Post-traumatic Stress Disorder / PTSD

PTSD is considered to be caused either by psychological or physical trauma, more frequently a combination of both. Traumatic events that may cause symptoms of PTSD are f.e. (experiencing or/and witnessing) violent assault, abuse, torture, being a hostage or kidnapping – so we are talking about a wide range of settings from violence in private context up to war, conflict, disaster and catastrophes. Not everyone experiencing such events will develop symptoms.

The most typical symptoms for PTSD are re-experiencing the original trauma through flash-backs and nightmares, avoidance of stimuli associated with the traumatic event, increased arousal (as irritation, anger, sleep-disorders), depression and anxiety. There is a wide range in severity of symptoms, some people might even develop “complex PTSD” (with dissociative symptoms)or a kind of “multiple identity”. On this page we have collected some useful links with information about PTSD:

• Post-traumatic stress disorder – Clinical Review
  This article provides an overview of understanding of the disorder, origin and developing, and therapeutic aspects. Scientific approach, target group: therapists. - BMJ British Medical Journal, Jonathan I Bisson, april 2007.
• DSM-IV criteria for PTSD-diagnosis
  The DSM-IV-manual (“Diagnostic and Statistically Manual of Mental Disorders”) is published by the American Psychiatric Association/APA, it covers all mental health disorders for both adults and children. Here you will also find some lists about known causes of these disorders, statistics, prognosis, research.
• ICD-10 criteria for PTSD-diagnosis
  ICD-10 (this 10th version is in use since 1994) stands for “International Classification of Diseases”, and is published by the WHO. It`s considered to be the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use.
• Post-Traumatic Stress Disorder (PTSD)
  A booklet on PTSD (18 p.) that explains quite simple addressed to interested and affected people, what it is, treatment options, how to get help. Target group: patients, family, interested persons.- NIMH - National Institute of Mental Health, 2008.
• PTSD in Children and Adolescents
  This abstract (16 p.) tries to focus on the challenge to diagnose PTSD correctly, especially in children. Quite theoretical in approach, therefore the target group are specialists in that field. – Univ.of Illinois/Chicago, 11/2005.
• How PTSD may manifest in children
  Very short overview with some import points concerning the symptoms children may develop after trauma, contrary to adults. Scientific article, target group: specialists in that field. – WHO, 10/2006.
• Trauma and PTSD Overview
  Very detailed overview, with chapters containing general information about PTSD, as well as about disaster and terrorism, war, and other types of trauma. – National Center for PTSD, 11/2009.
• Treatment of Post Traumatic Stress Disorder (PTSD) The Linen Cupboard Metaphor
  Very good metaphor on treatment of PTSD. - Psychologytools.org

Sometimes it can be difficult to know whether distress after a personal tragedy/catastrophe is just a normal reaction to an unormal, upsetting life experience or becomes a symptom to something more serious. Most of the people exposed to a trauma are distressed over a timeperiod of weeks or month, they become anxious, may be depressed, some cannot deal with their daily responsibilities as before, they get easily upset. After a time they are again better able to function, and the symptoms will lessen. Some people however will continue to be profoundly affected by the trauma months or years later, and so develop PTSD.

Lots of instruments have been developed to diagnose and measure PTSD. There are two main categories: structured clinical interviews and self-report questionnaires. So an evaluation can take from half an hour to get an overview up to several hours (when the information f.e is needed for legal claims). This evaluation is usually carried out by a psychiatrist, psychologist, or another trained mental health professional.

• Overview over the most used assessments
  The National Center for PTSD provides a catalogue of many assessments used to measure trauma exposure and PTSD. You will find lots of information about the scales and interviews, and the significance of each. You will not find the assessments themselves here (some can be purchased via website). – United States Dep. Of Veteran Affairs, NCPTSD, 10/2008.
• FAQs about PTSD: For Professionels
  A fact sheet that provides professionals/therapists with answers about the most common questions about PTSD-assessments. – United States Dep.of Veteran Affairs, NCPTSD, 11/2009.
• Psychiatric Rating Scales for PTSD
  A catalogue of the most used assessments, some as direct links, most of the assessments has to be purchased. Neurotransmitter.net

There are lots of assessments available, which should help to diagnose and measure PTSD-symptoms. Only some of these assessments are available for free, most of them have to be purchased. Specially the structured clinical interviews are thought to be used only by clinicians. Therefore we present here a list of the most common assessments just with names. More information about the respective assessment see link 1 in this chapter.

