abuse abuse
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Findings Suggestive of Physical Abuse Findings in physical abuse can manifest in any area of the body, although some injuries are more common than others: Head May present with external injury (hematoma, laceration, ecchymoses), increased head circumference, bulging fontanelle, and/or change in mental status. Factors that increase the risk of missing or misdiagnosis of acute head trauma: y y y y y Younger age "Intact" family Caucasian Asymptomatic Misinterpretation of radiologic findings
Eyes/ears Periorbital bruising may suggest a globe injury or orbital fracture. Retinal hemorrhages may occur with significant head injury. Bruising of the pinna may suggest more serious ear trauma. Oropharynx May present with torn frenulum, petechiae, dental trauma. Chest Note that bruising may not be evident with blunt trauma. May have costochondral tenderness or chest deformity. Abdominal trauma Bruising on the abdomen may not always be present with blunt injury. May present with abdominal distention, abdominal tenderness, absent bowel sounds, hematuria. Extremities Tenderness or deformity may not always be present. If physical abuse is suspected in a child less than two years of age, perform a skeletal survey. For more information see Skeletal Survey and the table The Specificity of Radiological Findings and Abuse in RADIOLOGY: Injuries Associated with Abuse. Skin May present with bruises that are patterned, multiple bruises of different ages, bruising in a nonambulatory child, burns, and lacerations. Culture-Based Practices that May Be Interpreted as Abuse Before making a diagnosis of abuse it is important to consider whether a culture-based practice could have caused the finding. When you recognize signs of bruising or other injury due to a culture-based practice, it is important to offer information and empathetic understanding to the parent. You may approach the situation by indicating that this practice is not acceptable in our culture and that we offer other methods of treatment. You may need to explain that such practices can be extremely harmful and that we expect that the child will not have to experience them again. Ecchymosis can be the result of y Cupping A coin is placed on the skin and topped with a candle about the size of a birthday candle. Then
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the candle is lit and a glass or jar is inverted over the candle. Or, a tissue is burned in a small glass jar. As soon as the flame is out, the jar is placed on the skin. The suction creates a dark circle of bluish skin. The procedure is done to suck out pain and is often used for headaches. It can also be used to create a place for the illness to exit the body. Pinching The skin is pinched until a bruise appears. When used as a headache remedy, a narrow bruise appears between the eyes. Coining A coin or spoon is rubbed over an area, creating a long, wide mark or an oval bruise with an irregular border. This is done to create an area for the disease to escape. The bruise may also be punctured with a needle to let the toxins escape.
Folk remedies may use substances such as: y y y y y Arsenic Lead Urine Feces Slime mold
Practices that may be interpreted as abuse include: y y y y y Co-sleeping Comfort nursing of older children Early marriage Physical punishment Refusal of treatment for reasons of religious belief
A parent has discretion to use home remedies and culture-based practices to the extent that they are providing a minimum degree of care. Leaving a burn, puncture mark, or other injury, or using arsenic, lead, feces, etc. to remedy a condition does not meet the standard for a minimum degree of care in New York State. Lack of knowledge of New York State law is not a defense or protection. Cultural practices that cause physical or psychological injury must be reported to the State Central Register. Medical providers are not exempt from reporting incidents where a child has been harmed or is in imminent danger of harm, even when it may be a result of culture-based custom.
Physical abuse of children includes any nonaccidental physical injury caused by the child's caretaker. It may include injuries sustained from burning, beating, kicking, punching, and so on. While the injury is not an accident, neither is it necessarily the intent of the child's caretaker to injure the child. Physical abuse may result from extreme discipline or from punishment that is inappropriate to the child's age or condition, or the parent may experience recurrent lapses in self-control brought on by immaturity, stress, or the use of alcohol or illicit drugs. Some children are more susceptible to being maltreated than others. Some require a great deal of care (e.g., premature babies or disabled or developmentally delayed children), and others may be difficult to raise (e.g., hyperactive children, children with behavioral problems). These children would fare well in some families, but not in other families where the burden is too great for the parents to cope with the special needs of these children. Regardless of whether the child has special needs or not, signs of physical abuse often are difficult to interpret with absolute certainty and may be confused with normal childhood injuries, such as bruises. Behavioral Clues That May Indicate Child Abuse
Although there are many other potential indicators, the abused child may: Be aggressive, oppositional, or defiant Cower or demonstrate fear of adults Act out, displaying aggressive or disruptive behavior Be destructive to self or others Come to school too early or not want to leave school²indicating a possible fear of going home; Show fearlessness or extreme risk taking Be described as "accident prone" Cheat, steal, or lie (may be related to too high expectations at home) Be a low achiever (to learn, children must convert aggressive energy into learning; children in conflict may not be able to do so) y Be unable to form good peer relationships y Wear clothing that covers the body and that may be inappropriate in warmer months (be aware that this may be a cultural issue as well) y Show regressive or less mature behavior y Dislike or shrink from physical contact²may not tolerate physical praise such as a pat on the back) Since children typically receive bruises during the course of play or while being active, the leading or bony edges of the body, such as knees, elbows, forearms, or brows, are most likely to be bruised. The soft tissue areas, such as cheeks, buttocks, and thighs, are not normally injured in such circumstances. Additionally, bruises received during the normal course of childhood activity are rarely in distinct shapes, such as a hand, belt buckle, or adult teeth marks. Bruises in soft tissue areas or in distinct shapes are much more indicative of physical abuse.
