As we continue our series on some common mental health diagnoses, it’s our sincere hope these posts spark conversations among individuals and families, helping to alleviate stigma and start the much-needed healing and education so desperately when addressing and helping this medical population. Today, we’d like to touch on a diagnosis that’s seen far too often in this world: Post-Traumatic Stress Disorder.
As we continue our conversation with Dr. Elizabeth Fitelson, Assistant Professor of Psychiatry at Columbia University and director of their Women’s Mental Health Program, we open the door to further discussion around this mental health diagnosis:
Philosophy: So, for those who have never heard of it or aren’t quite sure, what exactly is Post-Traumatic Stress Disorder?
Dr. Fitelson: Post-Traumatic Stress Disorder (PTSD, for short) is listed under the category of trauma and trauma-related disorders. It used to be considered an anxiety disorder, because anxiety is a big hallmark of PTSD. But it was placed in a different category because, unlike generalized anxiety disorder, you can’t have PTSD without trauma, without the ‘T’, so to speak. It’s a reaction to something or some things that have happened to you over either in a single episode or over the course of your development.
In order to get a diagnosis of PTSD, someone has to have experienced a trauma, which, according to the DSM is, “exposure to actual or threatened death, serious injury, and/or sexual violence, in one or more of the following ways: either directly experiencing the traumatic event, witnessing it in person, learning that a traumatic event has occurred to a close family member or friend, and/or experiencing repeated or extreme exposure to aversive details of the traumatic events.” A classic example would be the first responders of the 911 World Trade Center, who not only might have witnessed the tragedy with the Twin Towers but then went back every day to gather human remains, which resulted in repeated exposure.
Then there are the different symptom clusters in PTSD, the first one being the classic re-experiencing of the event, which is recurrent, involuntary, intrusive and distressing memories of the traumatic event, recurrent dreams about it, and even dissociative reactions that act like flashbacks. It’s not just remembering the event or thinking about it, but actually having the feelings and even sometimes seeing the images go through your head of the event itself and feeling like you’re reliving the moment. That can happen on a continuum where PTSD sufferers completely lose awareness of what’s actually going on around them when they’re in the flashback, or they have a dull awareness of ‘I’m here but I feel like I did when that happened.’ Exposures to people, places, things — even scents — have to cause distress and then there can be real physiological reactions. You can use the World Trade Center first responder example, or it could be someone who was raped suddenly finding themselves in a situation or an area that resembles their traumatic situation in some way, even a smell that might smell similar to their attacker can trigger very strong memories and reactions.
Another symptom cluster is avoidance where people with PTSD, because of their extreme reaction to those memories, start avoiding events, people, places, and things. So, if you feel terrible every time you go through Lower Manhattan, you’re going to start avoiding Lower Manhattan. That avoidance can actually get to the point where avoid going outside at all in order to avoid external reminders of people, places, conversations, activities, objects, and situations that arouse any of those memories.
There can also be problems with cognition and mood that begin after the event, like an inability to remember important aspects of the trauma, a sort of dissociative amnesia. PTSD sufferers can suffer a global lack of trust, where they feel the world is unsafe. Persistent, distorted cognitions about the cause lending to self-blame; negative emotional states like being stuck in a feeling of fear, guilt or shame; diminished interests; feelings of detachment and a depression symptom called ‘anhedonia’, which is an inability to really experience positive feelings — all of those are symptom clusters that occur due to PTSD.
There’s also the hyper-arousal cluster of symptoms where sometimes people can experience hypervigilance, which is a heightened state of awareness based in fear. If a door slammed in the room most of the room would have a little bit of a reaction, but someone with PTSD might jump off their chair and be half-way across the room before you’ve even registered the sound. Some people with PTSD have said that anytime they walk into a setting, they know exactly where the exits are at any moment and they’ve like cased the crowd.
Irritability and anger outbursts are very common, as are reckless or self-destructive behavior or problems with concentration and sleep disturbance. All of these symptoms must persist for a month in order to receive a diagnosis of PTSD. For some people, these symptoms can really persist and can affect the rest of their lives.