• CAPS - Clinician Administered PTSD-Scale, “gold-standard”, 30-item structured interview, to be administered by clinicians/professionals, corresponding to the DSM-IV
• SCID PTSD Module - Structured Clinical Interview DSM-IV / PTSD-module. Semistructured interview, to be administered by professionals/clinicians. Single item trauma event history query.
• MPSS-SR - modified PTSD symptom scale. 17-item self-report measure, assesses the 17 DSM-symptoms of PTSD.
• M-PTSD - Mississippi Scale for Combat-Related PTSD. 35-item self-report measure that assesses combat-related PTSD in veteran populations.
• MMPI-2 – trauma-spec. subscales - Minnesota Multiphasic Personality Inventory – 2, with possibilities in addition to the diagnoses of personality to look after PTSD-symptoms/severity.
• Trauma Symptom Check-list 33 and 40
  TSC is limited to professionals (should not be used as self-test). “The TSC-40 is a research measure that evaluates symptomatology in adults associated with childhood or adult traumatic experiences. It measures aspects of posttraumatic stress and other symptom clusters found in some traumatized individuals. It does not measure all 17 criteria of PTSD, and should not be used as a complete measure of that construct.” - John Briere, Marsha Runt.

There have been developed many methods to treat trauma-survivors suffering with PTSD. Lots of the randomized controlled trials of psychotherapy published have examined interventions considered to be components of cognitive-behavioral therapy CBT. Also often described are therapeutic approaches and techniques overlapping across psychotherapy. Some conclude that it is possible to group approaches according to objective effect (studies) in:

• - Exposure-based CBT - Cognitive behavior therapy (CBT) has been shown to be the an effective type of therapeutic treatment. CBT can help the patient/survivor to recognize and change inaccurate thoughts about himself and his future. Exposure therapy is the very good technique for recovery, it involves overcoming the patients anxieties by facing them in a controlled and safe environment. The survivor relive his fears all at once (flooding) or step-by-step (desensitization) in order to overcome them. Although this may seem frightening at first, this treatment is safe and works quickly.
• - EMDR - EMDR stands for Eye Movement Desensitization and Reprocessing (Francine Shapiro). It is a psychological method for treating emotional difficulties that are caused by disturbing life experiences, ranging from traumatic events which could be anything from a road traffic accident to an upsetting childhood event or a war/conflict/disaster- situation. For many clients, EMDR provides more rapid relief from emotional distress than conventional psychotherapies. EMDR brings together elements from well-established clinical theoretical methods including psychodynamic, cognitive and behavioral therapies. EMDR uses the bilateral stimulation (for exemple by left/right eye movement, or tapping left/right side of the body) which repeatedly activates the opposite sides of the brain. This helps the neurophysiological system to free itself of blockages and reconnect itself.
• - Other psychotherapies - Some other psychotherapies have been published (reference: guideline-watch from 2009, APA) since 2004, but the utility/generalizability of conclusions are limited (methodological issues). Some approaches are more body-orientated and are seen to have success (f.e. sensimotor psychotherapy/P.Ogden, focus on the effect of trauma also on body and brain). Otherwise to mention here cognitive restructuring, psychodynamic psychotherapy, some other narrative therapies.

