CRIS 304 Module 1

Signs & Symptoms of PTSD

Dr. Michael Lyles
People who experience PTSD, they do not remember, they literally relive what they are going through.
Post Traumatic Stress Disorder (PTSD) An anxiety disorder that occurs after exposure to a traumatic event,
which triggers memories of the traumatic event and is characterized by intense fear, helplessness, and horror.
25-30% of victims of significant (extreme or severe) trauma develop PTSD.
The lifetime prevalence of PTSD in this country is about 8%. That accounts for about 5 million adults.
That is a lot of people and unfortunately, we do not pay a lot of attention to these people. We dont think
about them enough in our clinical settings. In fact, these people utilize a number of medical
services.
It is estimated that about 11.8% of persons going to family care, in primary care settings, may have
people with PTSD, but its not something that we think about and recognize in primary or
specialty health care settings enough.
Its estimated that up to 50% of combat exposed military personnel have some form of PTSD.
It occurs 2x as common in women, particularly because of the impact of sexual trauma on women.
What is a trauma?
Trauma can occur from:
Witnessing or experiencing a traumatic event
Trying to help someone with a traumatic event
Rescue workers
Clergy person
Therapist
The risk for developing PTSD varies depending on the severity and duration of the trauma and how the
trauma was experienced by the person that was going through it.
What are traumatic events?
Natural disasters
Automobile accidents
Rape or sexual molestation probably the #1 reason for PTSD symptoms in women
Airplane crash
Torture
Physical assault
Terrorist attack
Robbery
Unexpected death of a loved one
Witnessing the death of another person the most common cause of PTSD in males.
Such as rescue workers on 9/11
Military Combat really is the one that put PTSD on the map

Study in New England Journal of Medicine in 2008, looking @ 47,000 soldiers from Iraq
and Afghanistan, some deployed some not deployed, some combat exposed, some
not combat exposed. Gave them questionnaires before deployment and then again
about 2 years later. They found that PTSD was higher in combat exposed
troops. 7-8% in combat exposed compared to 2-3% in non-deployed troops.
This is consistent with what we have seen in history, as military exposure is the thing that
defined PTSD.
As you look through history, the Civil War, talked about the soldiers heart.
Referring to cardiac symptoms
Irritability
Increased arousal that people had during that time period after coming
home from war.
During WWI, the concept of shell shock came into the vocabulary of our country.
Describes the changes behaviorally that soldiers had when they came
home.
The theory was that it was due to brain trauma because of the shells
exploding around their brain.
Same New England study said there may be something to this
because a lot of the soldiers who had PTSD also had some
sort of symptom of head trauma or head injury with loss of
consciousness, which almost 3x the rate of PTSD compared
to people who did not have head injuries.
WWII brought into our vocabulary the whole idea of combat neurosis or
operational fatigue that referred to, again, behavioral changes that people
had when they came home from combat.
It was Vietnam that really brought PTSD and defined it, as people came home
with symptoms that we as psychiatry had not thought about and studied
the way it needed to be. And was that group of veterans that led to the
1980 definition of PTSD by my profession coming into being. They
defined it. Thats what put the meat on the bones of this entity.
What are the diagnostic criteria, symptoms and what does PTSD look like?
PTSD Symptoms
Usually begins within 3 months of the trauma (can begin years later)
Occur for longer than a month
Keeps person from living a normal life
PTSD Diagnostic Criteria
1. Exposure to a traumatic event with both of the following:
The person experienced, witnessed or was confronted with an event(s) that involved
actual or threatened death or serious injury or a threat to the physical integrity of
self or others
The persons response involved intense fear, helplessness or horror
2. Repeatedly thinking about the trauma

Trauma is persistently relived in at least one of these ways:

Recurrent, upsetting, intrusive memories
Recurrent, upsetting dreams
Acting/feeling as if the event was occurring now
Intense psychological or physiological distress with exposure to internal or
external triggers of the event
3. Avoiding Reminders of the trauma
Avoiding the actual trauma itself, avoiding triggers of the trauma
Numbing ones selfs feelings so one doesnt experience reminders
Persistent avoidance of the stimuli associated with the trauma
Someone who had an accident would avoid driving on the highway
Someone who was molested near an elevator would avoid going on an
elevator or avoid going in tall buildings
A numbing of general responsiveness that was not present before the trauma
Bible study teacher who became irritated
Reminders would fall into at least 3 of the following categories
Efforts to avoid thoughts, feelings or conversations
Avoidance of activities, places or people
Inability to recall important aspects of the trauma
Marked decrease in interest in participation of pleasurable activities
Feeling detached/estranged from others
Feeling a restrictive range of emotions numbed or flat lined the normal
aspect of how someones personality is becomes extremely
constricted
A sense of doom that something bad is going to happen, that it is just a
matter of time, overreacting to things by thinking the worst
someones late coming home from the store then they have had a
car accident and died
4. Being constantly alert or on guard, hyper arousal
Two or more of the following persistent symptoms of increased arousal (not present
before the trauma):
Difficulty falling or staying asleep
Irritability or anger outbursts
Difficulty concentrating
Hypervigilance
Exaggerated startle response 0 to 100
All of this has lead to the common thought that the best way to wake up a combat
veteran is from across the room.
How do you make the PTSD diagnosis? What do you really distinguish whether someone has PTSD
versus something else?

