PTSD, terror, trauma  – how common and what to do after recognition?

A greater number of people, appear to be now having more exposure to terror events, trauma and are developing an increase in trauma-related illnesses, including PTSD. The causes could be attributable to any of a long list of suspected or debatable factors. It is valuable to focus on what we do know about trauma and the development of trauma-related illnesses, so as to work effectively on prevention, early recognition, treatment, and recovery.
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Are there more sensible and holistic approaches to trauma related problems?

About seventy percent of adults in the U.S. have experienced a traumatic event at least once in their lifetime. Ten percent or more of these people will develop PTSD according to some studies. Women are about twice as likely as men to develop PTSD (one out of nine women); see more at ptsdunited.org..  About 8 out of every 100 people (or 8% of the population) will have PTSD at some point in their lives. About 8 million adults have PTSD during any given year, which represents only a small portion of those who have experienced trauma; see more at ptsd.va.gov.

When you look at current statistics on PTSD (Post Traumatic Stress Disorder) and TRI (Trauma Related Disorders) – also referred to as Trauma Spectrum Disorders – two immediate questions come to mind. Is it a growing epidemic, or is it an expected outcome from the level of dysfunction and violence in our society — in our homes, on the street, in the workplace or on the battlefield? If the answer to both questions is yes, and if we are seeing more victims and sufferers from the effects of trauma, what then can we do as individuals and as a community? Can there be hope for a more sensible, comprehensive approach to include prevention; earlier recognition of the acute and lingering effects of trauma; timely interventions; proper diagnosis; application of more holistic, integrative and innovative treatments; and improvement in availability of services and resources.

Most people would not expect trauma-related illnesses and PTSD to show up from events which can occur outside of the military. Most people who are affected often go unrecognized and never seek treatment. They continue to suffer the ill effects of trauma and its aftermath.

Now it is recognized that the effects of trauma and it aftermath can occur to anyone at any life stage – childhood or adulthood.  The trauma itself can result from a wide variety of experiences:

1. Exposure to threatened death, serious injury, auto accidents or violence
2. Feeling helpless during a trauma as childhood sexual abuse, rape, physical assaults
3. Major overwhelming adverse life threatening events (early life or in adulthood) or poly-trauma (i.e., series of traumatic events: as a job loss, divorce, death of a significant other)
4. Sudden or major emotional losses
5. Witnessing domestic violence, death or injury to others
6. Natural disasters or mass causality event as a terrorist attack

The list of the many different types of trauma is extensive and affects each person differently.

There are a number of contributing factors that can make an individual more vulnerable to PTSD or TRI including earlier life traumas as listed above and some of the following additional vulnerability factors:

1. Having less social support
2. History of another physical or mental health problem such as a co-morbid substance use disorder
3. Recent losses
4. Contributing genetic factors

Martha is a survivor of terror and trauma.

Martha* was a well-liked and very effective 8th-grade teacher in her inner city school. Her students admired her for her understanding, effective teaching and leadership in several extracurricular programs – as the school drama club. She came to work one day, visibly shaken, reporting that two older teens had pushed her down and stole her purse when she was leaving her house – in what she thought was a safe neighborhood. She was upset and anxious for most of the day and the next, but she seemed to get back to her usual self and pace by the third day. Two weeks after this occurrence, arriving at school a half hour early to catch up on some paperwork, she was suddenly shoved through the entrance door by a large man from behind, causing her to fall to the ground. She started to scream but stopped when hit by the attacker with a glancing blow on her arm with a gun. Some other staff and students began to arrive, causing the nervous assailant to turn and flee. Martha went to her physician, and he found no physical injuries or any evidence of head injury. He offered some tranquilizers, which she refused. After a few days, she felt well enough to return to work. Over the next few weeks, going into a month, she felt easily distracted, began to startle easily, especially to sudden movement or noise. Her sleep was often disrupted with nightmares of being attacked or chased. For the first time, she began having what she and others described as panic attacks – with the sudden onset of a pounding rapid heart, an overwhelming feeling of dread that something terrible was going to happen and an urge to flee or leave the room. She could no longer drive herself as panic attacks would occur while driving. She had to take sick leave from her teaching work, and she sought out professional help.

