Description of the main symptoms - Post-Traumatic Stress Disorder (PTSD)

Это продолжение увлекательной статьи про посттравматическое стрессовое расстройство.

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desire to take revenge on him or to humiliate him (which in some cases may be expressed in outbursts of anger);

Description of the main symptoms

Changes in the arousal and reactivity of the nervous system

PTSD leads to a state of chronic overexcitation of the autonomic nervous system. This causes symptoms such as sleep problems, irritability (up to outbursts of anger), hypervigilance regarding potential threats (in extreme cases resembling paranoia). Because of the heightened reactivity of the nervous system, the patient may involuntarily flinch or even jump upon hearing an unexpected noise^[66].

Pathological re-experiencing (flashbacks)

Pathological re-experiencing, also called the "flashback effect", is a memory of the traumatic event that suddenly (often for no apparent reason) resurfaces, with the patient experiencing the sensation that the event is happening to him or her at that very moment^[67]. During flashbacks associated with traumas experienced in childhood, an adult may feel as though his or her body has become small and weak, as a child's body is^[68]

This symptom is very characteristic (flashbacks are observed in almost all persons suffering from PTSD)^[69] and is, moreover, one of the most severe and frightening in the clinical picture of PTSD. Patients are often embarrassed to talk about flashbacks: they are ashamed that memories evoke such intense fear in them.

Flashbacks may take the form of visual images, sounds, smells, and tactile and taste sensations that occurred at the moment of the trauma. Sometimes the patient experiences only one type of flashback, but often they occur simultaneously, creating a complete, very realistic, and frightening picture of the traumatic event. Flashbacks are usually activated by external stimuli (visual, auditory, tactile, gustatory, etc.) that resemble the event (triggers). A reminder of the traumatic event evokes severe negative emotions in the individual who experienced the trauma. In particular, smells are a very powerful trigger for the onset of flashbacks^[70].

When a flashback occurs, the following outward signs may be observed, which do not occur during ordinary memories:

• rigidity of the muscles of the arms or legs;
• clenching of the fists;
• signs of nervous excitation (change in breathing rhythm, increased sweating, reddening of the face);
• change in facial expression;
• a detached, vacant gaze;
• loss of spatial orientation;
• behavior that is strange and unusual for the given person;
• a sudden display of aggression, fear, or a desire to leave that is inexplicable in the context of the situation;
• confused speech, mutism, or a sudden change in manner of speaking;
• a trance-like state (for example, rhythmic rocking of the body)^[71].

Nightmares

In PTSD, nightmares are similar to flashbacks: they create a sense that what is happening is real and evoke intense fear. However, whereas flashbacks accurately reproduce fragments of the event, dreams may take a symbolic form that only distantly resembles what occurred at the moment of the trauma. Moreover, the content and form of flashbacks do not change over time, whereas in dreams a blending of memories of the trauma with memories of something that happened recently may occur. For example, a nightmare may contain scenes from a film watched the day before, if an associative link was formed at the subconscious level between the scene from the film and the traumatic event. Nightmares disrupt sleep: the individual wakes up in fear or tries not to fall asleep, fearing the onset of nightmares^[72].

In PTSD, nightmares are characterized by a "photographic" reproduction of past events. For this reason, patients suffering from sleep disturbances are asked about the content of their dreams; PTSD is suspected when very vivid and plausible nightmares are present. During sleep, a patient with PTSD may make various movements, and upon waking from a nightmare may be agitated, frightened, may scream, attack his or her partner in bed, or grip them tightly^[54].

Post-traumatic dissociation

Post-traumatic disorder can lead to the occurrence of dissociative symptoms. The term "dissociation" refers to a defense mechanism (or its result) by which a coherent set of actions, thoughts, attitudes, or emotions becomes separated from the integrated psyche of the personality and functions independently. In this case, two or more mental processes can coexist independently of one another^[73]. One of the results of this defense mechanism is that when a patient enters a state of dissociation, his or her pain sensitivity decreases. Most patients with PTSD do not show significant dissociative symptoms. According to research findings, their presence correlates with traumatic childhood experience. It has also been noted that the presence of dissociative symptoms leads to a higher risk of suicide in PTSD^[74].

The dissociative symptoms of PTSD are divided into three groups:

• Primary dissociation: if certain aspects of the traumatic event are unbearable for the individual's psyche, he or she may repress them from consciousness. In this case, the memory of the event becomes fragmented and individual details may be forgotten. This symptom is very typical of post-traumatic disorder^[75]. In this case, the sensory and emotional elements of the event cannot be integrated within a unified personal memory system; often they remain isolated from consciousness, and the re-experiencing of the traumatic situation becomes divided into isolated somatosensory elements^[73].

• Secondary dissociation: having experienced a trauma, the individual begins to perceive the events of his or her life in a detached way, as if he or she were an outside observer of what is happening to them^[76]. Secondary dissociation has an anesthetic effect: it allows the individual to distance himself or herself from fear, to reduce the level of pain and negative emotions, and to avoid fully becoming aware of all the consequences of the trauma^[73].