Philosophy: Are there core morbidities like eating disorders that can occur with PTSD?
Dr Fitelson: Yes, most certainly. Depression, major depressive disorder and other anxiety disorders are the most common, and panic disorder and generalized anxiety disorder are probably the most frequent of those, along with the strong associations between trauma and substance abuse disorders. And then, yes, certainly people who have had especially early trauma are more at risk of eating disorders. Some trauma can trigger the expression of bipolar disorder.
Interviewer: What is the treatment protocol for PTSD?
Dr Fitelson: So its multi-factorial; there’s not one-size-fits-all option. Medications can play a role for some people, and can be quite helpful for some of the anxiety symptoms, certainly for the co-morbid depression anxiety. Treating a co-occurring substance abuse disorder is really critical. It’s very difficult to heal from PTSD if someone is abusing substances because it often puts them right back into the trauma mind set or in dangerous situations.
One of the keys to treating PTSD is to establish real and psychological safety, so it’s very difficult to treat trauma if someone’s in a situation that prevents healing, like an ongoing, abusive relationship where they’re really not safe, where their hypervigilance might be quite well-justified. So it’s really hard to treat the actual PTSD if the trauma is ongoing. So helping someone to achieve safety is really the first step of dealing with PTSD.
There are different ways of getting at the different symptom clusters. Antidepressant medications can be helpful for some people. Sleep aids can be helpful in some cases, although in general they can help, but they’re usually not enough to help someone achieve remission from PTSD symptoms. In terms of psychotherapy, the classic and best studied modality for treatment of PTSD is exposure therapies, which basically involve helping someone again integrate those traumatic memories in a more healthy way into their memory and mind. That involves often just talking about traumatic event with a therapist at first, then working with them to deal with the fear and anxiety the event can trigger. PTSD is complicated because it’s not just like the memory causes these symptoms, but the avoidance of things that might trigger the symptoms is usually what causes a lot of distress in someone’s life. The therapy essentially helps someone face their biggest fear along with not avoiding the things that are triggering, but you have to do it in the context of safety, and in a very careful, graduated way. So you really have to start with the very basics. There are also a lot of different relaxation therapies and different ways of dealing with physiological symptoms of PTSD: guided imagery, relaxation techniques, and interpersonal psychotherapy can be helpful for some. There’s also something called ‘Trauma Focus CBT’, a cognitive behavioural therapy which can be helpful with families who have been exposed to violence, and ‘Child-Parent Psychotherapy’ that helps the parents and their children cope with the effects of the trauma. There are many different therapy modalities; some of them are classic psychotherapies, some of them are more alternative, and really I think the key with treating trauma is to be open to whatever is helpful.
Philosophy: If you suffer from PTSD, being open to different types of therapy would be one thing. What are some other best practices for self-care?
Dr. Fitelson: So, again, avoiding substances and getting treatment for any addiction issues if necessary is extremely important. Working on getting good sleep, relaxation, and not withdrawing are all incredibly helpful. Again, PTSD is very isolating, but reaching out to the people that you trust so you can talk about what’s going on is really important. Also, taking care of yourself in terms of nutrition, exploring all the different, healthy ways of coping with the effects of the trauma are all incredibly helpful. Finally, accepting that this really has affected you, and being conscious of the choices you make that aren’t about avoidance but self-care. Substance use might be a form of avoidance, for example, because when you can’t stand the feelings, you have to have a drink. But that’s not a healthy way of coping with it, whereas, ‘OK, I’m having this feeling, let me do some deep breathing,’ can be much more helpful and a healthier means of dealing with the symptoms.
Interviewer: If someone you love has PTSD, how do you best support them?
Dr. Fitelson: Be patient. PTSD is not something from which someone can recover right away. Have some understanding that they’re suffering with this tremendously, be supportive in their process and accepting of the times they might not be themselves: they might be depressed, they might be irritable, etc. That doesn’t mean you have to put up with all that behaviour, but dealing with people with empathy and respect is important. In the end, it’s vital to have an understanding that these symptoms are not in their control, and that they’re inevitably doing their best to cope and get them under control. Understanding and empathy are crucial for healing.