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Post-Traumatic Stress Disorder: Evidence-Based Research for the Third Millennium

Introduction

❶Treatments also seek to increase the subject's ability to manage trauma-related emotions and to greater confidence in coping abilities.

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In light of current events e. PTSD is a serious public health concern, which compels the search for novel paradigms and theoretical models to deepen the understanding of the condition and to develop new and improved modes of treatment intervention.

We discuss the domain of evidence-based research in medicine, particularly in the context of complementary medical intervention for patients with PTSD. We present arguments in support of the notion that the future of clinical and translational research in PTSD lies in the systematic evaluation of the research evidence in treatment intervention in order to insure the most effective and efficacious treatment for the benefit of the patient.

The twenty-first century rose in a ray of hope. The belief was commonly held that an age of worldwide prosperity was beginning with the new millennium. Only a few years ago, people spoke of peace. Today, the general trend in many populations across the globe is fear and anxiety about self and neighbor. Socio-political events have cast a shadow of uneasiness about one's own security and that of significant others at a personal as well as a societal level.

Case in point is Greg, a businessman from Southern California, who happened to be on a business trip in New York city scheduled for September 10—12, He was on the first plane out: Greg then drove at night to Philadelphia, where he was eventually able to board a plane and return to his anxious family. To this day, Greg does not fly as often as before, is reticent to fly to the east coast and will not return to do business in New York city.

His Type II diabetes has considerably worsened. Traumatic events are profoundly stressful. In its gravest form, this response is diagnosed as a psychiatric disorder consequential to the experience of traumatic events.

Post-traumatic stress disorder, or PTSD, is the psychiatric disorder that can result from the experience or witnessing of traumatic or life-threatening events such as terrorist attack, violent crime and abuse, military combat, natural disasters, serious accidents or violent personal assaults. Exposure to environmental toxins e.

Agent orange, electromagnetic radiation may result in immune symptoms akin to PTSD in many susceptible patients 1 , 2. Subjects with PTSD often relive the experience through nightmares and flashbacks. They report difficulty in sleeping.

Their behavior becomes increasingly detached or estranged and is frequently aggravated by related disorders such as depression, substance abuse and problems of memory and cognition. The disorder soon leads to impairment of the ability to function in social or family life, which more often than not results in occupational instability, marital problems and divorces, family discord and difficulties in parenting. The disorder can be severe enough and last long enough to impair the person's daily life and, in the extreme, lead the patient to suicidal tendencies.

PTSD is marked by clear biological changes, in addition to the psychological symptoms noted above, and is consequently complicated by a variety of other problems of physical and mental health. Whereas the terminology of PTSD arose relatively soon following the Vietnam conflict, the observation that traumatic events can lead to this plethora of psychobiological manifestations is not new.

The syndrome was first described by ABR Myers — in as combining effort fatigue, dyspnea, a sighing respiration, palpitation, sweating, tremor, an aching sensation in the left pericardium, utter fatigue, an exaggeration of symptoms upon efforts and occasionally complete syncope. This classic observation pertains to what we now know of allostasis, as we discuss below.

Da Costa reported in that the disorder is most commonly seen in soldiers during time of stress, especially when fear was involved 3. Whereas the onset and progression of PTSD is characteristic for every individual subject, data suggest that most people who are exposed to a traumatic, stressful event will exhibit early symptoms of PTSD in the days and weeks following exposure.

Because of the traumatic developments of recent years, and of ongoing turmoil worldwide, it is possible and even probable that the incidence of PTSD will sharply increase within the next decade and that it may become one among the most significant public health concerns of this new century.

This threat is all the more serious considering the fact that PTSD symptoms seldom disappear completely; recovery from PTSD is a lengthy, ongoing, gradual and costly process, which is often hampered by continuing reaction to memories.

