Posttraumatic Stress disorder (PTSD) is a mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault. The following data shows the gravity of the problem posed due to PTSD. The National Comorbidity Survey Replication study (NCS-R), conducted between February 2001 and April 2003, was comprised of interviews of a nationally representative sample of 9,282 Americans aged 18 years and older. PTSD was assessed among 5,692 participants, using DSM-IV criteria. The NCS-R estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%. Current past year PTSD prevalence was estimated at 3.5%. The lifetime prevalence of PTSD among men was 3.6% and among women was 9.7%. The twelve-month prevalence was 1.8% among men and 5.2% among women.
The presence of PTSD has been prevalent through the ages, although it has often been identified by various names. In fact, clinical pictures suggestive of PTSD have been recorded since the times of Herodotus and Homer. Swiss physician Johannes Hofer coined the term Nostalgia in 1678 to describe symptoms seen in Swiss Troops which included melancholy, incessant thinking of home, disturbed sleep or insomnia, loss of appetite, anxiety and cardiac palpitations. Napoleon’s Chief Surgeon prescribed a treatment for Nostalgia which consisted of regular exercise and listening to music.
In 1871 Jacob Mendez Da Costa noted the following symptoms in soldiers: chest-thumping, anxiety and breathlessness. These symptoms were referred to first as Soldier’s Heart and later as Da Costa Syndrome. Following a series of deadly train accidents in Great Britain, the term Railway Spine was coined. Railway spine was characterized by “the manifestation of a variety of physical disorders in otherwise healthy and apparently uninjured railway accident victims.”
In WWI the nomenclature changed to Shell Shock, of which symptoms included staring eyes, violent tremors, blue, cold extremities, unexplained deafness, blindness, or paralysis. During the World War II era, the disorder was renamed Combat Fatigue.
In the Diagnostic and Statistical Manual of Mental Disorders (DSM I), published in 1952, what we now know as PTSD was called “Stress response syndrome” and was purported to be caused by a “gross stress reaction.” In 1968, DSM II lumped together trauma-related disorders in a category titled “Situational disorders.”
Later, DSM III, published in 1980, first introduced Post-Traumatic Stress Disorder as a diagnosis. It was placed under a subcategory of anxiety disorders and there was a clearer organization of symptoms around three dimensions of stress response which included re-experiencing, avoidance and numbing, and physiological arousal. DSM-IV did not change these three core criteria.
However, the most recent version of the DSM, known as DSM-5, established new diagnostic criteria for PTSD, including the following: (i) the person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence; (ii) intrusion Symptoms; (iii) persistent avoidance of stimuli associated with the trauma; (iv) negative alterations in cognitions and moods that are associated with the traumatic event; and (v) alterations in arousal and reactivity that are associated with the traumatic event.
The treatment of PTSD is best accomplished by a multimodal approach. Combination of medication/s with various forms of psychotherapy is the main stay of treatment. Pharmacotherapy consists of SSRIs; other antidepressants like Mirtazapine; Prazosin (effective for nightmares associated with PTSD); older antidepressants; anticonvulsants (Topiramate- has shown promise) and D-cycloserine. Other novel treatments being explored include CRF/NMDA/NK-1 antagonists, hydrocortisone, and NPY enhancers. Use of benzodiazepine in PTSD has been controversial but in general should be considered relatively contraindicated for patients with PTSD or recent trauma.
Cognitive behavioral therapy, including Prolonged Exposure Therapy, Cognitive Processing Therapy, Stress Inoculation Training, and Trauma Focused CBT, and Eye Movement Desensitization and Re-Processing (EMDR)are considered to be effective treatments for PTSD.
It is not only important to explore for symptoms of PTSD in a patient exposed to trauma but also to be on the look out for the comorbidities that may develop either at the onset of PTSD or over the course of time. The comorbidities associated with PTSD may be classified broadly into medical and psychiatric comorbidities.
The most important medical comorbidities are traumatic brain injury (TBI), coronary heart disease and metabolic syndrome. PTSD has been associated with increased risk of coronary heart disease. In a retrospective cohort study of 253 veterans with PTSD (mean age 52 years; 92% males) 43 percent were found to have metabolic syndrome, a cluster of risk factors for heart disease, stroke and diabetes. This article will focus on TBI due to the complexity of the presentation and the nature of the symptoms that are shared by TBI with PTSD.