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Unlike bruises, abuse directed to the abdomen or the head, which are two particularly vulnerable spots, often are undetected because many of the injuries are internal. Injuries to the abdomen can cause swelling, tenderness, and vomiting. Injuries to the head may cause swelling in the brain, dizziness, blackouts, retinal detachment, or even death. Referred to more recently as the "shaken baby" syndrome, violent shaking can cause severe damage in children at any age. PTSD is an anxiety disorder that some people get after seeing or living through a dangerous event. When in danger, it¶s natural to feel afraid. This fear triggers many split-second changes in the body to prepare to defend against the danger or to avoid it. This ³fight-or-flight´ response is a healthy reaction meant to protect a person from harm. But in PTSD, this reaction is changed or damaged. People who have PTSD may feel stressed or frightened even when they¶re no longer in danger. PTSD can cause many symptoms. These symptoms can be grouped into three categories: 1. Re-experiencing symptoms: Flashbacks²reliving the trauma over and over, including physical symptoms like a racing heart or sweating Bad dreams Frightening thoughts. Re-experiencing symptoms may cause problems in a person¶s everyday routine. They can start from the person¶s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger reexperiencing. 2. Avoidance symptoms: Staying away from places, events, or objects that are reminders of the experience Feeling emotionally numb Feeling strong guilt, depression, or worry Losing interest in activities that were enjoyable in the past Having trouble remembering the dangerous event. Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.
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3. Hyperarousal symptoms: Being easily startled Feeling tense or ³on edge´ Having difficulty sleeping, and/or having angry outbursts. Hyperarousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic event. They can make the person feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating. It¶s natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a few weeks and become an ongoing problem, they might be PTSD. Some people with PTSD don¶t show any symptoms for weeks or months.
The main treatments for people with PTSD are psychotherapy (³talk´ therapy), medications, or both. Everyone is different, so a treatment that works for one person may not work for another. It is important for anyone with PTSD to be treated by a mental health care provider who is experienced with PTSD. Some people with PTSD need to try different treatments to find what works for their symptoms. If someone with PTSD is going through an ongoing trauma, such as being in an abusive relationship, both of the problems need to be treated. Other ongoing problems can include panic disorder, depression, substance abuse, and feeling suicidal.
After a traumatic experience, it¶s normal to feel frightened, sad, anxious, and disconnected. Usually, as time passes, the upset fades and you start to enjoy life again. But sometimes the trauma you experienced is so overwhelming that you find that you can¶t move on. You feel stuck with painful memories that don¶t fade and a constant sense of danger. If you went through a traumatic experience and are having trouble getting back to your regular life, reconnecting to others, and feeling safe again, you may be suffering from post-traumatic stress disorder (PTSD). When you have PTSD, it can seem like you¶ll never get over what happened or feel normal again. But help is available²and you are not alone. If you are willing to seek treatment, reach out to others for support, and work on developing new coping skills, you will be able to overcome the symptoms of PTSD and move on with your life.
What is post-traumatic stress disorder (PTSD)?
Post-traumatic stress disorder (PTSD) is a disorder that can develop following a traumatic event that threatens your safety or makes you feel helpless. Most people associate PTSD with battle±scarred soldiers±and military combat is the most common cause in men±but any overwhelming life experience can trigger PTSD, especially if the event feels unpredictable and uncontrollable. Post-traumatic stress disorder (PTSD) can affect those who personally experience the catastrophe, those who witness it, and those who pick up the pieces afterwards, including emergency workers and law enforcement officers. It can even occur in the friends or family members of those who went through the actual trauma.
