5. PTSD Theoretical Background

This article is part of a research study publication on Experience Design for PTSD. This section provides a definition, diagnostic criteria, background information on trauma and its neurological reactions in the body as well as common treatment approaches for PTSD.

Image: Edu Lauton

What is PTSD?

Post-traumatic stress disorder (PTSD) is defined as a condition that can develop after a person is exposed to a traumatic event or a life-threatening situation. The most widely used diagnostic manual is the current 5th edition of the ‘Diagnostic and Statistical Manual of Mental Disorders’ (DSM-5) which offers an extensive list of events that can potentially cause PTSD. Among them are major disasters, war, sexual, physical or emotional abuse, witnessing a violent death, a serious accident, traumatic childbirth, and other situations in which a person was very afraid, horrified, helpless, or felt that their life was endangered. In short, potentially traumatic events include any threat, actual or perceived, to the life or physical safety of the individual or those around them.

The unified diagnosis of PTSD regardless of the huge variation in origin events and frequency of experience is a much debated issue in the psychiatric community. This study concerns PTSD in adults as a condition caused by a singular traumatic and abnormal event. Other related conditions such as complex trauma which involves multiple repetitive traumatic stressors and cumulative traumas including several traumatic instances in a cumulative manner across one’s lifetime as well as the special condition of children and adolescents are not subjects of this paper.

Diagnostics

According to DSM-5 , PTSD is diagnosed by eight types of criterions:

Criterion A. Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation, in one or more of the following ways:

• Directly experiencing the traumatic event(s)
• Witnessing, in person, the traumatic event(s) as they occurred to others
• Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental
• Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.

Criterion B. Presence of one or more of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

• Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
• Recurrent distressing dreams in which the content or affect of the dream is related to the event(s) (Note: In children, there may be frightening dreams without recognisable content.)
• Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) are recurring (such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.
• Intense or prolonged psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).
• Marked physiological reactions to reminders of the traumatic event(s)

Criterion C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by avoidance or efforts to avoid one or more of the following:

• Distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
• External reminders (i.e., people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about, or that are closely associated with, the traumatic event(s)

Criterion D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred), as evidenced by two or more of the following:

• Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia that is not due to head injury, alcohol, or drugs)
• Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous”).
• Persistent, distorted blame of self or others about the cause or consequences of the traumatic event(s)
• Persistent negative emotional state (e.g., fear, anger, guilt, or shame)
• Markedly diminished interest or participation in significant activities
• Feelings of detachment or estrangement from others
• Persistent inability to experience positive emotions (e.g., unable to have loving feelings, psychic numbing)

Criterion E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:

• Irritable or aggressive behaviour
• Reckless or self-destructive behaviour
• Hyper-vigilance
• Exaggerated startle response
• Problems with concentration
• Sleep disturbance (e.g., difficulty falling asleep or restless sleep)

Criterion F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

Criterion G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion H. The disturbance is not attributed to the direct physiological effects of a substance (e.g., medication, drugs, or alcohol) or another medical condition (e.g. traumatic brain injury).

Within these criterions DSM-5 lists as many as 20 potential symptoms resulting in thousands of different possible symptom patterns such as difficulties with impulsivity, problems with emotional regulation, identity disturbance, inability to make plans and commitments, self-destructive behaviour, abnormalities in sexual expression, and somatic symptoms.

The PTSD diagnostic criteria of DSM-5 have been challenged by several authors (Shin and Handwerger, 2009; Bovin and Marx, 2011; Scaglione and Lockwood, 2014) in particular the emphasis on only physical threat to life. Other authors also consider severe emotional distress as significant traumatising factor that should be included in the diagnosis criteria.

Statistics

According to the National Collaborating Center for Mental Health, traumatic events are quite common — around 65% of the world population will experience at least one potentially traumatic event at some point during the lifespan. Some people are resilient towards trauma and recover fully, others may not have an immediate reaction to a distressing event but may develop PTSD symptoms in different variations months or years after the event. The latest comprehensive survey of adult psychiatric conditions in England states that around 25–30% of people may develop PTSD after experiencing a traumatic event, 3% of adults screened positive for current PTSD, lifetime prevalence rates are between 1.9% and 8.8%, and only 28% of people with PTSD were receiving treatment for a mental or emotional problem.

Although these figures are informative for understanding of PTSD rates, this type of data should be interpreted with some caution. The actual numbers of people with PTSD are likely to be much higher. PTSD symptoms and behaviours often coincide with other mental conditions leading to misinterpretation and wrong diagnosis. For example, a large study of traumatic injury survivors found that two-thirds did not have a diagnosis of PTSD but were diagnosed with either depression (16%), generalised anxiety disorder ( 11%), substance abuse (10%), agoraphobia (10%), social phobia (7%), panic disorder (6%) and obsessive-compulsive disorder (4%) (Isaacs et al., 2010). Moreover, the large portion of people who have experienced traumatic events do not report or seek medical help. They find alternative methods to tolerate and cope with the resulting symptoms and unfortunately rates of suicidal attempts related to trauma are significantly higher than in the average population.

