-6.

24. Bird TD, Sumi SM, Nemens EJ, Nochlin D, Schellenberg G, Lampe TH, Sadovnick A, Chui H, Miner GW, Tinklenberg J. Phenotypic heterogeneity in familial Alzheimer's disease: a study of 24 kindreds. Annals of Neurology. 1989 Jan;25(1):12-25.

25. Larson EB, Shadlen MF, Wang L, McCormick WC, Bowen JD, Teri L, Kukull WA. Survival after initial diagnosis of Alzheimer disease. Annals of Internal Medicine. 2004 Apr 6;140(7):501-9.

Examples of Post Traumatic Stress Disorder (PTSD)

From: www.anxietybc.com

What is Post Traumatic Stress Disorder?

PTSD stands for Post Traumatic Stress Disorder. PTSD is an anxiety disorder that can develop after an individual has experienced or witnessed a major trauma.

There are many different types of symptoms that someone can have after a trauma, but PTSD symptoms fall into 3 categories:

1. Reliving or re-experiencing the trauma
2. Attempts to avoid thoughts, situations, or people that are reminders of the trauma
3. Increased anxiety or arousal, including being constantly on guard for danger, and being easily startled

People with PTSD will have at least one or more symptoms of each of these categories

Recognizing PTSD. Do I Have It?

John's Story

John is a 54-year-old man who witnessed his grandson die in an automobile accident. A semi-truck trailer crashed into the car John was driving. His grandson was a passenger in the front seat. Although John had some minor injuries after the accident, his grandson died at the scene. Before the accident, John ran a successful small business and was very close to his family.

Since the accident 8 months ago, John has been having flashbacks, or very vivid images, of the crash; these flashbacks will sometimes cause him to dissociate, that is, he will lose track of where he is and feel like he is back at the scene of the accident. He is very scared of these flashbacks, and worries that it is a sign that he is going "crazy". He tries to avoid anything that reminds him of the crash, and will avoid looking at pictures of his grandson, going to his grave site, or talking about him with friends and family.

John also seems to be using work as a way of avoiding thinking about the accident. His wife is very concerned, because he is working over 10 hours a day and has started going in to work most weekends. However, when he is at work, he is constantly distracted and has difficulty concentrating. He also finds it hard to make important decisions. Several of his employees have told him that they are worried about the changes they have seen in him.

John has started drinking every day when he gets home. He does this to try to stop the memories and to lessen his feelings of anxiety. He feels angry and irritable much of the time. Although he is worried that he is pushing his family and friends away, he says that he often feels numb. He says that he has not felt positive feelings of love, joy, or sexual arousal for quite some time. He has not been able to drive by the place where the accident took place, and he will not take any passengers in his car. He is also extremely nervous when driving alone, and as a result tries to use public transit as much as possible, despite the inconvenience. John has difficulty remembering certain parts of the accident, even though he did not lose consciousness or hit his head. Recently, he has been thinking that life is not worth living this way, even though he never thought he would consider taking his own life. He does not want to hurt his family.

Sharon's Story

Sharon is a 23-year-old single woman who lives with her older sister. She left university two years ago after being raped while out on a date with a male student she met through class. Since being assaulted, she has experienced a variety of symptoms that have not gone away with time. She has unwanted memories of her trauma whenever she sees a man who looks like the person who assaulted her. She often has nightmares about the rape, and sometimes they are so upsetting that she is not able to fall back asleep without leaving the lights on or taking an extra sleeping pill. She has also had several panic attacks when thinking about the rape, and avoids watching movies that may show a rape scene. She has not been able to talk about the assault with her family doctor, even though she is afraid that she may have been exposed to a sexually transmitted disease. She has never told any friends or family about it either, because she is scared that they won't believe her or that they will think badly of her.

Sharon has been unable to go back to university, because she fears that she might see the man who raped her. She also worries that she won't be able to pay attention in class and do her homework because she now has a very hard time concentrating. Sharon says that she no longer feels any enjoyment when she is with her friends and family. She has let all of her hobbies go, including quitting the soccer team and not reading her favourite books anymore. She says that she feels cut off from everyone around her, and she doubts that she will ever be able to be intimate with a man again. This is especially upsetting to her, because she is afraid that this means she will never be able to start a family, and having children some day has always been very important to her.