PTSD develops differently from person to person. While the symptoms of PTSD most commonly develop in the hours or days following the traumatic event, it can sometimes take weeks, months, or even years before they appear.
Traumatic events that can lead to PTSD include:
The difference between PTSD and a normal response to trauma
The traumatic events that lead to post-traumatic stress disorder are usually so overwhelming and frightening that they would upset anyone. Following a traumatic event, almost everyone experiences at least some of the symptoms of PTSD. When your sense of safety and trust are shattered, it¶s normal to feel crazy, disconnected, or numb. It¶s very common to have bad dreams, feel fearful or numb, and find it difficult to stop thinking about what happened. These are normal reactions to abnormal events. For most people, however, these symptoms are short-lived. They may last for several days or even weeks, but they gradually lift. But if you have post-traumatic stress disorder (PTSD), the symptoms don¶t decrease. You don¶t feel a little better each day. In fact, you may start to feel worse.
A normal response to trauma becomes PTSD when you become stuck
After a traumatic experience, the mind and the body are in shock. But as you make sense of what happened and process your emotions, you come out of it. With post-traumatic stress disorder (PTSD), however, you remain in psychological shock. Your memory of what happened and your feelings about it are disconnected. In order to move on, it¶s important to face and feel your memories and emotions.
Signs and symptoms of post-traumatic stress disorder (PTSD)
The symptoms of post-traumatic stress disorder (PTSD) can arise suddenly, gradually, or come and go over time. Sometimes symptoms appear seemingly out of the blue. At other times, they are triggered by something that reminds you of the original traumatic event, such as a noise, an image, certain words, or a smell. While everyone experiences PTSD differently, there are three main types of symptoms: 1. Re-experiencing the traumatic event 2. Avoiding reminders of the trauma 3. Increased anxiety and emotional arousal
Symptoms of PTSD: Re-experiencing the traumatic event
Intrusive, upsetting memories of the event Flashbacks (acting or feeling like the event is happening again) Nightmares (either of the event or of other frightening things) Feelings of intense distress when reminded of the trauma
War Natural disasters Car or plane crashes Terrorist attacks Sudden death of a loved one
Rape idnapping Assault Sexual or physical abuse Childhood neglect
Intense physical reactions to reminders of the event (e.g. pounding heart, rapid breathing, nausea, muscle tension, sweating)
Symptoms of PTSD: Avoidance and numbing
Avoiding activities, places, thoughts, or feelings that remind you of the trauma Inability to remember important aspects of the trauma Loss of interest in activities and life in general Feeling detached from others and emotionally numb Sense of a limited future (you don¶t expect to live a normal life span, get married, have a career)
Symptoms of PTSD: Increased anxiety and emotional arousal
Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance (on constant ³red alert´) Feeling jumpy and easily startled
Other common symptoms of post-traumatic stress disorder
Anger and irritability Guilt, shame, or self-blame Substance abuse Feelings of mistrust and betrayal
Depression and hopelessness Suicidal thoughts and feelings Feeling alienated and alone Physical aches and pains
Symptoms of PTSD in children and adolescents
In children²especially those who are very young²the symptoms of PTSD can be different than the symptoms in adults. Symptoms in children include:
Fear of being separated from parent Losing previously-acquired skills (such as toilet training) Sleep problems and nightmares without recognizable content Somber, compulsive play in which themes or aspects of the trauma are repeated New phobias and anxieties that seem unrelated to the trauma (such as a fear of monsters). Acting out the trauma through play, stories, or drawings. Aches and pains with no apparent cause Irritability and aggression
Post-traumatic stress disorder (PTSD) causes and risk factors
While it¶s impossible to predict who will develop PTSD in response to trauma, there are certain risk factors that increase your vulnerability. Many risk factors revolve around the nature of the traumatic event itself. Traumatic events are more likely to cause PTSD when they involve a severe threat to your life or personal safety: the more extreme and prolonged the threat, the greater the risk of developing PTSD in response. Intentional, human-inflicted harm²such as rape, assault, and torture² also tends to be more traumatic than ³acts of God´ or more impersonal accidents and disasters. The extent to which the traumatic event was unexpected, uncontrollable, and inescapable also plays a role.