• Tertiary dissociation: in the case of repeated psychological traumas, a psychological defense arises in the form of the creation of mental sub-personalities (ego states), each of which stores part of the information about the traumatic experience. In this case, in different life situations, the person's behavior may reveal one or another sub-personality^[76]. Some of these ego states may become isolated from the psyche and experience within themselves the pain, fear, or anger associated with the traumatic situation experienced and its consequences. In parallel, other ego states remain, as it were, unaware of the trauma and allow the individual to successfully carry out his or her everyday duties. The most extreme expression of tertiary dissociation is multiple personality disorder^[77].

In dissociation in the form of depersonalization, the individual experiences a feeling of estrangement from his or her own body

There are several types of dissociative symptoms:

1. Dissociative amnesia: the inability to recall some piece of information in the absence of any memory disorder^[75].

2. Dissociative fugue (from the Latin fuga — "flight"), which is expressed in the occurrence of motor excitation against the background of a twilight state (undressing, running, and so on). The period spent in the twilight state is usually short, but it can last many hours and is usually forgotten by the individual^[78]. In some cases, the individual may leave his or her place of residence, forget his or her past life, and consider himself or herself to be a different person.

In dissociation in the form of depersonalization, the individual may not feel identical to his or her own reflection in the mirror; this can occur in severe cases of PTSD^[74]

3. Derealization — the individual perceives what is happening to him or her as something strange, supernatural, or even unreal. The duration of this state can vary. It usually arises in a state of intense stress and can cause severe fear. During derealization, the individual perceives reality in a detached way; it evokes no emotions in him or her. However, the experience of losing the sense of reality can be so frightening that it intensifies the individual's anxious state. Patients usually describe the sensations of derealization in the following terms:

• feels like an outside observer of what is happening;
• experiences a sensation of a veil before the eyes;
• "leaves his or her body", as if the individual were floating in the air and seeing himself or herself from the outside;
• is in a state resembling alcohol intoxication;
• feels as though everything were happening in a dream^[76];
• the surrounding world may also be perceived as strange, distorted, or frozen, "lifeless";
• the sounds of the surrounding world seem muffled, distant^[74].

4. Depersonalization — this symptom resembles derealization, but relates not to the external but to the internal world of the individual. It is expressed in the loss of the sense of one's own identity. The person remembers the events that happened to him or her, but has no internal sense of having taken part in what occurred. Sometimes it seems to him or her that he or she does not exist in reality, or is a character in a film. The individual may also develop a sense that he or she does not control his or her own behavior and statements. Bodily sensitivity and emotional response to external stimuli may decrease. Like derealization, this experience can be frightening and, in turn, intensify the person's estrangement from himself or herself^[76]. In an experimental study, when reading aloud a description of the traumatic event, patients with the symptom of depersonalization did not show an accelerated heart rate (as usually happens with anxiety), but rather a slowed one. The subjects explained that at that moment they "disconnected" from their bodies so as not to feel fear, and it seemed to them that everything was happening in a dream or that they were outside their own bodies^[74]. However, objective study shows a relative preservation of emotional activity, thought processes, and the capacity for perception at the level of the sense organs^[73].

Avoidance

This symptom is a common post-traumatic reaction. The individual tries to avoid everything that might evoke intense negative emotions in him or her (for example, fear, sadness, or shame). Avoidance may relate to:

• external stimuli — for example, avoiding visiting certain places or meeting certain people. Avoidance of external stimuli can lead to problems in the individual's social functioning or complicate his or her everyday life;
• internal stimuli — fear of certain memories, thoughts, and feelings arising within oneself. Sometimes the individual may use psychoactive substances for such avoidance. Avoidance of negative emotions leads to a loss of the ability to fully perceive the surrounding reality, disrupts emotional contact with people, and also leads to an inability to experience positive emotions. Sometimes avoidance of one's own sensations, thoughts, and emotions leads to self-estrangement and, as a consequence, to the occurrence of dissociative symptoms. Moreover, emotions are necessary for the normal functioning of the psyche, and their complete suppression is impossible. The more the individual strives to suppress his or her emotional reactions, the higher the risk becomes of their intense, uncontrolled manifestation in stressful situations.

All this means that, although avoidance provides short-term relief from inner discomfort, in the long term it intensifies the problems associated with post-traumatic disorder. Moreover, a consequence of avoidance is that the individual becomes increasingly sensitive to stressors, and as a result has to avoid an ever-growing number of triggers. Eventually, avoidance can become the individual's main activity. In addition, in order to work out avoidance strategies the individual is forced to constantly think through the aspects of the trauma experienced^[79].

Irritability and anger

These emotions are quite characteristic of PTSD. Sometimes the individual is ashamed of his or her anger, regarding it as an emotion unacceptable from the standpoint of his or her moral values. Suppression of anger occurs especially often in cases where post-traumatic anger is very intense: it seems to the individual that if he gives free rein to his emotions, his anger will manifest itself in a frightening and destructive form, or that those around him will condemn or reject him. Restraining anger can lead to various kinds of pain symptoms and psychosomatic illnesses. In addition, the individual begins to avoid everything that might reactivate the emotion of anger in him, and this aggravates the avoidance symptoms described above.