The first doctor felt she had ADHD or attention problems and prescribed a commonly use stimulant type drug to help her focus.  This only made her worse: more anxious with difficulty sleeping, jumpy and irritable. She went to someone else who felt that her main problem was depression and anxiety — he tried her on an antidepressant that again seemed to make her worse. When he wanted to change her to a bipolar condition medication, she decided to go to another health care provider. The therapist, who saw her, recognized the impact that the trauma experience was having on her. The therapist recommended someone specialized and experienced with specific trauma-related therapy and treatment. She also saw a holistic physician that helped her improve her lifestyle, nutrition and exercise program. Martha reported that she had been sexually and verbally abused as a child growing up with an alcoholic mother and often absent father. She was often bullied by her peers as she was somewhat shy as a child. Her recovery was gradual, but Martha was able to resume her effective classroom work with her students after three to four months.  *(To protect confidentiality, the above is a composite of some clinical experiences and does not represent an actual person or any prior patients).*

The annual cost to our medical care system for PTSD and TRI is staggering – in the billions of dollars, which is often compounded by misdiagnosis and improper treatment. Beyond the actual treatment costs, there are the related workplace costs; drug costs; and cost of other associated illness, disabilities and mortality.

It is estimated that 80%-90% of persons exposed to the various types of severe trauma will not develop PTSD. Predisposing — vulnerability factors — are the more important deciding factors as to whether an individual gets a trauma related illness or not, more so than the trauma itself. The traumatic experience can have profound effects on some and very little effects on others who experience the same event.  What makes one more susceptible to post-trauma problems and another not – is of great interest now. Where there is more exposure, there is more potential for traumatic experiences and the occurrence of trauma related illness – as was the situation with Martha, as described above.

For a detailed description of trauma related illness and PTSD symptoms see the official DSM-5  (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 by American Psychiatric Association (APA), available through the APA or at Amazon .

Recognizable intermittent or chronic emotional or physical symptoms that may be a sign of TRI or PTSD from prior trauma or trauma exposure may include:

1. Re-living: People with PTSD repeatedly relive the ordeal through thoughts and intrusive memories of the trauma — including flashbacks, hallucinations, nightmares, feeling great distress when reminded of the trauma, acting and feeling as if the trauma were recurring and psychological distress
2. Avoiding or feeling numb: the person may avoid people, places, thoughts or situations that remind him or her of the trauma, inability to recall an important aspect of the trauma; feeling of detachment or estrangement from others; isolation and withdrawal from family and friends – as well as a loss of interest in activities that the person once enjoyed; difficulty experiencing love, joy or intimacy – a restricted range of feelings; difficulty relating to others; diminished interest or participation in significant activities;  sense of foreshortened future
3. Increased arousal as: having excessive emotions, worry and guilt; difficulty falling or staying asleep; feeling nervous, fearful; increased irritability; outbursts of anger and agitation; difficulty concentrating; being hyper vigilant, guarded and constantly alert;  physiologic reactivity upon exposure to trauma cues and having exaggerated startled responses – being jumpy
4. Experiencing worsening physical symptoms and medical problems, e.g., increased blood pressure and heart rate, fatigue, rapid breathing, muscle tension, headaches, sweating, digestive problems, poor appetite, nausea, and diarrhea

The onset of trauma-related symptoms or illness can be delayed, emerging months after the traumatizing event. However symptoms may appear, earlier, be more subtle and difficult to recognize. Other symptoms or characteristics of TRI and PTSD that may occur include:

•  Feelings of hopelessness, helplessness, shame, despair or sadness
• Distrust of others
• Self-blame, negative views of oneself or the world
• Family, employment or school problems
• Relationship problems including conflicts, being over-controlling, violence and divorce
• Failure to engage in exercise, diet, safe sex or regular health care
• Excess smoking, alcohol and drugs problems
  See National Center PTSD Fact Sheet

More info at Medscape – does require a free registration)

An integrated holistic approach would be to bring together the tools, practices and scope of integrative psychiatry, psychology and medicine. The goal would be for early recognition, assessment, diagnosis and treatment of people with symptoms or problems resulting from trauma — including an investigation into contributing factors as those related to prior traumatic exposures; environmental, genetics, medical and psychological issues; and developmental and family history. The tools of integrated psychiatry and psychology would include in-depth clinical history and psycho-social assessment, physical examination, psychological testing, consulting with significant others – like family members, laboratory testing – and finally a comprehensive treatment program.