Other risk factors for PTSD include:
Previous traumatic experiences, especially in early life
History of depression, anxiety, or another mental illness
Family history of PTSD or depression History of physical or sexual abuse History of substance abuse
High level of stress in everyday life Lack of support after the trauma Lack of coping skills
etting help for post-traumatic stress disorder (PTSD)
If you suspect that you or a loved one has post-traumatic stress disorder (PTSD), it¶s important to seek help right away. The sooner PTSD is confronted, the easier it is to overcome. If you¶re reluctant to seek help, keep in mind that PTSD is not a sign of weakness, and the only way to overcome it is to confront what happened to you and learn to accept it as a part of your past. This process is much easier with the guidance and support of an experienced therapist or doctor. It¶s only natural to want to avoid painful memories and feelings. But if you try to numb yourself and push your memories away, post-traumatic stress disorder (PTSD) will only get worse. You can¶t escape your emotions completely ± they emerge under stress or whenever you let down your guard ± and trying to do so is exhausting. The avoidance will ultimately harm your relationships, your ability to function, and the quality of your life.
Why Should I Seek Help for PTSD?
Early treatment is better. Symptoms of PTSD may get worse. Dealing with them now might help stop them from getting worse in the future. Finding out more about what treatments work, where to look for help, and what kind of questions to ask can make it easier to get help and lead to better outcomes. PTSD symptoms can change family life. PTSD symptoms can get in the way of your family life. You may find that you pull away from loved ones, are not able to get along with people, or that you are angry or even violent. Getting help for your PTSD can help improve your family life. PTSD can be related to other health problems. PTSD symptoms can worsen physical health problems. For example, a few studies have shown a relationship between PTSD and heart trouble. By getting help for your PTSD you could also improve your physical health.
Source: National Center for PTSD
Treatment for post-traumatic stress disorder (PTSD)
Treatment for PTSD relieves symptoms by helping you deal with the trauma you¶ve experienced. Rather than avoiding the trauma and any reminder of it, you¶ll be encouraged in treatment to recall and process the emotions and sensations you felt during the original event. In addition to offering an outlet for emotions you¶ve been bottling up, treatment for PTSD will also help restore your sense of control and reduce the powerful hold the memory of the trauma has on your life. In treatment for PTSD, you¶ll:
Explore your thoughts and feelings about the trauma Work through feelings of guilt, self-blame, and mistrust Learn how to cope with and control intrusive memories Address problems PTSD has caused in your life and relationships
Types of treatments for post-traumatic stress disorder (PTSD)
Trauma-focused cognitive-behavioral therapy. Cognitive-behavioral therapy for PTSD and trauma involves carefully and gradually ³exposing´ yourself to thoughts, feelings, and situations that remind you of the trauma. Therapy also involves identifying upsetting thoughts about the traumatic event±particularly thoughts that are distorted and irrational²and replacing them with more balanced picture.
Family therapy. Since PTSD affects both you and those close to you, family therapy can be especially productive. Family therapy can help your loved ones understand what you¶re going through. It can also help everyone in the family communicate better and work through relationship problems. Medication. Medication is sometimes prescribed to people with PTSD to relieve secondary symptoms of depression or anxiety. Antidepressants such as Prozac and Zoloft are the medications most commonly used for PTSD. While antidepressants may help you feel less sad, worried, or on edge, they do not treat the causes of PTSD. EMDR (Eye Movement Desensitization and Reprocessing). EMDR incorporates elements of cognitive-behavioral therapy with eye movements or other forms of rhythmic, left-right stimulation, such as hand taps or sounds. Eye movements and other bilateral forms of stimulation are thought to work by ³unfreezing´ the brain¶s information processing system, which is interrupted in times of extreme stress, leaving only frozen emotional fragments which retain their original intensity. Once EMDR frees these fragments of the trauma, they can be integrated into a cohesive memory and processed.
Helping a loved one with PTSD
Be patient and understanding. Getting better takes time, even when a person is committed to treatment for PTSD. Be patient with the pace of recovery and offer a sympathetic ear. A person with PTSD may need to talk about the traumatic event over and over again. This is part of the healing process, so avoid the temptation to tell your loved one to stop rehashing the past and move on. Try to anticipate and prepare for PTSD triggers. Common triggers include anniversary dates; people or places associated with the trauma; and certain sights, sounds, or smells. If you are aware of what triggers may cause an upsetting reaction, you¶ll be in a better position to offer your support and help your loved one calm down. Don¶t take the symptoms of PTSD personally. Common symptoms of post-traumatic stress disorder (PTSD) include emotional numbness, anger, and withdrawal. If your loved one seems distant, irritable, or closed off, remember that this may not have anything to do with you or your relationship. Don¶t pressure your loved one into talking. It is very difficult for people with PTSD to talk about their traumatic experiences. For some, it can even make things worse. Never try to force your loved one to open up. Let the person know, however, that you¶re there when and if he or she wants to talk.