Treatment usually aims at reducing reactions and to diminishing the acuity of the reactions. Treatments also seek to increase the subject's ability to manage trauma-related emotions and to greater confidence in coping abilities. This work discusses our current understanding about PTSD. It explores current developments in stress research and discusses its applications and implication to the complex psychobiological prognosis of PTSD.

The work concludes by presenting a view into the future of PTSD treatment from the perspective of evidence-based medicine, which many regard as the break-open research of the next decades—systematic and critical research on research to establish and determine what is the best available evidence for treatment for the patients.

Indeed, this will be particularly true in the case of subjects with PTSD, if the austere predictions of a sharp rise in prevalence consequential to most recent terrorist and war events worldwide that involve US soldiers and civilians prove true. There are different psychiatric rating instruments and scales that can be used to assess adult PTSD. Some are part of comprehensive diagnostic manuals or instruments: Some are designed as either self-reports or as clinician-administered instruments specifically assessing adult PTSD: The underlying phenomena of PTSD are probably centrally mediated.

Case in point is a study targeting women with early childhood abuse-related PTSD that found correlates of the emotional Stroop Subjects with and without PTSD were compared. Both groups underwent PET scanning while performing in the color and emotional Stroop tasks and control condition.

The control condition involved naming the color of rows of XXs red, blue, green and yellow. The active color condition involved naming the color of color words again with the same four colors , while the semantic context of the word was incongruous with the color.

The active emotional condition involved naming the color again the same four colors of emotionally charged words rape, bruise, weapon, and stench. These words have been shown to produce emotional arousal The study examined the effectiveness of the Stroop task as a probe of anterior cingulate function in PTSD, because of the role of the anterior cingulate and medial prefrontal cortex in stress response and emotional regulation.

After comparing it with the color Stroop, the emotional Stroop displayed significantly decreased blood flow among the PTSD subjects in the anterior cingulate.

However, the emotional Stroop produced a relatively lower level blood flow response of anterior cingulate among PTSD abused women. These observations may indicate that PTSD anterior cingulate dysfunction is specific to the neural circuitry of the processing of emotional stimuli.

Taken together, these findings indicate that PTSD may have a neural component, which could significantly alter psychoneuroendocrine-immune regulation, as discussed below. Certain scales have been developed that specifically target military personnel. The prevalence of PTSD diagnosis varies depending on the assessment method. Such differences in rates, depending on the assessment instrument may hold significance. Symptoms may differ in both intensity and kind among older and younger prisoners of war.

In the paradoxical side, it is possible for an individual to be diagnosed with PTSD while reporting minimal stress levels; in fact, subjective stress can be seen as a confounding factor that can have an influence on diagnosis Such chronic and stable PTSD may not be clinically relevant and may not require focused intervention.

They recommend to measure symptom intensity with such instruments as the CAPS Such an approach could decrease PTSD-positive diagnoses among subjects with low levels of distress Allostasis refers to the psychobiological regulatory process that brings about stability through change of state consequential to stress.

Psycho-emotional stress can be defined as a perceived lack, or loss of fit of one's perceived abilities and the demands of one's inner world or the surrounding environment i. Traumatic events that trigger PTSD are perfect examples of such onerous demands that lead to the conscious or unconscious perception on the part of the subject of not being able to cope The perception of stress is often associated with psychological manifestations of anxiety, irritability and anger, sad and depressed moods, tension and fatigue, and with certain bodily manifestations, including perspiration, blushing or blanching of the face, increased heart beat or decreased blood pressure, and intestinal cramps and discomfort.

These signs mirror the spectrum of psychobiological symptoms in PTSD. These manifestations are generally associated with the nature of the stress, its duration, chronicity and severity.

A group of symptoms, now referred to as the sickness behavior, is also noted that is associated with clinically relevant changes in the balance between the psychoneuroendocrine and the immune systems 35 — By the early s, Walter Cannon — proposed that organisms engage in a dynamic process of adjustment of the physiological balance of the internal milieu in response to changing environmental conditions. Stress alters the regulation of both the sympathetic and the parasympathetic branches of the autonomic nervous system, with consequential alterations in hypothalamic control of the endocrine response controlled by the pituitary gland.