Making the Diagnosis

Symptoms last for more than a month and not present prior to the trauma
Symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning
Acute Stress Disorder (resolves within a month)
Acute PTSD (lasts less than 3 months)
Chronic PTSD (lasts 3 months or more)
Delayed Onset (begins 6 or more months after the traumatic event)
We are talking about this as if it is an easy thing. As if it is something that people are just going to run to
us and ask for help for. That is not the case.
People with PTSD, it adds new meaning to dont ask dont tell. So many people with this dont want to
talk about it or they are reluctant or dont feel safe talking about it.
Diagnostic Difficulties
Patient does not link their symptoms with trauma
Patient does not want to talk about the traumatic event. May feel a stigma.
Other symptoms/problems demand more attention. Especially with medical doctors, they are
presenting with depression, drinking, marriage problems. They get faked out to looking at
just the surface symptom and dont look at that there is a root to this and that root goes
back to their exposure to trauma, their inability to deal with that trauma, and if we dont
do that then they dont get better.
Focus on physical symptoms. People dont come in talking about PTSD or trauma because they
think that there is something terribly wrong with them.
Questions to ask
Study done in 2008, published by the American Journal of Public Health on 338 veterans of Iraq
and Afghanistan with a median of 9 months since they had left service
69% met criteria for 1 or more mental disorders
50% met the criteria for PTSD
They found this out because they screened for it. People did not volunteer. So if you dont
ask, they will not tell.
1. Where there missions on which you came into contact with life threatening situations?
2. Were you in situations where you feared for your life?
3. Were you in situations where team members were wounded?
4. Did you ever participate in any situations that involved the loss of life, friendly r enemy?
5. Did you unexpectedly witness a dead body or dead body parts?
What do people actually deal with?
Common PTSD Challenges.
Guilt and shame
Self destructive, impulsive behaviors
Feeling permanently damaged, damaged goods
Feeling constantly threatened, hypervigilance

Feeling ineffective, feeling like I am a looser or second class citizen

Despair, hopelessness
Hostility, personality change
Loss of previously sustained beliefs, challenge of faith, Where is God in this? Prisoner to
nightmares, Has God abandoned me? Rules of war, number 1. People die. Number 2. You
cant change rule number 1.
Social withdrawal, impaired relationships
Dissociative symptoms has periods of time where they feel as if they are not real. Some sense
of unreality in a situation.
Somatic Symptoms variety of things that represent that emotion being turned into a physical
expression.
Self-medication alcohol, the #1 treatment for PTSD is alcohol, not by Drs. but by people.
Another way of trying to numb the feelings.
Depression & Suicidal thoughts suicide becomes a logical thing to do.
Panic attacks
Feelings of mistrust
These are all very common kinds of symptoms to see in people with PTSD
One of the problems though is that the PTSD hides in the shadows a lot of time in other kinds of
problems
The National Comorbidity Survey found that 88.3% of men and 79% of women with PTSD have at least
one other psychiatric problem (usually depression).
59 % of men and 44% of women meet criteria for 3 or more psychiatric disorders.
When you have someone with several psychiatric disorders, PTSD goes down on the list because they
feel that they should be over it by now. They feel it has to be something else. As clinicians, we
can get seduced into just looking at the depression, panic attacks, alcoholism, and not looking
behind at what is going on with the PTSD.
The suicide attempt rate is 20% in some studies.
Co-Existing problems - What some of the problems PTSD will hide in the shadows?
Co-Existing disorders
*Depression
*Alcohol/Substance Abuse Disorders
Phobias
*Social Anxiety Disorder fears, feel people are looking at them
Panic Disorder
Eating disorder women in particular after a sexual trauma
Mood swings mimic bi-polar disorder because the mood swings so dramatically
Obsessive Compulsive Disorder
(*THE BIGGIES)
Course of PTSD