When Sharon is out in public, she is constantly on guard, especially if men are around. She is finding it difficult to keep a job, and she lives with her sister because she no longer feels safe living on her own. Recently, she got very angry at her sister when she brought some male friends over to their apartment. Sharon's relationship with her sister is now quite tense.

What kind of trauma leads to PTSD?

There is no one type of trauma that can lead to PTSD. Rather, there are several different kinds of traumatic situations that can do this, all of which have certain common elements:

1. The trauma was life threatening or it led to an actual or potentially serious injury
2. The individual reacted to the trauma with intense fear, helplessness, or horror.

You can develop PTSD if you have been directly involved in a serious traumatic event, or if you witnessed a traumatic event. Some common traumas that can lead to PTSD include:

• Being in, or seeing, a serious car accident
• Being sexually assaulted/raped
• Experiencing long-term sexual or physical abuse
• Undergoing major surgery (bone marrow transplant, extensive hospitalization, severe burns)
• Experiencing or witnessing natural disasters (earthquakes, hurricanes, floods, fire)
• Experiencing torture, a terrorist attack, or being a prisoner of war
• Experiencing or witnessing a violent crime (kidnapping, physical assault, assault or murder of a loved one)
• Being involved in a war or witnessing violence or death during wartime

Symptoms of PTSD

In order to receive a diagnosis of PTSD, you need to be currently experiencing at least one symptom from each of the following three categories.

1. Symptoms of reliving or "re-experiencing" the trauma

• Upsetting memories about the event. This usually involves having vivid images about the trauma come up again and again even when you do not want to have them. For example, if you were physically attacked, you might keep remembering your attacker's face. Or, if you were in a car accident, you might have strong memories about the sound of the crash or a vivid picture of blood all over yourself or someone else involved.
• Nightmares about the trauma.People with PTSD will often have very vivid nightmares of either the trauma or themes surrounding the trauma. For example, if you were in a car accident, you might have frequent nightmares about being in the accident yourself, or about other people being involved in accidents. Some people with PTSD who were assaulted will have nightmares of being chased, and the person chasing them in the dream might not be the person who assaulted them.
• Acting as if the trauma were happening again ("reliving the trauma"). This is also called "dissociation", where an individual loses touch with the present, and feels as if they are living through the trauma again. Some people with this symptom might speak and act as if they are physically in the traumatic situation, whereas others might appear to simply stare off into space for a period of time. Some people with PTSD will also have "flashbacks", which are very vivid images of the trauma they experienced. Flashbacks can seem very real, and some people describe it as a picture or movie that they can see clearly in their minds.
• Anxiety or distress when reminded of the trauma. Some people with PTSD become extremely upset or feel very anxious whenever they are confronted with a person, place, situation, or conversation that reminds them of the trauma. This can include becoming very upset when hearing tires squeal if you were in a car accident, or feeling anxious when watching violence on TV if you were assaulted.

Why do I have flashbacks and upsetting intrusive thoughts? When you live through a traumatic experience, your mind processes and stores the memory a little differently than it stores regular experiences. Sensory information about the trauma, that is, smells, sights, sounds, tastes, and the feel of things, is given high priority in the mind, and is remembered as something threatening. Once this happens, whenever you are faced with a touch, a taste, a smell, a feel, or a sight that reminds you of your trauma, the memory (and the feeling of threat) comes back up and you might have vivid memories or flashbacks about the trauma. This is just the way the mind works. It is not dangerous or a sign that you are going crazy.