• Psychological treatment of post-traumatic stress disorder
  This is an article in “The Cochrane Library”, where the author reviews lots of trials of all psychological treatments considered useful by The Cochrane Collaboration. Target group: clinicians/professionals. - J Bisson, M Andrew, The Cochrane Library 2009.
• Post-traumatic Stress Disorder: National Clinical Practice Guideline
  This is the complete PTSD-guideline (no 26, 176 p.) of the “National Institute for Clinical Excellence” / NICE. Great overview, considering all of the importend topics from symptoms, treatment (also regarding children), intervention, recommendations. - The Royal College of Psychiatrists & The British Psychological Society, 2005.
• Post-traumatic Stress Disorder (PTSD): Quick Reference Guide
  Here you`ll find the guidelines mentioned above as a short summary (20 p.), edited also by NICE. - 2005.
• Practice guidelines for the treatment of patients with ASD and PTSD
  A great overview of current approach and treatment, kind of clinical standard. This represents a so called “guideline-watch”, a supplement to get the original guideline (from 2004) up-to-date. Target group: clinicians - American Psychiatric Association APA, march 2009.
• Expert Consensus Guideline Series: Treatment of Posttraumatic Stress Disorder
  This is a supplement to the Journal of Clinical Psychiatry, where information about PTSD, recommended approaches and therapy suggestions are collected. Target group: clinicians/professionals. It gives an good overview, which is unfortunately kind of limited because it`s edited in 1999, and some of the newer therapies (as EMDR) are`nt mentioned yet, as well as recommendation concerning medication can be partially outdated. - The Journal of Clinical Psychiatry, Vol 60, 1999.
• Training manual - Brief Recovery Program BRP for trauma victims
  This manual (71 p.) is designed for mental health professionals who have been trained to deliver the specific procedures included in the Program. It presents a brief (4 session) psychological intervention to be delivered 2-12 weeks after an exposure to a trauma with the goal of facilitating recovery and preventing chronic post-trauma reactions such as posttraumatic stress disorder (PTSD). - Foa and Riggs.
• Helping Children and Adolescents Cope with Violence and Disasters: What Rescue Workers Can Do
  Useful booklet (20 p.)where the target group are Rescue Workers (police, fire, other first responders). Overview of the topic with description of symptoms, and how to cope (and talk) with young survivors. – National Institute of Mental Health, NIMH 03/2010.
• Pharmacotherapy for PTSD
  A review in The Cochrane Library, to assess the effects of medication on PTSD, by comparing trials. – The Cochrane Library, DJ Stein, JC Ipser, S Seedat, publ. 2009.

In this chapter we try to collect some articles which are highlighting some other aspects of PTSD. These may be the historical context – the origin of PTSD in the “Shell shock” of World War I, as well as some thoughts about the sociological impact or considerations on the aspect of “PTSD – a disease?” or just a normal reaction after catastrophes.

• The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category
  This article represents a debate on PTSD with several aspects not often to be seen in a clinical daily routine, with also ethical aspects. Is PTSD always to be seen as a disease? Which impact do sociopolitical and medical aspects have on setting a diagnosis? – Derek Summerfield, BMJ/British Mediacl Journal, 01/2001.
• Conflict Transformation – Civil Conflict Management
  On this website we find an overview of recent developments in the field of conflict transformation from various perspectives: from academic analysts and practitioners as well as from experts representing different areas of work inside and outside of conflict zones. The site intends to provide continually updated cutting-edge knowledge, experience and lessons learned for those working in the field of transforming violent ethnopolitical conflict. – Berghof Conflict Research, 2010.
• Post-traumatic stress disorder in children: Controversies and unresolved issues
  This article highlights some problems in the challenge to diagnose PTSD in children, with some thought whether PTSD is a valid diagnostic formulation, or may be is to revise. Some quite good considerations, although the article is some years old (and diagnostics have changed). - J. of Child and Adolescent Psychiatry Nursing, 10/2000.
• Usefulness and validity of post-traumatic stress disorder as a psychiatric category
  Quite good overview (although some years old and may be therefore in some aspects outdated) on some aspects of the diagnosis of PTSD as a psychiatric diagnosis. Highlights social aspects, the validity of the diagnosis, causes, effects as well as biochemical and anatomical findings. – BMJ, 11/2001.
• Planning needs and services after collective trauma: should we look for the symptoms of PTSD?
  This article presents some research results about the effect of traumatic events on the general population. Highlights how different results can be depending on measurements, definitions and other PTSD criteria used by the researcher. - Carmelo Vazquez & Pau Perez-Salesi, 2007.
• Shell Shock during World War One
  This represents an overview by the BBC on “Shell Shock”, here in World War I, the historical development of the term, symptoms, treatment at that time. – BBC World Wars in-depth, Prof. Joanna Bourke, 11/2009.