Duration of symptoms affected by the intensity, duration, subjective interpretation and proximity of the
trauma. Someone that was exposed to trauma such as combat for a few days will be different
from someone that was exposed for months or years; usually months in a combat situation. Or
someone who was involved in battle 2-3 time a week vs. someone who was involved 1 time a
week. Again, the intensity is important. How the person interpreted it their subjective
interpretation will influence how it affects them. Proximity how close or how long ago it was.
If it was a tornado that went over their home vs. a tornado that they saw on the side of the road.
Symptoms may come and go
Average duration of treated patients: 36 months
Average duration of untreated patients: 64 months
More than 1/3 never recover
About 50% recover within the first 3 months
Risk Factors
Child Abuse
History of alcohol or drug problems
Behavioral problems early in life
Dysfunctional family issues
Family history of anxiety problems depression, PTSD, etc.
Any kind of sever long lasting traumatic event that has occurred will put somebody at risk for PTSD
PTSD symptoms only occur in a minority of patients exposed to trauma, so something must be different with
those who develop PTSD.
The Brain and PTSD

Looking at the area in the middle of the brain at the top of the brain stem
Cingulate gyrus = cingulate cortex
Pituitary gland
Hypothalamus
Amygdala
Hippocampus

These areas are all big time players in the PTSD issue. In the emotional brain, limbic systems, these
areas are very important.
1. The Emotional Brain (Limbic System)
Amygdala activated by the sympathetic nervous system when danger is present. The HOT
system. The accelerator on a car. Its the lets get ready, lets go. Like the football team
jumping up and down about to run out on the field. The amygdala is going crazy:
activation.
Hippocampus filters the threat through emotional memory filters to evaluate the nature of the
threat. The COOL system. The breaks on the car. Says wait a minute, it may not be as bad
as it seems because remember when. The hippocampus stores emotional memory
filters that are used to evaluate whether a threat is really as bad as it seems. It say lets
cool down, calm down, breathe, and really think about this.
Cingulate The decision maker regarding impulse control and course of action. The steering
section.
Example
Normal
We have a combat veteran and someone stares at them for whatever reason.
Amygdala says that person is staring at me. He wants to fight so lets go. If he is
going to hit me, I am going to hit him first. It gets all excited
Hippocampus says wait a minute, maybe he likes the tie you have on or he is
looking at the emblem on your jacket. Remember the last time.
Cingulate says dont stare at him. Just dont look at him and make sure we dont
miss our next stop.
This is what is supposed to happen.
PTSD
What happens in PTSD is different
You have all accelerator, no brakes, and no steering system.
1. Brain Imaging Studies and this is at rest
Small hippocampus (cool system)
Hyperactive amygdala (hot system)
Inactive cingulate cortex (no mediator)
Normal systems that keep you from overreacting and those systems dont kick in.
2. Hypothalamic Pituitary Axis Refers to the hypothalamus, pituitary, and adrenal gland which sits
on top of your kidney. The HPA Chain of Command for military people that means something.

Hypothalamus is activated by the amygdala, cingulate, hippocampus

and sympathetic nervous fibers in response to a threat
Pituitary is activated by the hypothalamus
Adrenal gland (sits on top of your kidneys) takes orders from the
pituitary and sends cortisol out to engage the threat
Amygdala, cingulate, and
hippocampus are like the joint
chiefs. They are planning a war.
They send orders down to the
hypothalamus, which activates it.
The hypothalamus then sends
orders to the pituitary gland by
releasing factors such as hormones
in the blood stream.
The pituitary gland then sends orders, stimulating factors such as ACTH
(Adrenocorticotropic Hormone) to the adrenal glands, which sit on top of
your kidneys that pumps put cortisol.
Cortisol is kind of the soldier that are sent into the conflict, into the battle
to engage the enemy.
The HPA Cortisol Feedback Loop
The cortisol engages the stressful threat and handles it
with the appropriate intervention. Cortisol, once released
from the adrenal gland, goes out and attacks the stress. It
neutralizes the enemy which is the stress and handles it
with appropriate interventions. The problem is those high
cortisol levels cant stay there forever.
The high cortisol levels feedback to the HPA system to
turn the speed of cortisol production down like cruise
control on a car to keep cortisol levels from peaking
too high for too long (not healthy for heart, pancreas,
lipids, etc.)
The problem is those high cortisol levels and spikes
cannot stay there forever. If you run around with a
chronic state of high cortisol levels you develop
hypertension, diabetes, and a number of medical
problems.
There is a feedback loop that says you have done what
you needed to do. Lets turn down the signal. Stand
down, the threat is over.
Like when you have cruise control engaged in your car.
You come up to a slower car, move to passing lane and
hit accelerator to speed up and pass the car. After passing you take your foot off the accelerator and then go

back to you previous speed in cruise control. You set car at 65, can override it briefly, but it comes back to 65.
That is what the feedback loop does. It keeps the cruise control at 65.