On the other hand, some patients perceive anger as an emotional reaction that is more acceptable than fear, shame, tears, or an admission of one's own weakness and helplessness. In such a case, they tend to become aggressive in situations that activate any other negative emotion^[80].

Shame and guilt

Humiliation of the victim by the aggressor

Post-traumatic shame has little in common with normal shame — an emotion that helps a person adhere to moral norms and socially accepted rules. In PTSD, shame serves no useful social function. This shame prevents the individual from feeling compassion toward himself or herself and sometimes even creates in him or her the sense that he or she is no longer a full member of the human community^[81]. Sometimes shame can be a form of psychological defense against a feeling of helplessness: by blaming himself or herself, rather than the actual person responsible for what happened, the individual maintains the illusion that he or she had the potential ability to control events. The individual's belief that he or she is to blame for the misfortunes that befell him or her also helps him or her preserve the belief that the world is just and that everything that happens in the world is reasonable. In addition, this allows him or her not to experience aggressive feelings against the actual culprit^[82].

Intense post-traumatic shame more often arises in the case of repeated psychological traumas, especially in childhood. But even a single traumatic event can, for various reasons, evoke a feeling of shame:

• the victim may feel guilty for what happened to her (for example, because of her own carelessness);
• sometimes a victim of violence feels "contaminated" by what happened to her;
• in the victim's social environment there may be prejudices that lead to the condemnation or stigmatization of the victim (for example, victims of sexual violence);
• a feeling of shame and guilt can be caused by a person's inability to cope with the psychological consequences of the trauma in practical life (for example, an inability to drive a car after a traffic accident), as well as with post-traumatic emotions (anxiety, anger, etc.);
• shame may be linked to a person's belief that, at the moment of the traumatic event, he or she behaved differently from how he or she should have (for example, under the influence of fear);
• in some cases, internalization is possible of the contemptuous remarks made by the aggressor toward the victim at the moment of the trauma. In such a case, the tone of voice and words of the aggressor may later become part of the victim's inner dialogue and sometimes even a traumatic flashback that replays in the mind when the trauma is recalled or in situations that resemble the trauma in some way.

Shame relates to a threat of the social type; it is connected with the fear of being rejected by one's own group. Fear of this type can be very strong; it is instinctive and arose in the course of evolution — even in the relatively recent past, rejection by the group meant death for a person, and the loss of status or the sympathy of group members reduced the chance of receiving help from the group.

A feeling of shame evokes a sense of constant fear and an inability to feel safe even after the traumatic episode has ended. The person also feels incapable of coping with a similar situation or its consequences, should a situation of this type arise again in the future. All this sustains and intensifies the other post-traumatic symptoms. As a result, shame becomes the cause of various types of defensive behavior^[83].

There are 2 forms of shame:

• internal shame, associated with a feeling of guilt or low self-esteem;
• an individual's shame about what other people think of him or her, or what they might think of him or her if they learned certain negative facts about his or her behavior.

In a post-traumatic state, both of the above forms of shame can coexist in a person for a long time.

In the case of internal shame, the following reactions are possible:

• addiction;
• self-aggression (self-harm or inflicting physical injury on oneself) with the aim of self-punishment;
• shame about oneself does not allow the person to feel positive emotions or compassion toward himself or herself. The individual also believes that he or she does not deserve good treatment from others and has no right to treat himself or herself well, and therefore does not allow himself or herself to ask for help or to do anything that might improve his or her condition.

In the case of shame about the opinions of other people, the predominant fear is that of hearing critical remarks directed at oneself. There may also be concerns that, in the event of close contact, the people around the person will guess what happened to him or her, or realize his or her inability to cope with post-traumatic symptoms. For this reason, the following often occur:

• aggressive behavior — with the aim of keeping others at a distance and not allowing them to voice critical remarks;
• non-assertive behavior, used in order to avoid criticism or rejection by other people. In particular, the person agrees with everything he or she is told and does what is demanded of him or her, even if he or she does not consider these demands fair;
• avoidance of contact with people, social isolation. Avoidance may also apply to people whose presence brings to mind the event that caused the shame. In addition, the individual may avoid people capable of asking him or her questions that he or she would be ashamed to answer.

All these types of defensive behavior, being maladaptive, evoke even greater shame about oneself, which in turn intensifies the tendency toward defensive behavior^[83].

Emotional numbing (Emotional detachment)

In PTSD, a decline may appear in the ability to experience positive emotions and such feelings as love. Such people are described as cold, unfeeling, uncaring. This can lead to the breakup of a marriage and to instability in one's personal life^[84].

