Post-Traumatic Stress Disorder Is Based on Individual Response to Danger

More than 10 million people in the US experience symptoms of post-traumatic stress disorder (PTSD) each year, according to the National Institutes of Health, but a growing percentage of PTSD patients now receive successful treatment as more is learned about the condition and multiple therapies are employed to fight its often devastating effects on health and quality of life.

Still, as one Medical College of Wisconsin expert notes, there is no specific general "cure" for PTSD. It remains a complex medical problem rooted in some of humankind's most primal responses to life-threatening events. PTSD can be triggered by all sorts of traumatic occurrences, from car crashes to criminal assaults to combat horrors, and its symptoms range widely in their nature and severity.

"This is one of the psychiatric diagnoses that you can almost tell what it means by its title," said H. Steven Moffic, MD, Medical College of Wisconsin Professor of Psychiatry and Behavioral Medicine. "What the title 'post-traumatic stress disorder' says is that someone has a strong psychological reaction to a bad trauma.

"All of us in our lives are exposed to trauma of one sort or another. Little traumas, like the scares kids and even grownups get when doing Halloween activities, aren't going to be enough to cause post-traumatic stress disorder. We're talking about big, unusual traumas that may feel to the person as if their life is threatened, be it physically, mentally, or even spiritually.

"It could be one or many traumas that can cause the disorder, but it must be perceived as potentially life-threatening for it to be PTSD; whether people are directly involved in the trauma or, as bystanders, they feel their life is in danger. Think of the 9/11 attacks on the World Trade Center in that way - there were people directly in the trauma and then people who were close by or watching from further away. Any of those people potentially could have developed this disorder if they felt their life was in danger."

The Fight or Flight Response
The choices people make while they are experiencing significant trauma, and afterwards, aren't always consciously crafted decisions. They generally fit into three typical categories of self-preservation techniques that humans employ whether they think about it or not, Dr. Moffic said, and post-traumatic stress disorder is often the result when those techniques go far beyond simple coping mechanisms.

"Probably the best way to think about that is, when we're exposed to a trauma - whether it's a little one like on Halloween or a big one like a serious accident - our more primitive self-help responses go into motion," said Dr. Moffic. "This is generally called 'fight or flight.' If we're faced with a trauma, our initial, almost unconscious reaction, is to flee or fight. Or, if we can't do either, we may just sit and withdraw. Those kinds of responses have been known for thousands of years, since the cavemen. That's how humans respond to trauma.

"When the trauma is really severe or lasts for a long time, that kind of response goes awry in that it doesn't go away. You're always in a fight-or-flight or withdrawal mode to some degree. Instead of that system going off it's turned on to some degree all the time and that tells us what kind of symptoms we're going to see.

"For instance, if you're the kind of person who has responded to trauma by fighting, you're going to be hyper-aroused to one degree or another all the time. Hyper-arousal is one kind of symptom. You could be anxious all the time, you could have trouble sleeping, or you could feel agitated, or startle easily, or be irritable. All those things are a reflection of being over-aroused. You're almost in your fight mode, really ready to fight, all the time.

"Second, there's the flight response. If that's been over-stimulated or doesn't go away, what happens when 'flight' goes awry? Your symptoms could include being reserved, quiet, preoccupied, very fearful all the time, or do what we call 'dissociate', which is blanking out for a while, forgetting what you're doing That's what happens if the flight response goes awry."

Withdrawal, Symptoms and Severity
Withdrawal occurs when a person can't fight or flee, said Dr. Moffic. For example, this third basic response to trauma is often present during and after rape situations. "If you are truly overpowered the self-preservation response may be to do nothing," said Dr. Moffic. "When that gets over-stimulated and doesn't go away because the trauma has been so bad, what tends to happen afterwards is you get re-experiencing symptoms. These are generally of two different kinds.

"One, nightmares during sleep, where you dream about the trauma, for example you dream about the rape over and over again in some way. Or, you'll get what are called flashbacks, where even while you are awake during the day you'll get images of the trauma reoccurring in your mind. That could come out of the blue or it could be stimulated by something that reminds you of the trauma, often called a trigger.

Most Do Not Develop PTSD
Symptoms of PTSD can be relatively mild, such as harmful but manageable difficulty sleeping, or intense, such as continually reliving the traumatic event, or hard to spot, such as subtle forms of withdrawal from what had been normal life. Because so many combinations of factors are involved, from the event itself to the makeup of the individual, PTSD can be a real diagnostic challenge, and it does not offer a clear "checklist" of risk factors in advance.

"That's what makes anticipating or predicting who might get the disorder a little tricky," said Dr. Moffic. "One part of the equation is the nature of the trauma, how severe it is, how long it lasts, whether it is a one-time event or repetitive. And then, even for the same severe trauma that feels as if it is life threatening, not everybody is going to develop post-traumatic stress disorder. In fact, probably most won't.

"Picture the situation of those in concentration camps during the Holocaust. Those people were under severe trauma for a long time. Those who survived, the majority in fact did not develop post-traumatic stress disorder. A high percentage did, but not the majority, so there have to be other factors that lead to it. Some of those other factors are if you've ever been exposed to other trauma before the current one, and if so does that remind you of the current trauma? There is probably genetic predisposition also involved.

"And there's also a certain way of psychologically handling stress that makes it easier or harder to deal with trauma. If you're the kind of person who can put stress aside and move on easily, you're the kind of person who can probably deal with trauma better than those who don't handle stress as well. Multiple factors are involved."

Dan Ullrich
HealthLink Contributing Writer

In the January 15 issue of HealthLink, Dr. Moffic continues his discussion of Post-Traumatic Stress Disorder.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.