2. Symptoms of avoidance

• Avoiding reminders of the trauma. Many people with PTSD will try very hard to avoid anything that is associated with, or reminds them of, the traumatic event they experienced. Reminders can include:
  • Circumstances (e.g., the actual date of the event, clothes worn, place where the event occurred, etc.)
  • Things associated with the trauma (e.g. being in a car if the trauma was a car accident)
  • General signs of danger (e.g. TV shows about violence, news programs, police or fire department sirens, fire alarms, etc.)
• Avoiding thoughts, feelings, or memories related to the trauma. Although many people with PTSD will avoid any reminders of their traumatic experience, it is also common for people to avoid even thinking about what happened. For example, you might avoid talking to anyone about the trauma, and if you have thoughts or memories about what happened, you might try to push them out of your head.
• Not able to recall parts of the trauma. It is not uncommon for people who have lived through a trauma to have difficulty remembering parts of it, or the entire trauma, or to be confused about the timeline of events.
• Reduced interest in previously enjoyed activities. For example, after a trauma, you might stop wanting to spend time with friends and family, or you might stop all activities that you used to enjoy (such as sports or hobbies).
• Feeling detached/estranged from others. People with this symptom describe feeling cut off from others, even though they might have family and/or friends around them.
• Feeling numb/unable to experience feelings. Some people with PTSD will say that they generally feel numb, and don't experience loving feelings anymore (such as love, joy, or happiness). People with this symptom might have a hard time even describing how they feel, and are not able to recognize when they are happy, sad, or angry.
• Feeling of foreshortened future. It is not uncommon for people with PTSD to say that they have a feeling of "impending doom"; that is, they say that they don't expect to live long, that something bad is likely to happen again soon, or that they feel hopeless about the future.

3. Symptoms of increased anxiety or "hyperarousal"

• Sleep difficulties. Some people with PTSD will have trouble falling asleep or staying asleep. This often happens when you feel quite anxious throughout the day.
• Anger outbursts or irritability. It is not uncommon for people with PTSD to feel more irritable and angry. If you have this symptom, you might find yourself snapping at people, or getting extremely angry in a situation that reminds you of your trauma. For example, if you were in a car accident, and while driving someone cuts you off, you might get very angry and even yell or act inappropriately.
• Concentration difficulties. Many people with PTSD report that they have a hard time paying attention or concentrating while completing daily tasks. This is often the result of being very anxious; it is not a sign that there is something wrong with your memory.
• Hypervigilance. Often, people with PTSD feel as if they are "on guard" or "on alert" all the time. People with this symptom will be very easily startled, and will jump at the slightest sound (for example, the telephone ringing, someone tapping you on the shoulder).

KEEP IN MIND: Although most people with PTSD will develop symptoms within three months of the traumatic event, some people don't notice any symptoms until years after it occurred. A major increase in stress, or exposure to a reminder of the trauma, can trigger symptoms to appear months or years later.

When is it (and when is it NOT) PTSD

As you probably noticed, there are many symptoms of PTSD, and very few people have all of them. Also, it is normal to experience times of greater anxiety in your life, particularly when you are under a lot of stress. Some of the symptoms of PTSD, such as sleep or concentration problems, for example, are also seen in other anxiety disorders. So how do you know if you might have PTSD? Here are two tips that might be helpful: Tip #1: If you have at least one symptom in each of the 3 categories, and your symptoms only started after a traumatic event, then you might have PTSD. If your anxiety symptoms were already present before the trauma, then it is probably not PTSD.

Tip #2: It is normal to feel more anxious right after a trauma. But over time, these anxious feelings will settle down. Remember: not everyone who lives through a trauma will develop PTSD. But if your symptoms have been present for over one month, and you find that they are interfering significantly in your life, then you might have PTSD.

How else can I recognize if I have PTSD?

Many adults with PTSD have strong feelings of shame, guilt, or despair about what happened. It is also not uncommon to have increased feelings of hostility or anger, this is sometimes directed towards entire groups of people (for example, you might find yourself being very angry and suspicious of men if you were raped, or you might get extremely angry at drivers who speed if you were in a serious car accident).

Because living through a trauma can be such a life-changing experience, some adults with PTSD find that their relationships with others are different after a trauma. For instance, you might have difficulty maintaining a romantic relationship or trusting other people and their intentions following a sexual assault, or you might have some sexual or intimacy problems.

REMEMBER: Adults with PTSD can sometimes feel like they are "going crazy" or are "broken" following a trauma. But it is important to keep in mind that PTSD is a treatable anxiety disorder. No matter how bad you feel or how hopeless it seems, there is help for PTSD.