Somatic symptoms

According to research findings, patients with PTSD show^[54]:

Other symptoms

• Emotional instability.
• Difficulty making decisions.
• Perfectionism, caused by a desire to always keep control of the situation.
• Negative changes of character, with the appearance of traits such as cynicism, selfishness, intolerance, the emergence of prejudices, and a loss of compassion.
• Taking on the role of a pariah.
• Stockholm syndrome (attachment to the aggressor).
• In believers — loss of faith or involvement in destructive religious movements.
• Participation in collective violence.
• Inability to feel happy.
• Speech disorders.
• Health problems, such as, for example, elevated blood pressure;
• Symptoms of existing illnesses may become more severe.
• Physical weakness and rapid fatigability.
• Loss of sexual desire^[85].

Symptoms of PTSD in children and adolescents

In children and adolescents, more often than in adults, PTSD causes psychosomatic disorders, dissociation, aggression and self-aggression, and eating disorders. Regressive behavior (a return to behavior characteristic of an earlier age) and learning difficulties may also be observed. Trauma can leave its mark on the child's further development and even on the formation of certain character traits^[86], with a risk of personality disorder arising. The younger the child, and the less formed his or her character was before the trauma, the higher this risk^[87]. A symptom of PTSD specific to children is the reenactment of the trauma in repetitive play or drawings, withdrawal into an imaginary world, and intense attachment to transitional objects^[88]. Under the influence of trauma, some children mature faster, which shows itself in greater independence or in more rapid intellectual development^[89]. It is hypothesized that in girls, eating disorders (anorexia and bulimia) may be a protective form of behavior after experiencing sexual violence, since the girl is afraid of being sexually attractive^[90].

Coping behavior

A person suffering from PTSD gradually begins to use various conscious and subconscious coping strategies to reduce the intensity of post-traumatic symptoms. Of all these strategies, only behavior aimed at solving the problem is adaptive (. All the other strategies listed below only worsen the patient's situation and lead to the appearance of new symptoms:

• Regression — a return to childlike forms of behavior, with responsibility shifted onto other people. Certain forms of alcoholism and drug addiction belong to this type of reaction to difficulties.
• Passivity, based on the belief that any attempt to solve the problem is useless. This type of reaction is characteristic of people of the depressive or anxious-suspicious type.
• Affective reactions — most often these are outbursts of anger, sometimes with manifestations of aggression^[91].
• Attempts to control the symptoms of PTSD. This strategy is based on the patient's belief that, if he or she allows thoughts and emotions about the trauma into consciousness, he or she might, for example, go mad, become aggressive, or fall physically ill. An example of such a strategy is denial of the problem, or avoidance, with attempts not to think about anything connected with the trauma. But the result turns out to be paradoxical: unwanted memories of the event begin to arise much more often. Sometimes the patient tries to distract himself or herself from thoughts of the trauma by constantly keeping busy with something. However, such strategies do not allow the patient to work through and make sense of the traumatic event in detail, and then link it with the rest of his or her autobiographical memories. They also prevent the patient from recognizing that his or her fears are mistaken (for example, the conviction: "If I think about what happened, I will go mad"). In addition, attempts to keep one's emotions under control lead to a state of emotional numbness: the patient loses the ability to experience positive emotions.
• Behavior closely linked to the belief that the traumatic event will happen again if safety measures are not taken. For example, people who have suffered an attack in their own home may sleep with a knife under the pillow to minimize the risk of being killed. Pondering what needs to be done in order not to be endangered again, the patient constantly dwells on all the details of the traumatic event. In an extreme case, all this can take the form of an obsession.
• Constant thoughts about restoring justice and revenge. This strategy sustains a constant negative emotional background and a fixation on the most negative aspects of the traumatic event. Moreover, it confirms a pessimistic global assessment of the consequences of the trauma ("what happened has ruined my life forever").
• Taking alcohol and medication to relieve depressive-anxious symptoms. This strategy can reinforce the patient's belief that, if he or she stops controlling his or her emotional state in such ways, this could lead him or her to a nervous breakdown.
• Avoidance of many previously enjoyed activities or of contact with friends, in order to avoid stress, misunderstanding, or condemnation. This strategy prevents the desirable changes from occurring in pessimistic beliefs, such as "people will condemn me if they find out what happened to me, or will consider me weak because I cannot cope with my emotions" or "if I am exposed to stress, I might have a heart attack"^[92].