Posttraumatic Stress Disorder (PTSD)
SYMPTOMS
Post-Traumatic Stress Disorder (PTSD) is a debilitating condition that follows a terrifying event. Often, people with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. PTSD, once referred to as shell shock or battle fatigue, was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. These include kidnapping, serious accidents such as car or train wrecks, natural disasters such as floods or earthquakes, violent attacks such as a mugging, rape, or torture, or being held captive. The event that triggers it may be something that threatened the person's life or the life of someone close to him or her. Or it could be something witnessed, such as mass destruction after a plane crash. Whatever the source of the problem, some people with PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They may also experience sleep problems, depression, feeling detached or numb, or being easily startled.
They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Seeing things that remind them of the incident may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the event are often very difficult. PTSD can occur at any age, including childhood. The disorder can be accompanied by depression, substance abuse, or anxiety. Symptoms may be mild or severe--people may become easily irritated or have violent outbursts. In severe cases they may have trouble working or socializing. In general, the symptoms seem to be worse if the event that triggered them was initiated by a person--such as a rape, as opposed to a flood. Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A flashback may make the person lose touch with reality and reenact the event for a period of seconds or hours or, very rarely, days. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, usually believes that the traumatic event is happening all over again. Not every traumatized person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month. In those who do have PTSD, symptoms usually begin within 3 months of the trauma, and the course of the illness varies. Some people recover within 6 months, others have symptoms that last much longer. In some cases, the condition may be chronic. Occasionally, the illness doesn't show up until years after the traumatic event.
Specific Symptoms of PTSD:
The person has been exposed to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person's response involved intense fear, helplessness, or horror. The traumatic event is persistently reexperienced in one or more of the following ways: y y y Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Recurrent distressing dreams of the event. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
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The individual also has persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following:
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Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma Significantly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect (e.g., unable to have loving feelings) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2 or more of the following: y y y y y Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response
The disturbance, which has lasted for at least a month, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Definition
Post-Traumatic Stress Disorder (PTSD) is classified as acute, chronic, and with delayed onset. For pension purposes, acute PTSD, i.e. when duration of symptoms is less than 3 months, will not be pensioned. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) has defined PTSD as a psychiatric condition if it meets the following 6 criteria: A. The person has been exposed to a traumatic event in which: i. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and ii. The person's response involved intense fear, helplessness, or horror; and B. The traumatic event is persistently re-experienced in one or more of the following ways: i. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions; ii. Recurrent distressing dreams of the event; iii. Acting or feeling as if the traumatic event were recurring (including a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awaking or when intoxicated);
C.
D.
E. F.
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; v. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; and Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before trauma), as indicated by three or more of the following: i. Efforts to avoid thoughts, feelings, or conversations associated with the trauma; ii. Efforts to avoid activities, places, or people that arouse recollections of the trauma; iii. Inability to recall an important aspect of the trauma; iv. Markedly diminished interest or participation in significant activities; v. Feeling of detachment or estrangement from others; vi. Restricted range of affect (e.g. unable to have loving feelings); vii. Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span); and Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following: i. Difficulty falling or staying asleep; ii. Irritability or outbursts of anger; iii. Difficulty concentrating; iv. Hypervigilance; v. Exaggerated startle response; and Duration of the disturbance (indicated by the relevant symptoms set out in paragraphs (b), (c) and (d)) is more than one month; and The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
iv.
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Diagnostic Standard
A diagnosis from a qualified medical practitioner or a psychiatrist or a registered/licensed psychologist is required. The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible and should satisfy the requirements for diagnosis as outlined in the DSM-IV diagnostic criteria. Back to Top
Anatomy and Physiology
PTSD is a condition that can develop as a result of an individual's exposure to an extremely traumatic stressor, especially if the individual response involves intense fear, helplessness, or horror. The disorder may be particularly severe or long-lasting when the stressor is of human design (e.g. torture, rape), and trust is lost. Trauma may be personal trauma or witnessed trauma, examples of which are as follows: y The direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or
y
Witnessing an event that involves death, injury or threat to the physical integrity of another person.
