What is post-traumatic stress disorder?

September 11th affected all of us for it marked a new frightening turn in history. But obviously, those who lost a loved one or who were in direct danger that day had an emotional experience that was altogether different than the general reaction. The thousands of rescue workers who dug through the ruins afterward also shouldered special emotional burdens. In reality though, the list of traumatized people was very long and included those who witnessed the disasters, in reality or on TV.

Grief, shock and their elements of disbelief, apathy, and sometimes anger are normal – and healthy – responses to terrible events and sudden loss. Research from the aftermath of the Oklahoma City bombing in 1995 suggests that it may take a while, however, before people work through the shock and denial phases of their reaction and seek professional help.

Remarkably, many people recover – daunted and with a darker world view perhaps, but ready to get on with their lives. Studies have shown this to be true of Holocaust survivors, combat veterans, and rape victims. The human psyche is resilient.

New Term For Shell Shock

Post-traumatic stress disorder (PTSD) is a relatively new term for what used to be called "shell shock," the disabling anxiety disorder first noticed among soldiers who had been through battlefield horrors. (Every war produces its share of such cases.) But PTSD can affect civilians, too – people who’ve lived through bombardment, imprisonment, or torture; earthquake and hurricane survivors; children who witnessed terrible events or are subjected to abuse; and victims of rape or other forms of violence. And if past experience is any indication, some of the survivors of the September terrorist attacks may suffer from it, particularly rescue workers and the bereaved, as well as those who witnessed the events up close.

Symptoms can include intense feelings of helplessness, anger, denial coupled with numbness, grief, and possibly hatred and mistrust of everyone. Insomnia is common, along with bad dreams and nightmares. Survivor guilt ("Why didn’t I get killed, too?") may torment people. Many relive their experiences in flashbacks and dreams. A few think of suicide. Still, the great majority of people recover and move on. PTSD is usually diagnosed when the symptoms continue for more than a month. Nobody can explain why some people recover from trauma and others don’t.

No one knows exactly how many people sought crisis counseling in the aftermath of 9/11 – or how many needed it but did not seek it. For Americans, the attacks have no real parallel either in kind or degree. The closest precedent is the 1995 bombing of the federal office building in Oklahoma City that killed 167 people. A study of survivors of that terrorist attack was published in the August 25, 1999 issue of the Journal of the American Medical Association. The researchers interviewed approximately 200 people six months after the explosion. A person was eligible for the study if they were within a couple of hundred yards from the blast. Thirty-four percent met the criteria for a diagnosis of PTSD.

Who Qualifies? Who’s Vulnerable?

By definition, PTSD is a consequence of exposure to a traumatic experience, with trauma being some kind of serious harm. In 1994, the American Psychiatric Association broadened the definition of exposure considerably. In addition to facing a threat of death or serious injury directly, it now includes "witnessing or learning about the unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or close associate."

It stands to reason that the more direct and severe the traumatic experience, the more likely PTSD will develop. But there isn’t a predictable dose-response relationship. Some people with a fairly remote connection to an event will have a strong psychiatric reaction, whereas others will go through a horrifying experience and bounce back.

Researchers have found some patterns. Studies have shown consistently, for example, that women are more susceptible to developing PTSD than men. In the Oklahoma City survivor study, women had twice the PTSD rate as men (45 percent vs. 23 percent). A traumatic experience is more likely to trigger PTSD in someone who has had a prior experience. A study done several years ago of women recovering from rape found that those who had been raped before were three times more likely to develop PTSD. Most vulnerable of all are people with prior psychiatric problems such as depression, anxiety, or a personality disorder.

Researchers have looked at brain anatomy for clues. Several studies found that an unusually small hippocampus, the part of the brain believed to control the narrative structure of memories, is associated with PTSD. It isn’t settled, however, whether that is a cause or an effect.

When Does It Happen?

PTSD symptoms don’t stick to a decipherable timeline. They can happen right away or emerge months or years later. After disasters, however, they usually begin within three months, perhaps because there isn’t much stigma and people feel freer to express their emotions. In the case of the Oklahoma City bombing, 76 percent of the survivors said their PTSD started the same day.

The first set of PTSD symptoms includes insomnia, edginess, and irritability. People are easily startled. They have a hard time concentrating. Then, sometimes, an emotional flatness sets in as if the mind is struggling to bury or get rid of the whole experience. People feel listless. They may withdraw socially. They may start to have stomachaches, headaches, dizzy spells, and feel profoundly tired. At odds with the numbness is another set of classic PTSD symptoms that includes nightmares, flashbacks, and what psychiatrists aptly term intrusive thoughts. The slightest reminder of the traumatic experience may set people off and cause emotional suffering.

How Is It Treated?

No consensus exists about how best to treat PTSD. A wide range of antidepressants are used. Antiseizure medications like carbamazepine and valproate are sometimes prescribed on the theory that a traumatic experience may lower the arousal threshold of the brain’s limbic system, which is where seizures originate but it also contains emotions. Beta-blockers, traditionally prescribed to lower blood pressure, may quiet the nervous system and thereby reduce anxiety and restlessness.

Several varieties of psychotherapy have been tried, too, most with some but not complete success. Cognitive therapy focuses on memories and breaking negative thought patterns. Behavioral therapy aims to cut off a conditioned response that has become automatic.

Many therapists advocate using a technique called debriefing right after a traumatic event. It involves getting people to talk, usually in a group, about their experiences and vent their emotions. Some experts believe this is the best way to head off PTSD. Others see it as possibly stirring up thoughts and emotions that people might not otherwise have had.

Do We Have Ptsd, Too?

The possibility of future attacks may jangle many people’s nerves. The current peace and order situation in our own country and the poor economic situation may add to the background anxiety. Intrusive thoughts and flashbacks? We don’t need to think them up ourselves. Television and other news media produce plenty of frightening pictures.

But no, we don’t have PTSD. We are allowed though a pang of self-recognition in the broad outlines and descriptions of the condition. These are, after all, disordered times we’re living in.