The high occurrence of traumatic events together with severe lack of public understanding about the detrimental implications of trauma on the psychological and physiological well being highlight the importance of addressing the issue of PTSD. The following section explains what is trauma, how it develops and how it affects the body and mind.

What Is Trauma?

The word trauma is used inconsistently within the mental health field, referring either to the traumatic event or to the effect of the event. Clinical guidelines indicate trauma as a brain injury to the psyche detrimental to a person’s biological health as well as to the psychological, emotional, and social well being. Some psychiatrist authors consider the implications of this injury to be deeply ingrained in the nervous system and body.

Trauma is often described as a normal body reaction to an abnormal event. When an individual is faced with a perceived life-threatening situation the instinctual limbic part of the brain takes prevalence over the rational thinking neocortex. The autonomic nervous system (ANS) activates an instinctive motor plan for survival. This mechanism involves activation of the sympathetic nervous system in a coordinated preparation for strong energy expenditure, most commonly known as ‘fight-or-flight’ response. It activates the body systems responsible for survival: the motor system increases muscle tension and preparedness to act, the endocrine system releases high levels of stress hormones , and the central nervous system sharpens the sensory alertness to increase awareness of the danger (Payne et al., 2015).

If the person is captured and unable to fight or escape, the ANS executes a freeze response. This reflex paralyses the body to numb pain from potential death and/or to appear dead as protective mechanism. Physiologically, freezing occurs as a signal from the periaqueductal grey (part of the emotional system) to the pyramis (part of the muscle motor system) which causes the body to automatically freeze in place. Psychologically, freezing causes dissociation in the brain disconnecting the sensory centres from the feeling centres.

Under normal circumstances the successful completion of the fight-flight-freeze motor plan after the arousal is characterised by a muscle tremor reflex of spontaneous shaking and trembling followed by deep rhythmic breathing to calm the nervous system. Physiologically, this reflex naturally releases the excess energy generated for fight or flight and brings the sympathetic nervous system back to homeostasis. On a psychological level, the individual is re-associated with their feelings, senses, and cognitive capacity and returns to baseline functioning.

In humans this protective mechanism is often overridden by societal and cultural norms locking the excess energy in the body which burdens the nervous system and causes chronic anxiety and tension over time. The typical model for PTSD is threat coupled with restraint. Threat alone does not lead to trauma, only when the natural response to threat is restrained. When the completion of fight-flight-freeze defensive response is blocked by rational thought, the survival mechanism continues to run and repeatedly activates the ANS towards fight-flight-freeze in triggering situations resembling the original threatening event.

As a consequence the person develops various symptoms characterising PTSD: an incomplete fight/flight response is reflected in uncontrollable irritability, arousal, aggressive behaviour, startle, alertness; an incomplete freeze response is reflected in symptoms including but not limited to diminished emotional responses, chronic fatigue, depression, immune system problems, endocrine problems. In the long term, these symptoms are debilitating to the individual’s psychological, emotional, and social life.

Typical characteristics of PTSD are re-experiencing the traumatic event through intrusive memories and the effort to avoid these reminders. However, it is critical to understand that these negative reactions to a triggering situation are important messages from the inherent survival system giving notice about the incomplete motor response. The triggers in PTSD are invitation to complete what was not possible at time of event and are the potential key to healing.

Trauma treatments

A range of psychological and pharmacological treatments is currently used for PTSD. This section provides a brief summary of the most common interventions based on the guidelines by the National Institute for Mental Care Excellence (NICE).

Psychological therapies

Clinical guidelines recommend trauma focused psychological therapies based on evidence from systematic reviews and meta-analyses (NICE, 2005; APA, 2004; ACPMH, 2013). Individual trauma focused cognitive behavioural therapy (TF-CBT) and eye movement desensitisation and reprocessing (EMDR) are reported as equally effective and superior to waitlist supportive counselling (Bisson et al., 2015). These therapies involve confronting the traumatic memory and coming to terms with the experience.

• Trauma focused cognitive behavioural therapy (TB-CBT)

This treatment focuses on exposure to the traumatic memory and cognitive restructuring of the misinterpretations related to the event that lead to exaggeration of current danger. During the exposure element the person confronts the object of their anxieties repeatedly through a narrative of the traumatic experience and enactment of the situation in safe settings. This process is based on the premise of habituation to the anxiety-provoking stimuli with the expectation to reduce the future reactivity to them. The cognitive part of the treatment seeks to identify, challenge, and modify the distressing feelings and thoughts about the traumatic event as well as any destructive beliefs about oneself and the world that may have been developed as a consequence by deliberate training to rationally assess the surrounding at the present moment. Behavioural mechanisms and personal support are also offered to cope with emotional disturbances throughout the process.

