POST TRAUMATIC STRESS DISORDER (PTSD)
Stephen Cox MD
Susan was a lovely and likeable young expert horsewoman living in the mountains of Kentucky. One day in 1992 she saw smoke coming from her sister’s mobile home. Susan rushed over and tried to open the door, but it was locked tight. Then she heard her sister’s horrible screaming as she was burning to death inside. Susan tried everything to try to help save her sister but there was no use as the fire had consumed the mobile home. The screaming stopped as Susan sobbed uncontrollably and was forced to back away from the raging inferno.
Susan instantly developed severe PTSD with insomnia, horrible nightmares re-living the experience every night, anxiety and depression which could only be described as total anguish. She felt guilty that she had survived, but her sister did not. She avoided many normal activities that she previously enjoyed. Years later, she was still unable to watch a TV show showing an exploding car or a burning building or the sound of screaming without enduring several days of acute worsening of her chronic condition. I prescribed paroxetine for her PTSD, and prazocin at bedtime to try to block her vicious nightmares, and alprazolam ODT as needed for her anxiety attacks. She was counseled to keep active with as many normal activities as she could, particularly trail riding with her horse as equine-assisted psychotherapy. She eventually became partially improved. She still had occasional flashbacks and relapses lasting days or weeks. It was predicted that she would probably not recover completely. But she was very grateful to be so much better than she was that first year.
THE CLINICAL PICTURE OF ONE EXPERIENCING PTSD
Persons experiencing a truly traumatic event like Susan may develop acute PTSD. This trauma may involve:
• Near loss of the victims life,
• The witnessed loss of life of others
• Severe injury to self or others
• experienced or witnessed torture, rape, kidnapping, terror, or other catastrophic injury
One or more of these is usually present in the patient with PTSD:
flashback memories, recurring distressing dreams, mental re-experiencing of the traumatic event or intense negative psychological or physiological response to any reminder of the traumatic event
avoidance of things associated with the trauma, such as places, movies, activities that may lead to distessing memories. Dr. Carol North, a national expert and researcher on PTSD, once told me that avoidance may be the essential symptom of true PTSD.
• Inability to recall major parts of the trauma.
• Decreased involvement in significant life activities.
• Decreased ability to experience certain important emotional feelings.
• Persistent symptoms of increased arousal not present before.
• Startling to unexpected noises.
• Problem emotions of anger, anxiety and depression.
Significant impairment occurs. The symptoms reported lead to clinically significant distress or impairment of major domains of life activity, such as social relations, occupational activities, or other important areas of functioning. Technically, some opinions say PTSD does not exist until it persists for 30 days. Such opinions call it an acute stress reaction those first 30 days. Others call it acute PTSD from the moment of the trauma and the appearance of symptoms.
If the PTSD condition does not remit by 6 months it is deemed chronic. The prognosis for remission becomes worse past that point.
Both acute and chronic PTSD have in the past been treated with some success with various medicines directed at the core symptoms for that individual. These treaments might include antidepressants such as paroxetine (Paxil) for the depressive symptoms, benzodiazepines such as lorazepam (Ativan) for anxiety symtoms, and atypical antipsychotics such as olanzepine (Zyprexa) for agitation symptoms. Counseling is commonly employed to give psychological support and guidance. Cognitive behavior therapy is advised for some symptoms such as avaiodance of normal activities that remind the patient of the trauma.