Autonomic activation and the elevation of hormones, including those produced by the hypothalamic-pituitary-adrenal axis, play a pivotal role in regulating cell-mediated immune surveillance mechanisms, including the production of cytokines that control inflammatory and healing events 35 , In brief, the perception of stress leads to a significant load upon physiological regulation, including circadian regulation, sleep and psychoneuroendocrine-immune interaction.

In brief, stress is profound alterations in the cross-regulation and interaction of the hormonal-immune regulatory axis. The experience of stress, as well as that of traumatic events and the anxiety-laden recollections thereof, produce a primary endocrine response, which involves the release of glucocorticoids GCs.

GCs regulate cellular immune activity in vivo systemically and locally. They block the production of pro-inflammatory cytokines e. IL-2 at the molecular level in vitro and in vivo , but may have little effects upon TH2 cytokines e. The net effect of challenging immune cells with GC is to impair immune T cell activation and proliferation, while maintaining antibody production.

The secretion of GC by the adrenal cortex is under the control of the anterior pituitary adrenocorticotropin hormone ACTH. Immune challenges release pro-inflammatory cytokines e. Stressful stimuli also lead to the significant activation of the sympathetic nervous system and a rise in the levels of pro-inflammatory cytokines i. It follows that the consequences of stress are not uniform.

The psychopathological and the physiopathological impacts of stress may be significantly greater in certain people, compared with those of others. The impact of stress is dynamic and multifaceted and the same person may exhibit a variety of manifestations of the psychoneuroendocrine-immune stress response with varying degrees of severity at different times.

The outcome of stress can be multivalent Allostatic regulation now signifies the recovery and the maintenance of internal balance and viability amidst changing circumstances consequential to stress. It encompasses a range of behavioral and physiological functions that direct the adaptive function of regulating homeostatic systems in response to challenges 37 — The cumulative load of the allostatic process is the allostatic load.

The pathological side effects of failed adaptation are the allostatic overload. Allostasis pertains to the psychobiological regulatory system with variable set points. These set points are characterized by individual differences.

They are associated with anticipatory behavioral and physiological responses and are vulnerable to physiological overload and breakdown of regulatory capacities 39 , Type 1 allostatic load utilizes, as it were, stress responses as a means of self-preservation by developing and establishing temporary or permanent adaptation skills.

The organism aims at surviving the perturbation in the best condition possible and at normalizing the normal life cycle. In Type 2 allostatic load, the stressful challenge is excessive, sustained or continued and drives allostasis chronically.

An escape response cannot be found. Type I versus type II allostatic responses curiously reiterate Myers' observations that his patients seem to abandon themselves to the emotion and the fear that assailed them, rather than engage in the effort to counter and to overcome the challenge, which normal subjects typically undertook.

Future research in PTSD from the perspective of allostasis may reveal a learned helplessness component, which could become key in the development and evaluation of treatment interventions Fig. Allostatic regulation describes the recovery and the maintenance of internal balance and viability amidst changing circumstances consequential to stress.

It encompasses the Type 1 allostatic load that reflects the utilization by the organism of the range of behavioral and physiological functions that direct the adaptive function of regulating homeostatic systems in response to challenges i. Type 1 allostatic responses translate the organism aims at surviving the perturbation in the best condition possible and at normalizing the normal life cycle.

By contrast, the Type 2 allostatic responses reflect a load to the organism that is excessive, sustained, or continued, and drives allostasis chronically and that precludes effective escape from the stress. It is clear that stress research and PTSD research are intertwined.

Psychobiological manifestations in PTSD and in complex PTSD disorder of extreme stress evidently pertain to the same domain of mind—body interactions, which are elucidated in psychoneuroimmunology research. The stress response, more than likely, underlies the psychobiological sequelae of PTSD. The relevance of the field of current research on allostasis to PTSD is all the more evident when one considers that subjects position themselves along a spectrum of allostatic regulation, somewhere between allostasis i.