Traumatic Brain Injury (TBI)
“In order to understand the effects of the head injury, we must undertake full study of the individual’s constitution. In other words, it is not just the kind of injury that matters, but the kind of head that is injured” – Sir Charles Symonds, 1937
Greater than 1.5 million Americans suffer TBI every year. It is referred to as the “signature injury” of Operation Enduring Freedom and Operation Iraqi Freedom and the major cause of disability in young adults. Approximately 18% of returning soldiers have been identified as having mild traumatic brain injury (TBIm), primarily due to exposure to blasts.
TBI and PTSD present with common neuropsychiatric symptoms as seen below:
This overlap complicates diagnostic differentiation. Interestingly, both TBI and PTSD can be produced by overlapping pathophysiological changes that disrupt neural connections termed the “connectome.” TBI produces cognitive, emotional, behavioral, and physical disturbances.
Cognitive disturbances include impaired attention, memory, language, skills, and complex cognition (judgment, insight, problem solving). Emotional disturbances include depression, mania, affective lability, irritability, anxiety, panic attacks, PTSD, personality change, and rage or aggression. In addition, behavioral disturbances include diminished motivation/apathy, impulsivity, perseveration, and psychosis. Finally, physical disturbances include seizures, headaches, dizziness, balance and coordination problems, weakness or paralysis, visual disturbances, hearing impairments, and sensory impairments. Clinical presentations of TBI may include some or all of the following symptoms:
- Impulsivity (common reason that family wants evaluation)
- Disinhibition: no “filter” on thoughts or actions
- Poor control over primal urges
- Physical aggression
- Cognitive changes: inability to concentrate or focus
- Substance abuse
- Sleep difficulties
At present, there are no FDA-approved medications for psychiatric symptoms due to TBI and current recommendations are based on experts’ opinions only.
When receiving treatment for TBI, patients should be cautioned to minimize benzodiazepines and anticholinergic, seizure-inducing or anti dopaminergic agents as they may impair cognition, increase sedation or impede neuronal recovery. Avoid caffeine in any form as it may cause agitation and insomnia. In addition, patients are advised to avoid herbal, diet or “energy” products due to the risk of inducing mania, hypertensive crisis, or aggression.
When treating TBI it is important to consider social causes of symptoms (e.g., abuse, neglect, environmental factors, family conflict) and to consider non-pharmacologic interventions, if possible. Finally, avoid large quantities of potentially lethal medications due to suicide risk. The best approach in dosing medications is to “Start low – Go slow” and watch for toxicity and drug-drug interactions as patients are sensitive to side effects. Providers are advised to administer full therapeutic trials of medication before giving up as under- treatment is common.
Psychiatric Comorbidities of PTSD
80% of individuals with PTSD have at least one other psychiatric disorder. The commonest are depression mood disorders, anxiety disorders and substance use disorders. In addition to actual comorbidities, there are co-occurring problems which may be result of medical or psychiatric comorbidities or a combination of both. These may include suicidal behavior, anger or violence, insomnia, pain, marital or family disruption, impaired occupational functioning, and social withdrawal or disengagement.
Family Members and PTSD
The discussion on co-morbidities with PTSD is never complete without understanding its impact on the family members as they are the “extended victims.” Specific PTSD symptoms like avoidance, alienation, detachment, social withdrawal, constricted affect, hyper vigilance, irritability/angry outbursts have a direct impact on family members. Other associated problems the family might face are social isolation, aggression/violence, addiction and vocational, financial or legal problems. The snap shot of a family affected by PTSD would look like:
- “walking on egg shells” and being on constant high alert
- limited emotional expression
- mourning the loss of the traumatized member
- shifting role responsibilities and the feeling that there is no end in sight.
Strategies that may help the families cope with the stress:
- Acknowledging what has been lost
- Understanding the changes in relationships
- Improving communication
- Active problem-solving strategies
- Emotional regulation strategies
In conclusion, it is not only important to treat PTSD but equally imperative to identify the associated co-morbidities and treat them. The outcome depends on both conditions being addressed effectively.