PTSD: The Facts

• Several studies have shown that a majority of people will likely experience at least one traumatic event in their lives; but many of them will NOT develop PTSD.
• The chance of developing PTSD goes up if the trauma was very severe, chronic (that is, lasted a long time), or you were physically close to the event, that is, if the trauma happened right next to you or in front of you.
• Certain traumas are more likely to lead to PTSD than others. For example, you are more likely to develop PTSD if the trauma you experienced was a rape/sexual assault, combat exposure, or childhood neglect/physical abuse.
• If you develop PTSD symptoms within one month of a traumatic event, this is called acute PTSD. If you don't develop any symptoms until at least six months after the trauma, this is called delayed onset PTSD.
• Adults with PTSD can have other problems as well, including depression, drug and alcohol abuse, or other anxiety problems (for example, panic disorder, social anxiety).

Post-traumatic Stress Disorder (PTSD) -Symptoms, Treatment, and Self-Help

From: www.helpguide.org

If you went through a traumatic experience and are having trouble getting back to your regular life and reconnecting to others, you may be suffering from post-traumatic stress disorder (PTSD). When you have PTSD, it can seem like you’ll never get over what happened or feel normal again. But help is available – and you are not alone. If you are willing to seek treatment, stick with it, and reach out to others for support, you will be able to overcome the symptoms of PTSD and move on with your life.

What is post-traumatic stress disorder (PTSD)?

Post-traumatic stress disorder (PTSD) is a disorder that can develop following a traumatic event that threatens your safety or makes you feel helpless. Most people associate PTSD with battle-scarred soldiers – and military combat is the most common cause in men – but any overwhelming life experience can trigger PTSD, especially if the event is perceived as unpredictable and uncontrollable.

Post-traumatic stress disorder (PTSD) can affect those who personally experience the catastrophe, those who witness it, and those who pick up the pieces afterwards, including emergency workers and law enforcement officers. It can even occur in the friends or family members of those who went through the actual trauma.

Traumatic events that can lead to post-traumatic stress disorder (PTSD) include:

War Rape Natural disasters A car or plane crash

Kidnapping Violent assault Sexual or physical abuse Medical procedures (especially in kids)

Wendy’s Story

Three months ago, Wendy was in a major car accident. She sustained only minor injuries, but two friends riding in her car were killed. At first, the accident seemed like just a bad dream. Then Wendy started having nightmares about it: waking up in a cold sweat to the sound of crunching metal and breaking glass. Now, the sights and sounds of the accident haunt her all the time. She has trouble sleeping at night, and during the day she feels irritable and on edge. She jumps whenever she hears a siren or screeching tires, and she avoids all TV programs that might show a car chase or accident scene. Wendy also avoids driving whenever possible, and refuses to go anywhere near the site of the crash.

PTSD is a response by normal people to an abnormal situation

The traumatic events that lead to post-traumatic stress disorder are usually so overwhelming and frightening that they would upset anyone. When your sense of safety and trust are shattered, it’s normal to feel crazy, disconnected, or numb – and most people do. The only difference between people who go on to develop PTSD and those who don’t is how they cope with the trauma.

After a traumatic experience, the mind and the body are in shock. But as you make sense of what happened and process your emotions, you come out of it. With post-traumatic stress disorder (PTSD), however, you remain in psychological shock. Your memory of what happened and your feelings about it are disconnected. In order to move on, it’s important to face and feel your memories and emotions.

Symptoms of post-traumatic stress disorder (PTSD)

Following a traumatic event, almost everyone experiences at least some of the symptoms of PTSD. It’s very common to have bad dreams, feel fearful or numb, and find it difficult to stop thinking about what happened. But for most people, these symptoms are short-lived. They may last for several days or even weeks, but they gradually lift.

If you have post-traumatic stress disorder (PTSD), however, the symptoms don’t decrease. You don’t feel a little better each day. In fact, you may start to feel worse. But PTSD doesn’t always develop in the hours or days following a traumatic event, although this is most common. For some people, the symptoms of PTSD take weeks, months, or even years to develop.

The symptoms of post-traumatic stress disorder (PTSD) can arise suddenly, gradually, or come and go over time. Sometimes symptoms appear seemingly out of the blue. At other times, they are triggered by something that reminds you of the original traumatic event, such as a noise, an image, certain words, or a smell. While everyone experiences PTSD differently, there are three main types of symptoms, as listed below.

