Brief overview
- Therapy: psychotherapy, in adults sometimes with the support of medication, various forms of therapy such as confrontation therapy, psychodynamic imaginative trauma therapy, in children age-appropriate behavioral therapy with the involvement of parents or caregivers
- Causes: Traumatic experiences such as physical violence from war or rape, people without social support or with mental illness are more susceptible, complex PTSD usually has as its cause particularly severe, repetitive and long-lasting traumas such as torture, sexual exploitation
- Diagnosis: Determination of physical symptoms that occur with a time delay after trauma (differentiation from acute stress reaction with similar symptoms without a time delay is important), trauma therapist asks for medical history, standardized tests (such as CAPS, SKID-I), certain criteria according to ICD-10 must be met
- Prognosis:Often good chances of recovery, especially if appropriate therapy is started in time, supported by the social environment; if symptoms have been present for some time without treatment, there is a risk of a chronic course.
What is post-traumatic stress disorder?
Post-traumatic stress disorder (PTSD) is a mental illness that occurs after traumatic events.
The term trauma comes from the Greek and means “wound” or “defeat”. Trauma therefore describes a very stressful situation in which the affected person feels at the mercy of others and helpless. This does not refer to normal, albeit painful, life situations such as the loss of a job or the death of relatives. Post-traumatic stress disorder is caused by extraordinary and extreme distress.
Post-traumatic stress disorder is also called post-traumatic stress syndrome because it sometimes includes many different symptoms. Possible symptoms include anxiety, irritability, sleep disturbances or panic attacks (rapid heartbeat, trembling, shortness of breath). Flashbacks are also typical: the repeated experience of the traumatic situation, in that the affected person is flooded by the memories and emotions.
Frequency
Post-traumatic stress disorder usually occurs six months after the traumatic event and is possible at all ages. One U.S. study estimates that eight percent of the population experiences post-traumatic stress disorder once in their lifetime. According to another study, doctors, soldiers and police officers are at up to 50 percent increased risk for PTSD.
According to studies, rape leads to post-traumatic stress disorder in 30 percent of cases.
Complex post-traumatic stress disorder
Complex post-traumatic stress disorder requires particularly severe or particularly long-lasting trauma. Affected persons usually show a chronic clinical picture with personality changes. Symptoms thus primarily affect personality and behavior.
How is post-traumatic stress disorder treated?
Post-traumatic stress disorder should be treated by a psychiatrist or psychologist trained in trauma therapy. If the wrong treatment method is used, post-traumatic stress disorder may otherwise become more entrenched.
Some people who want to come to terms with a traumatic experience seek additional help by exchanging ideas with other sufferers and join self-help groups.
Psychotherapy
Step 1: Safety
The first priority is to create a protected setting and a sense of safety for the individual. The patient needs to feel reasonably safe and protected in order to address his or her post-traumatic stress disorder. Therefore, a partial or full inpatient stay is often recommended for the beginning of treatment. The length of a hospital stay depends, among other things, on the severity and whether the affected person is also suffering from severe depressive symptoms, for example.
Before psychotherapy is started, the patient is usually given information (psychoeducation) so that he or she can better understand post-traumatic stress disorder as a clinical picture.
Step 2: Stabilization
Supplemental medication support is sometimes helpful in relieving anxiety. However, medications are not used as the sole or primary therapy. In addition, patients who experience post-traumatic stress disorder have a higher risk of becoming dependent on medication. Therefore, medications are taken selectively and under observation. Only sertraline, paroxetine or venlafaxine are used as active ingredients.
It is not recommended to use psychotropic drugs in children and adolescents.
Step 3: Overcoming, integration and rehabilitation
At this stage, the patient has already gained confidence and learned techniques to help direct his or her emotions somewhat. Now the “trauma work” begins:
Another therapy method developed specifically for PTSD is Eye Movement Desensitization and Reprocessing (EMDR). Here, the patient is slowly introduced to the trauma in the protected setting of therapy. At the moment of recollection and when fear rises again, the aim is to achieve habituation to the trauma experience through a rapid, jerky change in the horizontal direction of gaze.
Ultimately, the traumatizing experience should be embedded in the mental processes and no longer lead to fear and helplessness.
Therapy of complex post-traumatic stress disorder
Complex post-traumatic stress disorder is often treated in German-speaking countries by psychodynamic imaginative trauma therapy (PITT) according to Luise Reddemann. This imaginative therapy generally combines various treatment techniques.
In this process, the patient learns to mentally create a safe space for withdrawal when the emotions related to the event become too strong. The goal here is to overcome post-traumatic stress disorder by embedding what was experienced into the normal emotional world.
Other treatment options include Prolonged Exposure Therapy (PE), in which the patient relives the traumatic situation and experiences the trauma again. The therapy session is tape-recorded. The patient listens to the recording daily until the emotions it triggers diminish.