Such personal trauma events include, but are not limited to: y y y y y y y y y y Military combat violent personal assault (sexual assault, physical attack, robbery, mugging) being kidnapped being taken hostage a terrorist attack torture incarceration as a prisoner of war or in a concentration camp being required to exhume a dead body or body parts natural or man-made disasters severe automobile accidents, of a nature which meets the above-noted criteria or equivalent
Witnessed events include, but are not limited to: y y y y y observing serious injury or unnatural death of another person due to violent assault accident war disaster unexpectedly witnessing a dead body or body parts
Studies indicate that the prevalence of PTSD for at risk populations (e.g. Vietnam veterans, rape victims, Rwandan peacekeepers, and Armenian children after an earthquake) ranges from 14 - 75%. It is considered that the wide range of prevalence rates reflects the variety of measurement criteria used to diagnose PTSD. Epidemiological studies show that PTSD often remains chronic, with a significant number of persons remaining symptomatic several years after the event. The disorder cannot exist unless the individual has been exposed to a traumatic stressor with a particular set of properties. While trauma is a necessary factor, few would consider it to be sufficient to cause PTSD. The relative importance of the traumatic event, predisposing factors, and environmental factors shortly before or after the trauma must all be considered in understanding the etiology of PTSD. In most instances, occurrence of the disorder represents the outcome of an interaction amongst these three groups of factors. Predisposing factors include the identification of genetic vulnerability to the development of PTSD. Because of different reactions to the same traumatic event, it cannot be said that psychological models alone fully account for the development of PTSD. Other than genetics, premorbid vulnerability factors include a prior history of psychiatric disorder, a family history of psychiatric disorder, a pre-existing personality disorder or traits, poor peer and social support, and a prior history of trauma. Normal adaptive mechanisms for processing life experiences may eventually become overwhelmed by psychological trauma, if the trauma is sufficiently severe. There are 3 psychological theories of PTSD, which are briefly described as follows:
1. Psychodynamic Theory y When faced with an overwhelming traumatic experience, the mind mobilizes defences in order to survive. In order to make sense of the trauma, the survivor develops intrusive and avoidance symptoms, and through the use of repetition and compulsion attempts to master the memories. This is adaptive in Adjustment Disorder and Acute Stress Disorder, but in PTSD the process is overwhelmed and symptoms persists. 2. Cognitive/Behavioural Theory y Fears associated with PTSD develop through classical conditioning, i.e. an unconditioned stimulus produces an unconditioned response which becomes associated with a conditioned stimulus. For example, a person is robbed in an elevator by a man in a yellow raincoat. The robbery (unconditioned stimulus) produces fear (unconditioned response), and the sight of a yellow raincoat (conditioned stimulus) becomes associated with the same fear. These new, classically-condition fears are maintained through operant conditioning. Escape or avoidance behaviours are reinforced by their anxiety-relieving effects. Over time, increasing numbers and types of stimuli may become elicitors of anxiety, and symptoms of PTSD are maintained. 3. Cognitive Network Theory y Original traumatic events conflict with prior beliefs. For example, a person who grows up to believe that women and children are to be protected may find this principle challenged when placed in a combat situation. New information that is congruent with prior beliefs about self or the world is assimilated quickly and without effort because the information matches current schemas. When schema-discrepant effects occur, as in trauma, individuals must reconcile the effect with their beliefs about themselves and the world. Accordingly, their schemas must be altered or accommodated to incorporate this new information. Because of the strong effect associated with the trauma, this process is often avoided. Thus, rather than accommodating beliefs to incorporate the trauma, victims may distort the trauma to ensure that their beliefs remain in tact. PTSD has been shown to have a number of unique biological features, separate from other mental disorders. These include changes to the hypothalmic-pituitary axis (which regulates the body's response to stress), decreased cortisol levels, and higher glucocorticoid receptor sensitivity. These factors demonstrate that the body's response to traumatic stress in PTSD differs from other mental health disorders. Despite exposure to the same trauma, it is only those who suffer from PTSD who undergo biological changes in response to the trauma. Subsequent stressors may also contribute to biological alterations. Back to Top
Clinical Features
For pension purposes, PTSD is classified as "chronic" or "with delayed onset". Chronic PTSD is used when symptoms last 3 months or longer. PTSD of delayed onset is used when at least 6 months have passed between the traumatic event and onset of symptoms. To make a diagnosis of PTSD for pension purposes, it is required that symptoms last for a minimum period of 3 months and that the disturbance causes an impairment or clinically significant distress.
The characteristic symptoms of PTSD are as follows: y y y y Re-experiencing the traumatic event, Avoidance of stimuli associated with the event, Numbing of general responsiveness, Increased arousal.
i.
Re-experiencing the traumatic event The traumatic event can be re-experienced in a variety of ways. Commonly, the person has recurrent and intrusive recollections of the event or recurrent distressing dreams during which the event is re-experienced. In rare instances there are dissociative states lasting from a few seconds to several hours or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment. There is often intense psychological distress when the person is exposed to a situation that resembles an aspect of the traumatic event or that symbolizes the traumatic event, e.g. an anniversary of the event.
ii.