Types of PTSD

• The anxious type of PTSD is characterized by symptoms of anxiety, irritability, inner tension, intrusive anxious thoughts about the traumatic situation and one's condition, and sleep disturbances (difficulty falling asleep). Patients are often afraid of nightmares about the trauma and for this reason deliberately put off falling asleep. In the evening and at night, sensations of shortness of breath, palpitations, sweating, chills, or hot flushes may occur. Such patients seek out social contact and some kind of purposeful activity, since they find relief in being active.
• The asthenic type of PTSD is characterized by passivity, indifference to events in life that previously held interest, and indifference toward the people around them and toward professional activity. A characteristic feature is the experience of a loss of the sense of enjoyment of life. Thoughts about one's own inadequacy dominate consciousness. Unlike the anxious type, in these cases memories of the traumatic event lack vividness, detail, and emotional coloring^[93]. Touchiness and irritability may occur^[54]. Hypersomnia is noted, with an inability to get out of bed and agonizing drowsiness (sometimes throughout the entire day).
• The dysphoric type of PTSD is characterized by the constant presence of discontent and irritation (up to outbursts of fury) against a background of a depressed, gloomy mood. Images of punishing the offenders and scenes of aggression in which the patient himself takes part as the aggressor dominate the imagination. Patients are often unable to control themselves and subsequently regret their aggressive reactions. Sometimes this forces them to minimize their contacts with those around them. Outwardly, such patients look gloomy; their behavior is marked by withdrawal, reserve, and taciturnity. They usually do not seek help themselves and come to the attention of specialists because of behavioral disorders that those around them notice.
• The somatoform type of PTSD is distinguished by an abundance of somatoform disorders, with unpleasant sensations localized mainly in the region of the heart (54 %), the gastrointestinal tract (36 %), and the head (20 %), combined with psychovegetative paroxysms. Avoidant behavior against a background of panic attacks is frequently encountered. The patient is troubled primarily by unpleasant bodily sensations (often with hypochondriacal fixation). Anxious anticipation of the onset of symptoms appears. This anxiety can be stronger than the fear related to the traumatic event experienced^[93].
• The hysterical type of PTSD shows itself in the form of demonstrative behavior, a striving to attract attention to oneself, and heightened suggestibility and self-suggestibility.
• The depressive type is characterized by lowered mood and pessimism^[54].
• In addition to the types listed above, there are variants of PTSD called "dissociative", "hypochondriacal", and "mixed"^[93].

Comorbid disorders

In most cases (except for mildly expressed forms of PTSD), other mental disturbances (called comorbid) appear at one stage or another^[77]:

• Depression is observed in approximately 50 % of patients with PTSD.
• Anxiety disorder with panic attacks. In PTSD, panic attacks usually arise under the influence of traumatic triggers, but in some patients the anxiety can become generalized, in which case panic attacks may occur in situations that are in no way connected with the trauma experienced.
• Addictions, which are linked to the patient's striving to reduce the intensity of post-traumatic symptoms.
• Suicidal behavior.
• Psychosomatic illnesses.
• Problems with sexual desire. A decrease in sexual desire is particularly common among victims of sexual violence. But in some cases, conversely, intense sexual activity becomes a kind of addiction for them^[94].
• Social phobia: patients with PTSD often begin to fear conflict situations, which makes them avoid contact with people. In addition, victims of deliberately inflicted trauma frequently become distrustful of those around them.
• Asociality: the symptoms of PTSD (social phobia, irritability, outbursts of anger, rapid fatigability, and loss of interest in socializing and various kinds of activity) can lead to a breakdown in relationships with family and friends, to the breakup of the family, and to an inability to start a family or make friends. Problems also arise in the professional sphere. This leads to social isolation and marginalization, which in turn aggravate the symptoms of PTSD.
• Aggressiveness and antisocial behavior: in some victims of violence, reenactment of the trauma in the role of the aggressor may occur, which can lead to the commission of unlawful acts. Studies show that many offenders were victims of physical or sexual abuse in childhood^[11].
• Other disorders associated with PTSD, but occurring somewhat less often, include phobias, personality disorders (especially of the schizoid type), and somatoform disorders.

A distinctive feature of PTSD is a high degree of comorbidity. This was one of the reasons that, for a long time, PTSD was not regarded as a separate nosological entity, since many of its symptoms resemble the clinical picture of other disorders^[95].

Statistics on comorbid disorders in PTSD^[96].

Trigger

Most often, a trigger is part of the traumatic experience: a child crying, the noise of a car, objects flying low over the ground, being at height, an image, a text, a television broadcast, and so on. For victims of violence (psychological, sexual, physical), a touch, a word, even an invitation on a date, or any reminder of before the act of violence or of the period of the violent actions, can become a trigger.

Listed below are the most common triggers:

• a particular context of the situation — for example, crowded streets, sunrise or sunset, particular clothing;
• movement — for example, someone running toward the individual;
• films;
• sounds, especially unexpected ones;
• smells;
• reading or discussing something that brings the trauma to mind;
• touch or particular tactile sensations;
• situations — for example, crossing open spaces, a feeling of one's own vulnerability, or a lack of control^[97];
• a particular time of day^[98];
• a particular time of year or date^[99];
• objects^[100];
• details of the setting, for example light falling at a particular angle^[101];
• particular places^[98] — the place where the event occurred, or any place resembling it^[100];
• people^[100] who were present at the moment of the trauma, or those who resemble them in some respect^[98];
• conflict situations^[98];
• smells^[100] or taste sensations^[101] (for example, the taste of food that the person ate during or shortly before the traumatic event);
• physical pain^[101].

Triggers can provoke the appearance of post-traumatic symptoms, such as flashbacks, intrusive thoughts, and nightmares. Sometimes a trigger has only a distant connection with the traumatic event. As PTSD progresses, post-traumatic symptoms can be activated even by a neutral stimulus^[102]. .