Re-experiencing the traumatic event

• Intrusive, upsetting memories of the event
• Flashbacks (acting or feeling like the event is happening again)
• Nightmares (either of the event or of other frightening things)
• Feelings of intense distress when reminded of the trauma
• Intense physical reactions to reminders of the event (e.g. pounding heart, rapid breathing, nausea, muscle tension, sweating)

PTSD symptoms of avoidance and emotional numbing

• Avoiding activities, places, thoughts, or feelings that remind you of the trauma
• Inability to remember important aspects of the trauma
• Loss of interest in activities and life in general
• Feeling detached from others and emotionally numb
• Sense of a limited future (you don’t expect to live a normal life span, get married, have a career)

PTSD symptoms of increased arousal

• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance (on constant “red alert”)
• Feeling jumpy and easily startled

Other common symptoms of post-traumatic stress disorder

• Anger and irritability
• Guilt, shame, or self-blame
• Substance abuse
• Depression and hopelessness
• Suicidal thoughts and feelings
• Feeling alienated and alone
• Feelings of mistrust and betrayal

Getting help for post-traumatic stress disorder (PTSD)

If you suspect that you or a loved one has post-traumatic stress disorder (PTSD), it’s important to seek help right away. The sooner PTSD is confronted, the easier it is to overcome. If you’re reluctant to seek help, keep in mind that PTSD is not a sign of weakness, and the only way to overcome it is to confront what happened to you and learn to accept it as a part of your past. This process is much easier with the guidance and support of an experienced therapist or doctor.

It’s only natural to want to avoid painful memories and feelings. But if you try to numb yourself and push your memories away, post-traumatic stress disorder (PTSD) will only get worse. You can’t escape your emotions completely – they emerge under stress or whenever you let down your guard – and trying to do so is exhausting. The avoidance will ultimately harm your relationships, your ability to function, and the quality of your life.

Why Should I Seek Help for PTSD?

• Early treatment is better. Symptoms of PTSD may get worse. Dealing with them now might help stop them from getting worse in the future. Finding out more about what treatments work, where to look for help, and what kind of questions to ask can make it easier to get help and lead to better outcomes.
• PTSD symptoms can change family life. PTSD symptoms can get in the way of your family life. You may find that you pull away from loved ones, are not able to get along with people, or that you are angry or even violent. Getting help for your PTSD can help improve your family life.
• PTSD can be related to other health problems. PTSD symptoms can worsen physical health problems. For example, a few studies have shown a relationship between PTSD and heart trouble. By getting help for your PTSD you could also improve your physical health.

Source: National Center for PTSD

Finding a therapist for post-traumatic stress disorder (PTSD)

When looking for a therapist for post-traumatic stress disorder (PTSD), seek out mental health professionals who specialize in the treatment of trauma and PTSD. You can start by asking your doctor if he or she can provide a referral, however, he or she may not know therapists with experience treating trauma. You may also want to ask other trauma survivors for recommendations, or call a local mental health clinic, psychiatric hospital, or counseling center.

Beyond credentials and experience, it’s important to find a PTSD therapist who makes you feel comfortable and safe, so there is no additional fear or anxiety about the treatment itself. Trust your gut; if a therapist doesn’t feel right, look for someone else. For therapy to work, you need to feel respected and understood.

Help for U.S. veterans with PTSD

If you’re a veteran suffering from PTSD or trauma, you can turn to your local VA hospital or Vet Center for help. Vet Centers offer free counseling to combat veterans and their families. To find out more about the resources and benefits available to you, you can also call the VA Health Benefits Service Center at 1-877-222-VETS.

Click here for a nationwide directory of facilities for veterans, including VA hospitals and Vet Centers, provided by the U.S. Department of Veterans Affairs.

Trauma therapist referral

For help locating a trauma therapist, treatment center, or support group in your area, contact the Sidran Traumatic Stress Institute by email or by phone at (410) 825-8888 ext. 203.