The System is Different in PTSD

Normally
Cortisol increases with stress
Few cortisol receptors (radar) in pituitary &
hypothalamus because the cortisol signal is so strong

PTSD
Cortisol decreases with stress
More radar (cortisol receptors) because the cortisol
signal is so low. The feedback loop is too sensitive.
Feedback inhibition is trigger happy and overresponds to cortisol changes (cruise control over reacts
Feedback inhibition works properly (cruise control0
to manual pedal and speeds up too fast.) Instead of
going from 65 to 70, it goes from 65 to 100.
Cortisol receptor is like radar. Radar that is looking to see if the threat is over; if you
really need that much cortisol. Its like the cruise control; its looking to see how
fast you are going if its too fast you need to slow down. The receptor system
(radar) tells you this. Normally what happens is everything is ok, it shuts back
down and you go back to normal. With PTSD, you have more radar. In fact, you
have tons and tons of radar. The feedback loop is too sensitive and it becomes
trigger happy. You are doing your 65 and you come up on a 55 person and you tap
the gas to from 65 to 70 and normally that is what would happen. In PTSD, you
go from 65 to 100 and you wreck the car or you almost wreck the car. You put
yourself in danger because you go a lot faster than you needed to under those
circumstances. So you cruise control, your cortisol feedback loop, overreacts to
changes in the environment.
This hyper sensitive axis, because it is so sensitive, it doesnt take a lot of cortisol to do it.
Only minor changes in cortisol (a minor degree of pressure on the accelerator)
will cause the system to way over react and do something that is out of character
or out of response to the situation. The radar is so sensitive it is like it reads a
flock of birds as an enemy planes coming in and it generate a nuclear response, to
a flock of birds. The situation really did not deserve it, but that is what it got.
The Chicken vs. Egg Debate
Are the physiological and anatomical changes the result of the trauma or were these
changes present prior to the trauma, predisposing the person for PTSD?
People argue about whether these changes anatomically are because of the trauma and the
stress that has happened, or is it a predisposing thing that these people have
changes in their brain anatomy and in their hormonal HPA system prior to the
trauma.

We dont know if head trauma, alcohol and substance abuse, co-existing other
disease states, like depression contribute too why their brains perform
differently. There is a lot that we dont know, but what we do know is that
their brains perform differently.
When to Seek Help
Symptoms for more than a month
Affecting work, relationships, peace of mind
Self-medicating with alcohol, drugs, etc.
Progressively worsening symptoms
Suicidal thoughts
Good Prognostic Variables
Early intervention
Early and ongoing social support
Avoidance of re-traumatization
Healthy lifestyle prior to the trauma; if they had a history of being able to deal with stressors in the past
they will deal better with it now.
Absence of psychiatric, substance abuse, problems prior to the trauma predicts good prognosis
Treatment
Psychotherapy Counseling Cognitive Behavioral Therapy, Exposure therapy, EMDR (Eye
Movement Desensitization and Reprocessing),
Marital, Family Therapy
Support Groups
Self-Care be aware of triggers, exercise, diet, sleep, building relationships with others
Medications there are certain medications that will help people with PTSD. While there are many good
medications, many times patients are reluctant to take medications for fear they will become
addicted, that it will cause side effects, because of stigma of taking medications but as a general
principle it indicates that there will be a number of people that you are working with that are
taking medications. They will be from a number of different sources, obgyn, medical doctor, or
from a psychiatrist. You need to build working relationships with these people to make sure that
the patients needs are met because many times they will tell you their concerns and not tell the
authority figure who prescribes the medicine of their fears of taking the meds.
Be aware that while the medications are good, the collaborative relationships that you can develop as a
therapist or clergy with the treating person is very important.
Closing
2 rules of war 1. People die 2. You cant change rule number one.
What is learned in combat is never, ever forgotten.
What we cant do is forget as providers the pain, trauma, and shame of the PTSD that hides behind the other
problems in the lives of men and women long after the war is over.
Our job is to make sure we give them a safe, educated, and help providing place where the trauma can end and
they can get on with living a healthy abundant life as designed and intended.