In brief, the recent advances in our understanding of the adaptation of the organism to stressful challenges, the allostatic process, present a new and a rich paradigm for research in the psychobiology of PTSD.

Future research must investigate whether or not the dichotomy of Type I and Type II allostatic responses will provide an effective theoretical model for the development of novel and improved modes of intervention to treat PTSD. The treatment of PTSD is complex, both in terms of available treatments and the myriad of trauma possibilities that cause it. This should be followed by treatments with various degrees of demonstrated efficacy Historically, it was in the early eighties when research on the treatment efficacy for PTSD began, with multitude of case studies dealing with different kinds of PTSD having been produced since then.

Overall, both cognitive behavioral approaches and selective serotonin reuptake inhibitor regimes have been proved to be effective to deal with different kinds of PTSD. At the same time, there is also evidence that other treatment modalities, such as psychodynamic psychotherapy, hypnotherapy, eye movement desensitization and reprocessing can be effective as well; albeit their evidence is derived from less numerous and less well-controlled studies i.

PTSD intervention is complicated further by the fact that co-morbidities e. Particularly in situations where co-morbidity exists, a combined approached should be considered. Of interest due to the perilous state of the world i. According to experts, combat veterans with PTSD may be less responsive to treatment that other victims of other traumatic exposures 41 , Following is a list of possible reasons:.

Combat-caused PTSD is often associated with other psychiatric disorders, including depression, anxiety, mood disorders and substance abuse disorders It is usually believed that the most effective treatment results are obtained when both PTSD and the other disorder s are treated together rather than one after the other.

It is becoming increasingly critical to ascertain this position because the prevalence of PTSD and disorder of complex stress is bound to rise sharply in the next decade consequential to the present multinational state of alert and anxiety following ongoing tragic, wanton and widespread terrorism and particularly with respect to combat-related PTSD in present times. Some have more proven efficacy than others. Some of these approaches may be appropriate to address the initial stages of trauma.

Psychological debriefing is an intervention given shortly after the occurrence of a traumatic event. The goal is to prevent the subsequent development of negative psychological effects. In fact, psychological debriefing approaches to PTSD can be described as semi-structured interventions aimed at reducing initial psychological stress. Strategies include emotional processing via catharsis, normalization and preparation for future contingencies Gulf War veterans who underwent psychological debriefing showed no significant differences in their scores of two scales measuring PTSD when compared with the control group In general, there is little evidence of psychological debriefing approaches effectively acting to prevent psychopathology, although participants seem to be open to it, which may indicate its usefulness as a rapport builder or as a screening tool.

In general however, there is a lack of rigorously conducted research in this area. To this day there is paucity in the data to orient the treatment of combat-related PTSD for veterans The International Consensus Group on Depression and Anxiety supports that exposure psychotherapy is the most appropriate approach for this disorder 41 , although this approach does not show a significant influence on PTSD's negative symptomatology, such as avoidance, impaired relationships or anger control In terms of proven efficacy, cognitive behavior therapy and eye movement desensitization and reprocessing are effective approaches to deal with PTSD 50 — 54 , while other psychotherapeutic approaches e.

Cognitive-behavioral psychotherapy encompasses a myriad of approaches i. Vietnam veterans receiving exposure therapy displayed improvement as evidenced in terms of reducing intrusive combat memories 55 , physiological responding, anxiety 56 , depression and feelings of alienation, while also promoting increased vigor and skills confidence Exposure therapy, combined with a standard treatment also showed effectiveness with other Vietnam veterans in terms of subject self-report symptoms related to the traumatic experiences, sleep and subjective anxiety responding to trauma stimuli In fact, typically, there is a combination of psychotherapy and medication treatments to treat chronic PTSD In general, the different co-morbidities associated with PTSD play a role in the kinds of pharmacotherapeutic treatments used for its treatment.