Avoidance of stimuli There is persistent avoidance of any stimuli associated with the traumatic event or a numbing of general responsiveness that was not present before the trauma. The person commonly makes deliberate efforts to avoid thoughts or feelings about the traumatic event and about activities or situations that arouse recollections of it. This may include psychogenic amnesia for an important aspect of the traumatic event.
iii.
Numbing of general responsiveness Diminished responsiveness to the external world, referred to as "psychic numbing" or "emotional anesthesia", usually begins soon after the traumatic event. A person may complain of feeling detached or estranged from others, that he or she has lost the ability to become interested in previously enjoyed activities, or that the ability to feel emotions of any type, especially those associated with intimacy, tenderness and sexuality, is markedly decreased.
iv.
Increased arousal At least one of the five of the following symptoms not present before the trauma is required: i. Difficulty falling or staying asleep (recurrent nightmares during which the traumatic event is relived are sometimes accompanied by middle or terminal sleep disturbance) Irritability or anger Poor concentration Hyper-vigilance Exaggerated startle response
ii. iii. iv. v.
Some persons complain of difficulty in concentrating or in completing tasks. Many report increased aggression. In mild cases, this may take the form of irritability with fear of losing control. In more severe forms, particularly in cases in which the survivor has actually committed acts of violence (as in war veterans), the fear is conscious and pervasive and the reduced capacity for expressing angry feelings may lead to unpredictable explosions of aggressive behaviour. Avoidance of stimuli, numbing of general responsiveness, and hyperarousal symptoms must occur after the exposure to trauma if they are to be valid diagnostic symptoms. This can be a difficult judgment to make in cases in which PTSD has arisen from an ill-defined set of early childhood traumas or even a clearly defined event some 20 or 30 years earlier. A detailed summary of symptoms and manifestations of PTSD includes the following: Cognitive Symptoms anticipation of misfortune distrust of others inattentiveness intrusive memories memory impairment self-criticism trouble concentrating worry Behavioral and Physiologic Symptoms angry outbursts compulsive, repetitive acts diarrhea faintness headaches hyper alertness hyperventilation impatience insomnia nausea numbness nightmares palpitations withdrawal The long term course of PTSD is variable. Recovery varies from permanent recovery to no resolution of symptoms and deterioration with age. There may exist a relatively unchanging course with only mild fluctuations, or obvious fluctuations with intermittent periods of wellbeing and recurrences of major symptoms. The startle response, nightmares, irritability, and depression have been noted to increase with time in many persons. These symptoms often represent a poor prognostic sign. Affective Symptoms anger crying emotionally reliving the trauma guilt irritability loss of control low self-esteem sadness Identity Changes alienation from self, others work discontinuity from the past feelings of inadequacy or unworthiness sense of foreshortened future sense of pervasive unreality
It is important to remember that there are diseases other than PTSD which can result from trauma, e.g. mood disorders, other anxiety disorders, dissociative disorders, eating disorders, and substance abuse. It should also be noted that PTSD is unlikely to occur alone. Psychiatric comorbidity is the rule rather than the exception, and a number of studies have demonstrated that in both clinical and epidemiological populations a wide range of disorders is likely to occur. These include some depression disorders, all of the anxiety disorders, alcohol and substance abuse disorders, somatization disorders, schizophrenia and schizophreniform disorder. Schizophrenia and schizophreniform disorders are not commonly observed in the military, having been screened out early in an individual's military career. It should also be noted that PTSD may overlap with impulse control disorders in view of the anger, irritable outbursts and periodical recourse to violence that occur in PTSD. Back to Top
Pension Considerations
A. Causes and / or aggravation B. Medical conditions which are to be included in Entitlement / Assessment C. Common medical conditions which may result in whole or in part from PostTraumatic Stress Disorder and / or its treatment
A. Causes and/or Aggravation
The timelines cited below are not binding. each case should be adjudicated on the evidence provided and its own merits. 1. Exposure to a traumatic stressor prior to clinical onset or aggravation PTSD need not have its onset during combat. For example, vehicular or airplane crashes, large fires, floods, earthquakes, and other disasters could evoke significant distress in most involved persons. Trauma may be experienced alone (e.g. rape or assault), or in the company of groups of persons (e.g. military combat). A stressor should not be limited to one episode. A group of experiences may lead to PTSD. In some circumstances, for example, assignment to a grave registration unit/burn care unit, or liberation/internment camps could have the cumulative effect of powerful, distressing experiences essential to a diagnosis of PTSD. PTSD can be caused by events which occur before, during, or after service. The relationship between stressors during service and current problems/symptoms will govern the question of service- connection.