Treatment considerations would be:

1. Lifestyle and nutritional improvements
2. Reduction in psycho-social stressors
3. Individual or group psychotherapies that address current, past developmental and trauma issues
4. Interventions as suggested by clinical finding and lab testing

Medication use is a consideration after other contributing factors have been addressed, and non-medication interventions have not been adequate. Medications commonly considered are:

• Selective serotonin re-uptake inhibitors for depression and anxiety (SSRIs; e.g., fluoxetine, sertraline)
• Symptomatic treatments with sleep agents or more helpful for trauma-related nightmares in adults — prazosin — an anti-hypertensive
• Benzodiazepines (tranquilizers)— long-term use does not appear beneficial and difficult to wean and stop
• β-blockers — used to reduce arousal but of questionable benefit.

If there has been significant trauma and apparent TRI or PTSD — a team or network approach would be optimal — this would include health care practitioners trained in the modalities referred to above, plus the presence and needed interventions by an experienced trauma therapist. Therapy may involve different approaches depending on the training of the available trauma therapist as:

1. Individual or group psychotherapy
2. Behavioral or cognitive behavioral therapy (CBT)
3. Exposure therapy, trauma-focused cognitive behavioral therapy, trauma systems therapy
4. Body-mind therapies, somatic experiencing, eye movement desensitization and reprocessing (EMDR), Emotional Freedom Technique, Reset Therapy –  see E-book on RESET by Lindenfeld.
5. Other natural alternatives or medication

See PTSD.VA.gov treatment of returning vets

The role of the holistic and integrative health care practitioner would be to add his unique skills and knowledge to the team or network of practitioners, experienced with the treatment and management of someone experiencing TRI or PTSD. As there is often dysfunction or problems in multiple areas, a careful and thorough diagnostic evaluation is needed. Any corrective interventions will help to alleviate symptoms or  illnesses – as treating any infections; digestive disturbance; nutritional or hormonal imbalances; allergies; drug, alcohol addiction problems; emotional and mood problems; personal or family stressors – with the goal of improving comfort, well-being, sleep and restoration; and improvement of autonomic regulation. All of these interventions would be potentially helpful in assisting recovery, along with the assistance of a trauma therapist when needed. Procedures or lab testing that is indicated would be done: as nutrition and digestive evaluation, thyroid and hormonal testing, blood chemistry as complete blood count, blood sugar, lipids, B12 and folic acid levels, vitamin D 25-hydroxy levels, and more specific and advanced testing if indicated.  If with treatment, the person can become less stressed from contributing psycho-social and medical factors, have more restorative sleep, be more free of pain and discomfort, get relief from environmental related illness and allergies, and relief from traumatic memories — there would be more possibilities for the body, mind and spirit to recover from the wounds of trauma.

Other treatments, mind-body therapies or psychotherapies, tests currently available or in development are beyond the limited scope of this article. If interested, see above linked references and my prior article and references – PTESD.

Be knowledgeable and prepared for when anybody that you know or meet with TRI or PTSD needs your support, help or encouragement. Healing or reducing somatic, emotional, mental and spiritual issues, and other factors contributing to the severity of TRI and PTSD – in conjunction with medication when needed — has the potential for relief and the reduction of  suffering from illness associated with recent or prior trauma.

Article by Ron Parks, MD and edited by Shan Parks – see related slide presentation in Library http://ronparksmd.com/jfk-lecture-092016/

[reminder]How could you be helpful to yourself or a significant other when suggestive or actual symptoms of TRI or PTSD appear? I’d be interested in your comments.[/reminder]