Narrative Exposure Therapy (NET) is a combination of Testimony Therapy (a short-term procedure for treating traumatized survivors of political violence) with classical behavioral therapy procedures. In this process, the patient’s entire life history of unresolved trauma is processed. Over time, the patient becomes accustomed to these and places them in his or her life history.
Brief Eclectic Psychotherapy for PTSD (BEPP) combines cognitive-behavioral and psychodynamic elements in 16 therapy sessions. It includes five elements: psychoeducation, exposure, writing tasks and working with memory gaps, meaning attribution and integration, and a farewell ritual.
Therapy with children and adolescents
The extent to which parents or caregivers are involved depends on the age of the person affected. The younger the child, the more urgent the support of close people is in order to implement what has been learned in therapy.
What are the underlying causes?
The causes of post-traumatic stress disorder are sometimes very diverse. In any case, however, it is a traumatic experience. The person affected suffers a serious threat – it is a matter of his or her own survival.
Physical experiences of violence in the form of rape, torture or war are usually even more conducive to post-traumatic stress disorder than natural disasters or accidents for which no one is directly responsible. The experienced human violence is usually not compatible with the previously existing world view. There is then a direct “enemy” who represents the threat.
The complex form of post-traumatic stress disorder is usually caused by particularly severe, repetitive and long-lasting traumatic experiences. Examples include childhood trauma from physical abuse or sexual abuse. Other severe traumas after which people develop complex post-traumatic stress disorder include torture, sexual exploitation, or other forms of severe organized violence (such as human trafficking).
What are the tests and diagnoses?
Post-traumatic stress disorder must be distinguished from acute stress reaction. The symptoms are similar in both cases (such as anxiety, confusion, isolation). However, acute stress reaction refers to a state of psychological overwhelm immediately following a severe physical or psychological condition experienced. Post-traumatic stress disorder, on the other hand, presents with a time delay after the trauma.
If a sufferer experiences physical symptoms such as shortness of breath, rapid heartbeat, trembling or sweating, the first person he or she usually consults is his or her family doctor. He or she will first clarify organic causes. If post-traumatic stress disorder is suspected, he or she will refer the patient to a psychiatrist or psychotherapist.
Medical history
In the initial consultation with a specially trained trauma therapist, the diagnosis of “post-traumatic stress disorder” is not usually made. Rather, the therapist first asks questions about the patient’s life history and any existing medical conditions. During this anamnesis, the therapist also asks the patient to describe the symptoms in detail.
Test
Various standardized questionnaires are available for the diagnosis of post-traumatic stress disorder:
The so-called Clinician-Administered PTSD Scale (CAPS) has been developed specifically for the diagnosis of post-traumatic stress disorder. It initially contains questions about the trauma itself. This is followed by questions about whether, how often and in what intensity the various PTSD symptoms occur. Finally, depression or suicidal thoughts are clarified.
The SKID-I test (“structured clinical interview”) is also a frequently used method to diagnose post-traumatic stress disorder. It is a guided interview: The interviewer asks specific questions and then codes the responses. For inpatients, an SKID-I test takes an average of 100 minutes to complete. The diagnosis of PTSD can be confirmed with this test.
Whether a complex post-traumatic stress disorder is present is usually also defined with the help of an interview. The “Structured Interview of Disorders of Extreme Stress” (SIDES) has proven successful for this purpose.
A German-language test version is the “Interview on Complex Posttraumatic Stress Disorder” (I-KPTBS). Here, the physician or therapist also asks the patient questions and then codes the answers.
Diagnostic criteria
To diagnose post-traumatic stress disorder, the following criteria must be met, according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10):
- The patient was exposed to a stressful event (of extraordinary threat or catastrophic magnitude) that would cause helplessness and despair in almost anyone.
- There are intrusive and persistent memories of the experience (flashbacks).
- Irritability and outbursts of anger
- Difficulty concentrating
- difficulty falling asleep and staying asleep
- Hypersensitivity
- Increased jumpiness
- A partial to complete inability to remember the stressful event
- Symptoms appear within six months of the trauma.
In addition, the International Classification of Functioning, Disability and Health (ICF) classification system is considered for functional health. The ICF is used, for example, to capture psychosocial aspects of disease sequelae and the degree of disability.
What symptoms occur?
You can read about how post-traumatic stress disorder manifests itself in detail and what long-term consequences are possible in the article “Post-traumatic stress disorder – symptoms”.
What is the course of the disease and prognosis?
With adequate psychotherapy, post-traumatic stress disorder lasts an average of 36 months. Without therapeutic support, it lasts significantly longer, 64 months on average. Support from the social environment is also extremely important for the healing process and to reduce the risk of relapse. However, if the symptoms persist for years, about one third of those affected develop a chronic course.
Some patients succeed in seeing the trauma as a process of maturation and in gaining something positive from the experience (called “traumatic growth”). They often then help other victims to address their post-traumatic stress disorder or become involved with victims’ organizations.