Diagnosis of PTSD

The diagnosis of PTSD is established in accordance with the criteria of the DSM-5 manual given above^[103].

Special questionnaires and tests can be useful for refining the diagnosis and assessing the intensity of PTSD symptoms^[104]. As for possible malingering, research findings indicate that satisfactory results are given by the Minnesota Multiphasic Personality Inventory (MMPI), which includes a "lie scale" and a "correction scale" (for detecting aggravation and simulation of symptoms)^[105]. Attention should also be paid to the following possible signs of malingering:

• complaints about every possible problem that could be related to PTSD;
• mention of a large number of flashbacks in the absence of avoidance symptoms^[106].

There exists a program that recognizes PTSD from characteristics of the patient's voice, in particular from less clear speech and a "lifeless", metallic timbre. It is hypothesized that PTSD causes negative changes in the areas of the brain responsible for emotions and for muscle tone, which affects the tone of the voice^[107].

In the differential diagnosis of PTSD, criteria are taken into account that distinguish PTSD from disorders having similar symptoms:

• depression;
• phobia;
• adjustment disorder;
• personality disorder;
• dissociative disorder;
• psychosis^[108] (sometimes such patients are diagnosed with schizophrenia^[109]);
• anxiety disorder;
• panic disorder;
• social phobia;
• obsessive-compulsive disorder^[110].

Unlike these disorders, PTSD has the following important features:

• PTSD is characterized by such typical symptoms as flashbacks and nightmares.
• The cause of PTSD is an event that posed a threat to the life or safety of the individual or of another person. Depressive, anxiety, and panic disorders are usually caused by stressors of considerably lower intensity (such as, for example, problems in the professional or family sphere). A psychotic disorder does not have a traumatic event as its cause.
• In PTSD, depressive symptoms may be observed (emotional blunting, loss of interest in life, a desire to cry, weight loss, suicidal thoughts), but they are usually less intense than in major depressive disorder.
• In panic disorder, the individual avoids situations in which panic symptoms might occur. In PTSD, situations in which an event reminiscent of the trauma might occur are avoided more often. For example, in panic disorder an individual may be afraid to ride the subway because, in the event of a panic attack, he would not be able to quickly get out of the car. In PTSD the individual may be afraid, for example, of encountering the aggressor in a subway car.
• In anxiety disorder, fears concern possible everyday problems in the future (such as, for example, losing one's job, illness, etc.). In PTSD, the predominant fear is of finding oneself in a dangerous situation again.
• In phobias, avoidance is limited to the object of the phobia. In PTSD, avoidance concerns a greater number of varied situations. Moreover, unlike in phobia, there is hyperactivation of the sympathetic nervous system.
• In social phobia, the individual avoids communicating with people for fear of becoming an object of judgment or ridicule. In PTSD, avoidance of communication is related to the fear of again becoming a victim of aggression.
• Unlike PTSD, in obsessive-compulsive disorder the obsessive thoughts have no connection with the trauma experienced; they usually concern imagined catastrophes that might happen in the future. Moreover, they are perceived by the individual as irrational, meaningless, and alien to the personality; sometimes they have immoral or obscene content. None of this is characteristic of PTSD^[110].
• Severe forms of PTSD (especially those arising in victims of violence in childhood) may resemble schizophrenia; however, in PTSD the thoughts and behavioral features of patients concern themes of violence and sex to a greater extent than in schizophrenia. To establish a correct diagnosis, it is necessary to question the patient in detail about the events of his life^[109].

Malingering of PTSD symptoms

Diagnosing PTSD is complicated by possible malingering of symptoms. The reasons for malingering may include, for example, the desire to:

• obtain financial compensation or various benefits^[111],
• avoid responsibility, for example criminal responsibility^[112],
• gain the recognition and admiration of others (especially in cases where the psychological trauma being simulated was sustained in combat)^[113].

According to research, satisfactory results in detecting malingering are provided by the Minnesota Multiphasic Personality Inventory (MMPI), which includes a "lie scale" and a "correction scale" (for detecting aggravation and simulation of symptoms)^[105].

Classification of PTSD by severity

By severity, the following types of PTSD can be distinguished:

1. Uncomplicated PTSD. In this type of PTSD, good results are achieved with pharmacotherapy targeting PTSD symptoms and with many types of short-term trauma-focused psychotherapy^[114]. In the mildest form of PTSD, the ability to function well in the professional sphere and in interpersonal relationships is preserved.^[109].
2. PTSD accompanied by comorbid disorders of a transient nature (addictions, anxiety disorder, depression). This type of PTSD occurs more often than the previous variant. In some cases the comorbid disorders become a more important problem for the patient than the PTSD itself. Therapy for PTSD must simultaneously be aimed at treating the comorbid disorder.
3. "Post-traumatic personality disorder" (for example, borderline personality disorder, somatoform disorder, and dissociative disorder), which often arises as a result of prolonged psychological trauma in childhood (for example, sexual abuse). This type of PTSD is often accompanied by behavioral problems (impulsivity, anger escalating to rage, aggression and self-directed aggression, problems with sexual behavior, eating disorders), emotional instability, emotional blunting, depression, panic disorders, cognitive problems (for example, amnesia or fragmentation of memories). Dissociation is often observed. This type of PTSD requires prolonged therapy that includes developing communication and emotion-control skills (especially in the area of family relationships), treatment of addictions, and development of the skills needed for employment. In the course of therapy it is necessary to create a sense of safety in the patient before the therapist can move on to working with the trauma^[114].
4. In the most severe cases, the patient is completely unable to function normally; his condition looks like a chronic mental illness. Sometimes such patients are diagnosed with schizophrenia^[109].

Therapy

Treatment of PTSD should employ a collaborative approach using a variety of methods of correction and support. It is important to observe the following principles:

1. Medications should be prescribed strictly according to indications and for as short a period as possible.
2. Psychotherapy should begin as soon as possible after the psychological trauma occurs.
3. Social support for the patient is also necessary^[115].
4. Drug therapy for PTSD must always be combined with psychotherapy^[116].

Psychotherapy

The World Health Organization recommends applying the following methods of PTSD therapy first:

• individual or group trauma-focused cognitive behavioral therapy (CBT-T);
• eye movement desensitization and reprocessing;
• training in stress-reduction techniques (for example, breathing techniques, progressive muscle relaxation);
• assistance in finding positive coping strategies and social support^[117].

Research shows that psychotherapy, particularly cognitive behavioral therapy, can be effective in treating PTSD. For many methods of therapy there is currently no evidence of effectiveness, but this does not mean that they do not work; the lack of evidence — is simply a consequence of the fact that they have not been subjected to rigorous scientific testing^[118].

In most cases, the main goal of therapy is to eliminate PTSD symptoms. However, sometimes attention is directed first to symptoms and behavior associated with comorbid disorders (for example, addictions or suicidal problems). Sometimes it is necessary to work on stress associated with present-moment problems that may cause further deterioration of the patient's condition or prevent therapy from beginning. In some cases, family members and other people significant to the patient must be included in the therapeutic process if problems in the relationship with them adversely affect the manifestation of PTSD symptoms^[119].

The choice of type of treatment therapy should be made taking into account the patient's needs as well as his abilities and preferences. In addition, it is necessary to take into account the potential difficulties and side effects of treatment^[120].

A combination of different therapeutic methods is often used in PTSD. This is due to the complexity of the phenomenon of PTSD as a disorder manifesting simultaneously at the psychological, biological, and social levels^[121]. Psychotherapy for PTSD may continue from several months to several years^[122].

Pharmacotherapy

In PTSD, the effect of SSRI-group antidepressants, which reduce anxiety and make it easier for the patient to begin the process of psychotherapy, has been best studied^[123]. In PTSD, the goal of using antidepressants is to reduce not only depression, but also obsessive-compulsive symptoms, intrusive thoughts and anxious-phobic experiences, outbursts of anger, and cravings for alcohol. The advantages of antidepressants include the low risk of abuse of these drugs and of developing dependence, which is of great significance in PTSD^[116]. In addition, SSRI-group antidepressants cannot be used for suicide by taking large doses. They are prescribed for a period of not less than 12 weeks and are often used in chronic PTSD for 12—24 months. Discontinuation of the drug should be gradual (over 3 months) in order to avoid the return of symptoms^[124]. If, during treatment with SSRI-group antidepressants, some PTSD symptoms persist, the following medications may prove effective^[124]:

Here, tranquilizers reduce anxiety, anticonvulsants and mood stabilizers reduce nervous excitation and panic anxiety (they may be prescribed if medications of another type have proved ineffective), and antipsychotic drugs help reduce nervous excitation and feelings of anger^[123]. However, none of the medications listed cures PTSD; the drugs only help to temporarily control the symptoms^[125].

There are some preliminary indications that, for patients whom other types of treatment have not helped, psychotherapy combined with the use of MDMA may be effective, although further research on this question is needed^[126][127]. This substance enhances the state of awareness and clarity of perception, and also reduces anxiety, allowing the patient to activate the traumatic memory without excessive neurophysiological activation of the body and without experiencing agonizing emotions. However, MDMA is a powerful psychoactive substance and may have dangerous side effects if used outside a therapeutic context^[128]. It should also be kept in mind that the MDMA used in this type of therapy is not the equivalent of the drug ecstasy — it is a pure form of the substance, produced under strictly controlled conditions^[129].

Propranolol inhibits the action of norepinephrine (the neurotransmitter responsible for the consolidation of memories in long-term memory). One study found that taking it immediately after a traumatic event reduces the severity of PTSD symptoms and may prevent the disorder from arising^[130]. In addition, it is known that a memory undergoes reconsolidation in long-term memory ( within a few hours after the individual recalls that memory. Taking propranolol at this moment can reduce the negative emotional impact of already existing memories^[131].