Antidepressants and other medications commonly used are tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, antianxiety and adrenergic agents and mood stabilizers Sertraline has been found effective to reduce PTSD symptomatology 61 , Sertraline and fluoxetine have produced clinical improvements among PTSD patients in randomized clinical trials Paroxetine, another selective serotonin reuptake inhibitor like sertraline, is also habitually used to treat chronic PTSD Mirtazapine was another successful agent when used in the treatment of PTSD afflicted Korean veterans In addition, Olanzapine and fluphenazine have been successfully used with combat-induced PTSD subjects from the Balkans.

Both medicines were successful in ameliorating both PTSD and psychotic symptomatology Rigorous, well-controlled methods are necessary for conducting studies on the efficacy of PTSD treatments. Well-controlled studies are characterized by the following characteristics:. Future clinical research in PTSD requires the stringent, rigorous and systematic approach provided by evidence-based medicine. Evidence-based research in medicine goes beyond the routine narrative literature review.

It systematically evaluates the strength of the available evidence and generates a consensus statement of the best available evidence in the form of a systematic review of the available research Fig.

What are the interventions being looked at, e. A research team of 5 that conducted a PTSD survey on soldiers with amputated limbs or spinal injuries in a rehabilitation facility in Sri Lanka. The treatment for soldiers in the war in Sri Lanka is more physically based then mentally and it is a known fact that there is a higher risk of PTSD in soldiers who have been in battle Abeyasinghe The study was one of the first done in Sri Lanka since no one has thought to do it previously and was carried out in The questionnaire was translated into Sinhala and it was pre-tested in other injury groups and then from that, they refined the questionnaire to fit their needs and gave that to the spinal injuries and amputees Abeyasinghe The research they did was a cross sectional study, which means that they used different people who had similar interests to the study, and then got willing participants to take part in the research.

The results showed that of the 96 participants, 40 of them indicated a diagnosis of PTSD Abeyasinghe That means that This study shows that even though we give our soldiers the medical attention they need, they are not getting all of it and that should be fixed. There was an experiment done about the medical research done on twins, combat exposed and non-combat exposed, along with comparing previous studies of PTSD to their medical research.

They used PTSD patients and a control group. Their hippocampal area was also enlarged when compared to the control twins who had no PTSD and a low risk factor Pitman The article goes through every part of the brain and compares the scans of the combat exposed and combat unexposed twin groups, control and experimental, comparing the area of study, like the prefrontal cortex.

Which is the area of the brain that corresponds to Brodmann area and can also be called anterior mid-cingulate cortex Pitman It goes through every biological aspect you could think of and speculates off of the research previously done to the medical tests they have conducted to show how PTSD affects the brain, hormones, genes, and animal studies.

Then their conclusions at the end to tell you how this will help future medical treatments of PTSD. Even placebo-trials of other medications for PTSD have failed and recent studies of medications that are approved have failed to show desired results in patients Pitman


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Post-traumatic Stress Disorder Research Paper Post-traumatic Stress Disorder research papers diagnose the disorder and give the main characteristics of the disease. Professional writers at Paper Masters will custom write research papers on any aspect of post-traumatic stress disorder or PTSD.

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Post Traumatic Stress Disorder Many people throughout the world suffer from Post Traumatic Stress Disorder also known as PTSD. This is a disorder that must be diagnosed and can be caused from a variety of reasons. Specifically, this research paper will focus on PTSD, or in other words: post traumatic stress disorder. PTSD has shown up as a factor from many wars, but for some reason, one war in particular stands out from all others regarding the the PTSD numbers.

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PTSD Research Paper. Posttraumatic stress is a set of psychological and physical symptoms that follow a traumatic experience READ MORE HERE. RESEARCH PAPER APPROVAL THE EPIDEMIC OF POST TRAUMATIC STRESS DISORDER AMONG VETERANS By Tai Hawk A Research Paper Submitted in Partial Fulfillment of .