Treatment for post-traumatic stress disorder (PTSD)

Treatment for post-traumatic stress disorder (PTSD) relieves symptoms by helping you deal with the trauma you’ve experienced. Rather than avoiding the trauma and any reminder of it, you’ll be encouraged in treatment to recall and process the emotions and sensations you felt during the original event. In addition to offering an outlet for emotions you’ve been bottling up, treatment for PTSD will also help restore your sense of control and reduce the powerful hold the memory of the trauma has on your life.

Types of treatments for post-traumatic stress disorder (PTSD)

• Trauma-focused cognitive-behavioral therapy. Cognitive-behavioral therapy for PTSD and trauma involves carefully and gradually “exposing” yourself to thoughts, feelings, and situations that remind you of the trauma. Therapy also involves identifying upsetting thoughts about the traumatic event–particularly thoughts that are distorted and irrational—and replacing them with more balanced picture.
• EMDR (Eye Movement Desensitization and Reprocessing) – EMDR incorporates elements of cognitive-behavioral therapy with eye movements or other forms of rhythmic, left-right stimulation, such as hand taps or sounds. Eye movements and other bilateral forms of stimulation are thought to work by “unfreezing” the brain’s information processing system, which is interrupted in times of extreme stress, leaving only frozen emotional fragments which retain their original intensity. Once EMDR frees these fragments of the trauma, they can be integrated into a cohesive memory and processed.
• Family therapy. Since PTSD affects both you and those close to you, family therapy can be especially productive. Family therapy can help your loved ones understand what you’re going through. It can also help everyone in the family communicate better and work through relationship problems.
• Medication. Medication is sometimes prescribed to people with PTSD to relieve secondary symptoms of depression or anxiety, but it does not treat the causes of PTSD.

Self-help and support for post-traumatic stress disorder (PTSD)

Recovery from post-traumatic stress disorder (PTSD) is a gradual, ongoing processing. Healing doesn’t happen overnight, nor do the memories of the trauma ever disappear completely. This can make life seem difficult at times. But there are many things you can do to cope with residual symptoms and reduce your anxiety and fear.

Reach out to others for support

Post-traumatic stress disorder (PTSD) can make you feel disconnected from others. You may be tempted to withdraw from social activities and your loved ones. But it’s important to stay connected to life and the people who care about you. Support from other people is vital to your recovery from PTSD, so ask your close friends and family members for their help during this tough time.

Also consider joining a support group for survivors of the same type of trauma you went through. Support groups for post-traumatic stress disorder (PTSD) can help you feel less isolated and alone. They also provide invaluable information on how to cope with symptoms and work towards recovery. If you can’t find a support group in your area, look for an online group.

Avoid alcohol and drugs

When you’re struggling with the difficult emotions and traumatic memories, you may be tempted to self-medicate with alcohol or drugs. But while alcohol or drugs may temporarily make you feel better, they make post-traumatic stress disorder (PTSD) worse in the long run. Substance use worsens many symptoms of PTSD, including emotional numbing, social isolation, anger, and depression. It also interferes with treatment and can add to problems at home and in your relationships.

Challenge your sense of helplessness

Overcoming your sense of helplessness is key to overcoming post-traumatic stress disorder (PTSD). Trauma leaves you feeling powerless and vulnerable. It’s important to remind yourself that you have strengths and coping skills that can get you through tough times.

One of the best ways to reclaim your sense of power is by helping others: volunteer your time, give blood, reach out to a friend in need, or donate to your favorite charity. Taking positive action directly challenges the sense of helplessness that contributes to trauma.

Post-traumatic stress disorder (PTSD) and the family

If a loved one has post-traumatic stress disorder (PTSD), it’s essential that you take care of yourself and get extra support. PTSD can take a heavy toll on the family if you let it. It can be hard to understand why your loved one won’t open up to you – why he or she is less affectionate and more volatile. The symptoms of PTSD can also result in job loss, substance abuse, and other stressful problems.

Letting your family member’s PTSD dominate your life while ignoring your own needs is a surefire recipe for burnout. In order to take care of your loved one, you first need to take care of yourself. It’s also helpful to learn all you can about post-traumatic stress disorder (PTSD). The more you know about the symptoms and treatment options, the better equipped you'll be to help your loved one and keep things in perspective.