Glucocorticoids may be useful when prescribed for a short period of time to prevent neurodegenerative processes that may arise under the influence of stress^[132].

The World Health Organization recommends prescribing antidepressants in cases where psychotherapy methods have proved ineffective or cannot be applied for some reason. Antidepressants may also be prescribed to patients whose PTSD is accompanied by depressive symptoms of moderate to high intensity. It is not recommended to prescribe antidepressants to children and adolescents suffering from PTSD. Benzodiazepines may be prescribed for a short term and in exceptional cases (benzodiazepines are often prescribed without sufficient necessity) for sleep disturbances, if sleep problems interfere with normal daytime functioning. It is not recommended to prescribe benzodiazepines to children and adolescents for the treatment of insomnia. It is not recommended to prescribe benzodiazepines to patients suffering from depression due to the loss of a loved one^[117].

Additional recommendations

Physical activity, including sports (if there are no medical contraindications), helps the patient to distract from negative experiences and to restore self-respect and a sense of control^[133]. The practice of martial arts (for example, aikido, jiu-jitsu, taekwondo) and team sports involving competition help to express anger in an acceptable form. Relaxing yoga asanas, tai chi, and qigong are methods of relaxation in movement^[134]. Autogenic training and progressive muscle relaxation can be useful for correcting muscle tension, sleep disorders, increased excitability, irritability, and anxiety. Activating exercises of autogenic training can reduce avoidance of trauma-related stimuli, improve concentration, and eliminate feelings of depression, hopelessness, uselessness, a sense of reduced energy, lack of interest in anything, and lack of motivation^[135].

First psychological aid in the acute period

The system of providing aid to US Army service members with maladaptive combat-stress reactions

In the early post-traumatic period (acute phase), it is possible to begin informing the affected person about the possible reactions that arise during and after traumatic events. It should be explained that these are normal mental reactions, with emphasis on the fact that they will disappear as recovery progresses. It is not advisable to ask the affected person to recount what happened over and over again; discussions of the trauma are appropriate only if the person himself wishes it^[19]. Emotional support and advice are also necessary so that the affected person can move on to concrete actions to solve the problem. Even if these actions occur on an automatic level, this gives the affected person a sense of control and reduces the intensity of emotional reactions. In conversation with the affected person, one can help him activate pleasant or, at the very least, neutral memories of his past, especially of his personal achievements, in order to give him the strength and confidence to cope with the problem^[20]. To assist in this direction, one can ask the affected person questions about what he is able to do now (for himself or for others) and what should be done first^[19]. At this stage, irritability and even aggressive behavior may appear in the affected person, but if the person has thereby become able to solve his own problems independently, this can be considered a certain amount of progress in overcoming the trauma^[20].

Therapy in the prolonged period

In this period, work is carried out with memories of the trauma and with delayed post-traumatic reactions^[21]. Therapy for PTSD is a lengthy process; it may continue for several years.

Horowitz (Horowitz, 1998) identified five stages of the reaction to a traumatic event. Each stage corresponds to a particular goal of psychotherapy:

Choice of therapeutic approach and determination of therapy goals

In most cases, the main goal of therapy is to eliminate PTSD symptoms. However, sometimes attention should first be directed to symptoms and behavior associated with comorbid disorders (for example, addictions or suicidal problems). Sometimes it is necessary to work on stress associated with present-moment problems that may cause further deterioration of the patient's condition or prevent therapy from beginning. In some cases, family members and significant people must be included in the therapeutic process if problems in the relationship with them adversely affect the manifestation of PTSD symptoms.^[22]

The choice of type of treatment therapy should be made taking into account the patient's needs, as well as his abilities and preferences. It is also necessary to take into account the potential difficulties and side effects.of treatment.^[23]

A combination of different therapeutic methods is often used in PTSD. This is connected with the complexity of the phenomenon of PTSD as a disorder that manifests simultaneously at the psychological, biological, and social levels.^[24]

The therapeutic approach depends on the severity of the PTSD:

1. Uncomplicated PTSD. In this type of PTSD, good results are given by pharmacotherapy targeting PTSD symptoms, and by many types of short-term trauma-focused psychotherapy.
2. PTSD accompanied by comorbid disorders of a transient nature (addictions, anxiety disorder, depression), which occurs more often than the previous variant. In some cases the comorbid disorders become a more important problem for the patient than the PTSD itself. Therapy for PTSD must simultaneously be aimed at treating the comorbid

продолжение следует...

Продолжение:

Часть 1 Post-Traumatic Stress Disorder (PTSD)
Часть 2 Description of the main symptoms - Post-Traumatic Stress Disorder (PTSD)
Часть 3 Cognitive behavioral psychotherapy for PTSD - Post-Traumatic Stress Disorder (PTSD)
Часть 4 Possible problems and ways to solve them - Post-Traumatic Stress
Часть 5 In culture - Post-Traumatic Stress Disorder (PTSD)

See also

• 4. Neuropsychological syndromes with lesions of the frontal brain.