Symptoms and Diagnosis of PTSD ( II)

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Symptoms and Diagnosis of PTSD
By Harold Cohen, Ph.D.


There are three main kinds of symptoms that clinicians look for when diagnosing posttraumatic stress disorder (PTSD). These include re-experiencing symptoms, avoidant symptoms and symptoms of increased arousal.

Re-experiencing symptoms include ways in which the person persistently re-experiences the traumatic event. These symptoms may include the following:

•Intrusive memories of the traumatic event
•Recurrent, distressing dreams about the traumatic event
•Acting or feeling as if the traumatic event is reoccurring
•Mental and physical discomfort when reminded of the traumatic event (e.g., on the anniversary of the traumatic event)
Avoidant symptoms are ways in which the person tries to avoid anything associated with the traumatic event. These symptoms may also include a “numbing” effect, where the person’s general response to people and events is deadened. Avoidant symptoms include the following:

•Avoiding thoughts or feelings, people or situations (anything that could stir up memories) associated with the traumatic event
•Not being able to recall an important aspect of the traumatic event
•Reduced interest or participation in significant activities
•Feeling disconnected from others
•Showing a limited range of emotion
•Having a sense of a shortened future (e.g., not expecting to have a normal life span, marriage or career)
Symptoms of increased arousal may be similar to symptoms of anxiety or panic attacks. Increased arousal symptoms include the following:

•Difficulty concentrating
•Exaggerated watchfulness and wariness
•Irritability or outbursts of anger
•Difficulty falling or staying asleep
•Being easily startled
Difficulty in Diagnosing PTSD
Identifying people with PTSD can be difficult and this disorder is often unrecognized. PTSD is unique among psychiatric disorders in that it is identified not only by symptoms, but also by the precursor of the illness (the traumatic event). Since talking about trauma may evoke painful emotions, people often refrain from discussing past traumatic events.

When a person is unable or unwilling to discuss a traumatic event, accurate diagnosis is difficult. For example, domestic violence and sexual abuse are subjects that many persons feel uncomfortable in raising, even with professionals. For others, feelings of shame and guilt related to the event and social pressures to “deal with” the symptoms that come afterward make talking about it difficult. Additionally, persons with PTSD often have other disorders, such as substance abuse or depression. These other disorders share some of the symptoms of PTSD and can also make diagnosis more difficult.

Doctors and health professionals may also ignore the signs and symptoms of PTSD. Indeed, it has been argued that at times society turns a blind eye to the existence of traumatized individuals, denying that posttraumatic responses constitute a disorder. Indeed, PTSD has only recently been recognized by the official psychiatric nomenclature. Persons who suspect that they are suffering from PTSD should seek out professionals who have experience with this disorder.



Differential Diagnosis of PTSD SymptomsBy Harold Cohen, Ph.D.


While the symptoms of posttraumatic stress disorder (PTSD) may seem similar to those of other disorders, there are differences. For example, PTSD symptoms may seem similar to those of anxiety disorders, such as acute stress disorder or obsessive-compulsive disorder. However, there are distinct differences between these disorders.

In general, the symptoms of acute stress disorder must occur within four weeks of a traumatic event and come to an end within that four-week time period. If symptoms last longer than one month and follow other patterns common to PTSD, a person’s diagnosis may change from acute stress disorder to PTSD.

While both PTSD and obsessive-compulsive disorder have recurrent, intrusive thoughts as a symptom, the types of thoughts are one way to distinguish these disorders. Thoughts present in obsessive-compulsive disorder do not usually relate to a past traumatic event. With PTSD, the thoughts are invariably connected to a past traumatic event.

PTSD symptoms can also seem similar to adjustment disorder because both are linked with anxiety that develops after exposure to a stressor. With PTSD, this stressor is a traumatic event. With adjustment disorder, the stressor does not have to be severe or outside the “normal” human experience.

Treatment of PTSD
There are two primary types of treatment for posttraumatic stress disorder (PTSD) — psychotherapy and medications.

Psychotherapy for PTSD
Most people who experience post-traumatic stress disorder undergo some type of psychotherapy (most commonly either cognitive-behavioral therapy or group psychotherapy, or combination of the two). You can learn more about psychotherapy for PTSD now.

Psychotherapy techniques commonly prescribed include group psychotherapy, cognitive-behavioral therapy, EMDR and hypnotherapy.

Medications for PTSD
Medications are nearly always used in conjunction with psychotherapy for PTSD, because while medications may treat some of the symptoms commonly associated with the disorder, they will not relieve a person of the flashbacks or feelings associated with the original trauma. If one is receiving a medication from a general practitioner or their doctor, they should nearly always seek a psychotherapy referral in addition to the prescription.

Antidepressants

The most commonly prescribed class of medications for PTSD (and the one approved by the U.S. Food and Drug Administration) are the selective serotonin reuptake inhibitor (SSRI) antidepressants. These include drugs such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). Research shows that this group of medicines tends to decrease anxiety, depression, and panic associated with PTSD in many people. These types of antidepressants may also help reduce aggression, impulsivity, and suicidal thoughts that can occur in people with PTSD.

This class of antidepressants generally takes 6 to 8 weeks to work, so patience is needed when taking them. Many people don’t always respond to the first type of antidepressant tried, so another antidepressant may need to be tried if the first one is ineffective. A relapse of posttraumatic stress disorder is less likely if antidepressants are prescribed for at least a year. Antidepressants are particularly useful in patients who also suffer from depression (although they can be useful even in the absence of depression). They are also useful when there is a history of abuse of alcohol or other substances,

Other Medications
There are a variety of other medications often prescribed to try and help reduce the symptoms associated with PTSD. The most common alternative to antidepressants are the atypical antipsychotics. Atypical antipsychotics include medications such as risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). Antipsychotic medicines seem to be most useful in the treatment of PTSD in those who suffer from agitation, dissociation, hypervigilance, intense suspiciousness (paranoia), or brief breaks in being in touch with reality (brief psychotic reactions).

Other less directly effective but nevertheless potentially helpful medications for managing PTSD include mood stabilizers like lamotrigine (Lamictal), tiagabine (Gabitril), and divalproex sodium (Depakote). Medicines that help decrease the physical symptoms associated with PTSD include drugs such as clonidine (Catapres), guaneficine (Tenex), and propranolol.

Benzodiazepines (commonly referred to as minor tranquilizers, sleeping tablets, or anti-anxiety medications) are sometimes prescribed for certain symptoms of PTSD because they provide rapid relief of anxiety, but are also associated with dependence. In general, there is far more evidence for the use of antidepressants in PTSD than for the use of benzodiazepines. There is even a small amount of data indicating that although the benzodiazepines can provide immediate relief of symptoms, over the long haul they can exacerbate PTSD.

In general, medications should be prescribed for PTSD only by a psychiatrist. Specialists may prescribe two medications at the same time for people with PTSD who fail to respond to various single medications.