Helping a loved one with PTSD

• Be patient and understanding. Getting better takes time, even when a person is committed to treatment for PTSD. Be patient with the pace of recovery and offer a sympathetic ear. A person with PTSD may need to talk about the traumatic event over and over again. This is part of the healing process, so avoid the temptation to tell your loved one to stop rehashing the past and move on.
• Try to anticipate and prepare for PTSD triggers. Common triggers include anniversary dates; people or places associated with the trauma; and certain sights, sounds, or smells. If you are aware of what triggers may cause an upsetting reaction, you’ll be in a better position to offer your support and help your loved one calm down.
• Don’t take the symptoms of PTSD personally. Common symptoms of post-traumatic stress disorder (PTSD) include emotional numbness, anger, and withdrawal. If your loved one seems distant, irritable, or closed off, remember that this may not have anything to do with you or your relationship.
• Don’t pressure your loved one into talking. It is very difficult for people with PTSD to talk about their traumatic experiences. For some, it can even make things worse. Never try to force your loved one to open up. Let the person know, however, that you’re there when and if he or she wants to talk.

To Learn More: Related Helpguide Articles

Emotional Trauma: Causes, Symptoms, Effects, and Treatment EMDR Therapy: A Guide to Making An Informed Choice.

Stress Relief: Yoga, Meditation, and Other Relaxation Techniques Coping with Grief and Loss: A Guide to Grieving and Bereavement

Related links for post-traumatic stress disorder (PTSD)

General information about post-traumatic stress disorder (PTSD)

Post-Traumatic Stress Disorder Research Fact Sheet – Overview of the latest research on PTSD, including its causes, risk factors, and promising new treatments. (National Institute of Mental Health)

Myths and Facts About PTSD – Learn the truth behind common misconceptions about PTSD. (Post-traumatic Stress Disorder Alliance)

How Common is PTSD? – Fact sheet on the prevalence of PTSD in the U.S., including its occurrence in the military. Also includes information on PTSD causes and risk factors. (National Center for PTSD)

Symptoms of post-traumatic stress disorder (PTSD)

Post-Traumatic Stress Disorder Self-Test – Online self-test for PTSD to help you evaluate your symptoms. (Anxiety Disorders Association of America)

The Symptoms of Post-Traumatic Stress Disorder: Chronic and/or Delayed – Description of PTSD’s many symptoms, including withdrawal, avoidance, isolation, and flashbacks. (PTSD Support Services)

Treatment and help for post-traumatic stress disorder (PTSD)

Treatment of PTSD – Guide to the treatments for PTSD, including cognitive therapy, exposure therapy, and EMDR. (National Center for PTSD)

Finding a Therapist – Advice on how to find a therapist for PTSD treatment. Includes questions to ask a potential therapist. (National Center for PTSD)

Therapy for Post-Traumatic Stress and Dissociative Conditions: What to Look for and How to Choose a Therapist – Tips on choosing a therapist and treatments for PTSD. Includes a phone number for referrals. (Sidran)

VVA's Guide on PTSD – Advice for combat veterans on how to get help and claim military benefits. (Vietnam Veterans of America)

Coping with post-traumatic stress disorder (PTSD)

Coping with PTSD and Recommended Lifestyle Changes for PTSD Patients – Tips on how to cope with PTSD in healthy ways that promote healing and recovery. (National Center for PTSD)

Managing Stress and Recovering from Trauma: Facts and Resources for Veterans and Families – Learn how to manage traumatic stress and cope with the symptoms of PTSD. (National Center for PTSD)

Helping a loved one with post-traumatic stress disorder (PTSD)

Returning from the War Zone: A Guide for Families (PDF) – Advice for service members and their families on what to expect and how to adapt after returning home from war. (National Center for PTSD)

Partners with PTSD – Article for the friends and family members of people with PTSD. Includes an explanation of symptoms and what you can do to help. (Gift from Within)

Partners of Veterans with PTSD: Caregiver Burden and Related Problems – Learn how to help a loved one with PTSD while still taking care of yourself. Includes tips for dealing with caregiver burnout. (National Center for PTSD)

Melinda Smith, M.A., Robert Segal, Ph.D., and Jeanne Segal, Ph.D., contributed to this article. Last modified: November 2008