Here we tried to collect some manuals (partly very concrete how-to-do, partly as a textmanual with plain description of procedure) useful in targeting survivors of catastrophes, with focus on how to recognize/prevent possible development of PTSD in the aftermath.

• Psychological First Aid
  This is a very good manual (186 p.) about “Psychological First Aid”, means intervention strategies which are intended for use with children, adolescents, parents/caretakers, families, and adults exposed to disaster or terrorism, and in the immediate aftermath. It can also be provided to first responders and other disaster relief workers. Psychological First Aid is designed to reduce the initial distress caused by traumatic events and to foster short- and long-term adaptive functioning and coping. It comes along with lots of very useful and practical examples (f.e. how to talk to survivors). Target group: mental health and other disaster response workers. - National Child Traumatic Stress Network, Veteran Affairs National Center for PTSD 2006.
• Wounded Spirits, Ailing Hearts Training Manual
  A manual about PTSD, its symptoms and treatment, with lots of general thoughts, but all over with the very interesting focus on the impact of PTSD on American Indians and Alaska Native (American Veterans). Maybe in some aspects outdated, but quite interesting. – National Center for PTSD, 2000.
• Post-traumatic stress disorder – the management of PTSD in adults and children in primary and secondary care
  Here you will find “Presenter slides”, a slide-show which presents an overview about PTSD, symptoms, and some considerations according treatment.- Clinical Guidelines, NHS National Institute for Health and Clinical Excellence, 05/2005 .

• The International Society for Traumatic Stress Studies (ISTSS)
  ISTSS is an international multidisciplinary, professional membership organization that promotes advancement and exchange of knowledge about severe stress and trauma. This knowledge includes understanding the scope and consequences of traumatic exposure, preventing traumatic events and ameliorating their consequences, and advocating for the field of traumatic stress.
• The European Society for Traumatic Stress Studies
  ESTSS is the European network for professionals in the field of psychotraumatology, and seeks to ensure continued prominence is given to all aspects of traumatic stress and its many repercussions. It promotes networking between individuals and organisations within the field of psychotraumatology.
• Queensland program of assistance to survivors of torture and trauma
  This Australian site offers lots of services addressing the needs of torture survivors and refugees.
• Online Resources For Dating with PTSD
  For those who are married to or dating someone dealing with PTSD, it can be a difficult road to travel and frustrating at times, here are some useful information.
• Sidran Institute – Traumatic Stress Education and Advocay
  This institute offers information about the topic as well as teaching-courses (not for free available).
• National Center for Posttraumatic Stress Disorder
  The Center for PTSD is organized under the U.S. Department of veteran affairs. It provides information, research, education, training on trauma and PTSD to veterans and others.
• PTSD Online Resource Center
  A good collection of useful links related to PTSD.
• AsianSTSS
  AsianSTSS was founded for professionals to advance knowledge about the nature and consequences of highly stressful events and to provide a forum for the sharing of research, clinical strategies, public policy concerns and theoretical formulations on trauma around the Asian region, as well as promoting high standards and ethical practice in the trauma field.
• The Australian center for posttraumatic mental health
  This center at the University of Melbourne undertakes trauma related research, policy advice, service development and education. Their services help organisations and health professionals who work with people affected by traumatic events.
• The Israel Center for the Treatment of Psychotrauma
  Information about PTSD, trauma, research about the topic.
• David Baldwin`s Trauma Information Pages
  These Trauma Pages focus primarily on emotional trauma, traumatic stress and PTSD – following both individual traumatic experience and a large-scale disaster. It provides information for clinicians and researches. It`s represents a huge collection of very useful articles and links to these topics.
• A Guide to Post Traumatic Stress Disorder
  A site for military personnel and others, with a list of facts and resources for patients and their family members who are coping with PTSD, as well as medical professionals assisting with the care and treatment of PTSD patients.

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