Matthew Runyan, MD, section chief, PPG Psychiatry Hospital Section, explores some of the common triggers for Post-Traumatic Stress Disorder and the role our natural biology plays.
As humans, we are designed to deal with stress. Numerous brain and body systems exist to help us recognize stressors, categorize them, deal with them or ignore them. But what happens if one or more of those stressors is too much? What happens in severe trauma cases where the body can get hijacked by a panic response? The result is often Post-Traumatic Stress Disorder (PTSD). Many people have heard of PTSD, and typically attribute it to a condition impacting our veterans. While it is true there are many servicemen and women who suffer from this disorder, there are millions of civilians who have developed this disorder as a result of a traumatic event, such as a car accident, witnessing a death, or sexual assault to name a few.
What is PTSD?
Ever watch a show like National Geographic – one with lions, gazelles, zebras, etc.? A lion sees a gazelle and starts to give chase. The gazelle takes off running for its life. Both animals have automatically turned on the “fight or flight” mechanism, also known as the sympathetic nervous system. This is an automatic response to perceived danger that causes heart rate and blood pressure to go up, the pupils to dilate, the blood to move from the digestive organs to the muscles. In short, it’s the body’s response to danger to get ready to do something - anything!
Say the lion catches the gazelle, lunch is served. The other gazelles don’t run miles off into the distance. They stop a few hundred yards away and return to eating. The danger is over. Blood pressure and heart rates drop, blood goes back to the digestive organs, and they return to grazing. This is how the system is supposed to work, like a light switch. When danger is present, the switch turns on. When it disappears, the switch turns off. But what happens if the body decides to never turn the switch off?
A change in the brain
Just like the lion and the gazelle, humans have the fight or flight (sympathetic) response. But sometimes after a trauma, or maybe a series of traumas, the brain essentially decides to put a piece of tape over that switch. The brain has decided unconsciously that it is always in danger and leaves that switch on – fully engaging the fight or flight mechanism even when the body isn’t in danger.
People who have this condition have a very predictable pattern of behaviors because the unconscious brain is running the show. Typically they despise and will not tolerate crowds - no malls, concerts or crowded places. They usually cannot stand people behind them and will sit with their back to the wall if at all possible facing the door, and if forced to sit elsewhere usually appear nervous and look behind them frequently. Often they will have daytime flashbacks to traumatic events or nightmares about the event, because the brain is hypervigilant and looking for a return of the danger. They are living in a state of perpetual panic and quite frankly, it is exhausting! Every room they walk into, they are assessing where it’s safe or dangerous. They will often go grocery shopping at odd hours to ensure nobody is there, and some will wake up in the early morning reliving the worst moments of their lives. Many come to fear sleep, due to these nightmares, which only pushes the brain into a further state of now sleep deprived panic.
Note how I am really leaning on the biology of this condition. This is crucial, because this is an automatic response, not a choice. True, they have a choice to go to the grocery store at 5 p.m. when it is crowded or go to the front row of the rock concert, but their brain makes it so anxiety provoking, so upsetting, that this doesn’t even seem like a choice. The mere thought of being in these situations is so upsetting to people with this disorder that they will go to fairly extreme measures to avoid thinking of them, let alone actually trying to do them.
This last part is very important for family members. Often I have conversations with people who do not understand why their loved one acts this way. Almost every single time, they tell me that their family is trying to understand, but just can’t comprehend why the patient can’t do certain things, or reacts in certain ways to social situations or just loud noises. It’s an incredibly freeing moment for them to hear that it isn’t their loved one’s fault - it’s biology. And we can help change that biology back to normal functioning, turning that switch off when it isn’t needed.
PTSD is very complex and so is the treatment. The best approach is a combination of medications and therapy. No matter what medication or therapy we use, we cannot make people forget their memories, which are typically extremely painful. The goal is to separate the painful emotions from those memories, give some relief from the chronic panic, and work through those traumas to see how they are affecting the person today. I tell patients that it took years of trauma and problems to get to the point of treatment, and it’s likely it will take years of treatment to reverse those issues. Recovery from PTSD is hard work, but it is possible and very worth it.
Common therapy options include:
- Eye Movement Desensitization and Reprocessing
- Rapid Resolution Therapy
- Cognitive Behavioral Therapy
- Stress Inoculation Training
- Trauma Based Psychotherapy
Common medications include:
- Antidepressants - Fluoxetine, sertraline, citalopram
- Anti-anxiety - buspirone, hydroxyzine, very short duration benzodiazepines
A medication called prazosin (minipress) can be extremely helpful for some patients in relieving nightmares. It is a blood pressure medication that helps tamp down that fight or flight response during sleep, and can help prevent those 3 a.m. panicked wake ups that make falling asleep or having a normal day afterward difficult. If you suffer from nightmares that are severe, trauma-based and disruptive, ask your physician if prazosin could be helpful. Some people aren’t ready to talk about their trauma or go to therapy. But if we can get them some restful sleep, things almost always improve.
Many times, people with PTSD have other psychiatric issues. Depression, anxiety and substance abuse are very common. Quite a few patients I see who use drugs or alcohol have learned to use the drugs as a coping skill. Many feel they are self-medicating. I disagree. If it was medicating it would help. The drugs aren’t fixing the problem, but they are numbing it; Making it tolerable, even just for a little while.
But those drugs bring their own problems and consequences, including addiction, and things generally degrade to an even worse situation. If someone wasn’t able to tolerate their traumas and symptoms prior to drug use, after drug use they are usually significantly worse. If we only focus on the drug use, we are missing the underlying factors that are fueling this use, which is like seeing only the 10 percent of an iceberg that is above the ice. That’s the drug use. Below the surface, resides 90 percent of the problem, but it’s not as visible and often overlooked. If we don’t treat and learn to deal with that 90 percent, the drug use becomes extremely difficult to treat, because we aren’t treating the root of the problem.
The following is the diagnostic criteria for PTSD. This condition is diagnosed after a person experiences symptoms for at least one month following a traumatic event. However, symptoms may not appear until several months or even years later. The disorder is characterized by three main types of symptoms:
- Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares.
- Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma.
- Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.
If you or a loved one are experiencing any of the symptoms above, talk to your primary care provider immediately. If you’re looking for a place to start the conversation, consider taking this quick quiz from the Veterans’ Affairs website to assess the potential that you are experiencing PTSD.