• Eye movement desensitisation and reprocessing (EMDR)

EMDR is a trauma focused procedure featuring bilateral eye movement, tapping and/or tones. It is based on the latest clinical understanding that during a traumatic event, the overwhelming emotions block the information processing capacity of the brain and hence the experience remains ‘unprocessed’ and relived over and over again as if it is happening in the present. This is why trauma-related memories do not follow a coherent sequential timeline and are experienced as vivid sensory flashbacks. In EMDR session the person is instructed to concentrate on trauma-related image including associated thoughts, emotions, and body sensations while simultaneously moving their eyes rapidly side to side following the therapist’s fingers. The person is encouraged to let go of the memory and discuss any arising thoughts and visuals. Then a positive cognition about the event is installed with the same procedure. The positive association helps to neutralise the negative belief about the memory and also to influence a positive behaviour in a future situation similar to the traumatic event. EMDR stimulates the brain’s information processing capacity to help store the targeted event as a memory in a past context. As a result the emotional reaction is settled and the rational thinking about the event as a past fact is activated. EMDR has consistently demonstrated better effectiveness in reducing PTSD symptoms relative to waitlist, and standard counselling.

Medication Therapies

Clinical guidelines recommend that drug treatment should only be secondary to trauma-focused psychological therapies. It may be considered in cases of inability, unwillingness, or limited access to therapy, as well as when additional mental health problems are present.

• Antidepressants

A recent study shows evidence of reduction in severity of PTSD symptoms for four drugs (fluoxetine, paroxetine, sertraline, and venlafaxine) (Hoskins et al., 2015). Still, medication treatment effectiveness is comparably lower than trauma-focused psychological interventions.

• Methylenedioxymethamphetamine (MDMA)

Microdoses with psychedelics are used with people who did not respond favourably to any other conventional treatment. The therapy involves intake of MDMA in a therapeutic setting under close monitoring for several days with overnight stays. The drug is supposed to reduce the neurobiological fear reactions and thus activate the information processing capacity to allowing people to reprocess the traumatic memory without anxiety and emotional overwhelm. Clinicians support patients throughout the treatment to examine the traumatic event from a calm standpoint without directive guidance. Multiple studies have shown statistically and clinically-significant effects in symptom relief persisting over time with no subjects reporting harmful reactions (Amoroso and Workman, 2016; Mithoefer et al., 2012; White, 2014; Chabrol and Oehen, 2013).

Physical Therapies

Beyond verbal-cognitive and pharmacological methods there are physical treatments addressing the implications of trauma on the nervous system. They aim at restoring the balance by releasing traumatic blockage in a physiological way.

• Somatic Experiencing (SE)

SE is a neurobiology-based trauma therapy that involves physiological processing of trauma by directing attention to internal sensations of the body — interoceptive (senses), kinaesthetic (movement), and proprioceptive (position and orientation). Unlike the cognitive focus of CBT and EMDR, the SE treatment treats trauma by targeting the the core response network of the nervous system encompassing the autonomic nervous system (ANS); the emotional motor system, the reticular arousal systems ; and the limbic system.

SE originated from the idea that trauma resides in the nervous system and the whole body not just in the brain. It involves a set of neurophysiological mechanisms aiming at discharging and regulating the excess arousal in the body through completion of blocked instinctual defensive responses lingering after the traumatic event.

SE is founded on the theory of interoception suggesting that perception through the senses has significant effects on pre-conscious judgments about the environment with relevance to the sense of self, cognition, and decision making. To date there are no randomised studies with control variable on this novel treatment to ensure clinical effectiveness, however, there have been documented empirical studies of outcome effects demonstrating significant symptom improvement or complete resolution in 90% of participants maintained over time.

• Acupuncture

This treatment is considered to correct imbalances in the flow of energy through channels known as meridians by stimulating acupuncture points in the skin by needles insertion. There are clinical trials supporting the efficacy of acupuncture for PTSD. The method is also endorsed by the NHS and the World Health Organisation.

PTSD is a debilitating condition affecting a significant portion of the population. It is commonly associated with severe disasters and violence. However, trauma can happen at any instance of emotional overwhelm in abnormal situation. Lack of public literacy about the causes and implications trauma contribute to widespread disregard of the characteristic symptoms leading to unnecessary suffering in society at scale. This chapter presented a theoretical overview of PTSD and trauma as well as the most common treatment approaches. The next chapter looks into the primary research exploration seeking to uncover the personal perspective of trauma experience.