PTSD can occur hours, months, or years after a service-related stressor. Despite this long latent period, service-connected PTSD may be recognizable by a relevant association between the stressor and the current presentation of symptoms. 2. Inability to obtain appropriate clinical management B. Medical Conditions Which are to be Included in Entitlement/Assessment y Anxiety disorders y Mood disorders y Schizophrenia and other psychotic disorders y Adjustment disorders y Personality disorders y Eating disorders y Substance-related disorders y Dissociative disorders y Pain disorders/chronic pain syndromes
Common Medical Conditions Which may Result in Whole or in Part From Post-Traumatic Stress Disorder and/or its Treatment y Sexual dysfunction (e.g. erectile dysfunction) y Irritable bowel syndrome
Eyes/ears Periorbital bruising may suggest a globe injury or orbital fracture. Retinal hemorrhages may occur with significant head injury. Bruising of the pinna may suggest more serious ear trauma. Oropharynx May present with torn frenulum, petechiae, dental trauma. Chest Note that bruising may not be evident with blunt trauma. May have costochondral tenderness or chest deformity. Abdominal trauma Bruising on the abdomen may not always be present with blunt injury. May present with abdominal distention, abdominal tenderness, absent bowel sounds, hematuria. Extremities Tenderness or deformity may not always be present. If physical abuse is suspected in a child less than two years of age, perform a skeletal survey. For more information see Skeletal Survey and the table The Specificity of Radiological Findings and Abuse in RADIOLOGY: Injuries Associated with Abuse. Skin May present with bruises that are patterned, multiple bruises of different ages, bruising in a nonambulatory child, burns, and lacerations. Culture-Based Practices that May Be Interpreted as Abuse Before making a diagnosis of abuse it is important to consider whether a culture-based practice could have caused the finding. When you recognize signs of bruising or other injury due to a culture-based practice, it is important to offer information and empathetic understanding to the parent. You may approach the situation by indicating that this practice is not acceptable in our culture and that we offer other methods of treatment. You may need to explain that such practices can be extremely harmful and that we expect that the child will not have to experience them again. Ecchymosis can be the result of y Cupping A coin is placed on the skin and topped with a candle about the size of a birthday candle. Then
y
y
the candle is lit and a glass or jar is inverted over the candle. Or, a tissue is burned in a small glass jar. As soon as the flame is out, the jar is placed on the skin. The suction creates a dark circle of bluish skin. The procedure is done to suck out pain and is often used for headaches. It can also be used to create a place for the illness to exit the body. Pinching The skin is pinched until a bruise appears. When used as a headache remedy, a narrow bruise appears between the eyes. Coining A coin or spoon is rubbed over an area, creating a long, wide mark or an oval bruise with an irregular border. This is done to create an area for the disease to escape. The bruise may also be punctured with a needle to let the toxins escape.
Folk remedies may use substances such as: y y y y y Arsenic Lead Urine Feces Slime mold
Practices that may be interpreted as abuse include: y y y y y Co-sleeping Comfort nursing of older children Early marriage Physical punishment Refusal of treatment for reasons of religious belief
A parent has discretion to use home remedies and culture-based practices to the extent that they are providing a minimum degree of care. Leaving a burn, puncture mark, or other injury, or using arsenic, lead, feces, etc. to remedy a condition does not meet the standard for a minimum degree of care in New York State. Lack of knowledge of New York State law is not a defense or protection. Cultural practices that cause physical or psychological injury must be reported to the State Central Register. Medical providers are not exempt from reporting incidents where a child has been harmed or is in imminent danger of harm, even when it may be a result of culture-based custom.
Physical abuse of children includes any nonaccidental physical injury caused by the child's caretaker. It may include injuries sustained from burning, beating, kicking, punching, and so on. While the injury is not an accident, neither is it necessarily the intent of the child's caretaker to injure the child. Physical abuse may result from extreme discipline or from punishment that is inappropriate to the child's age or condition, or the parent may experience recurrent lapses in self-control brought on by immaturity, stress, or the use of alcohol or illicit drugs. Some children are more susceptible to being maltreated than others. Some require a great deal of care (e.g., premature babies or disabled or developmentally delayed children), and others may be difficult to raise (e.g., hyperactive children, children with behavioral problems). These children would fare well in some families, but not in other families where the burden is too great for the parents to cope with the special needs of these children. Regardless of whether the child has special needs or not, signs of physical abuse often are difficult to interpret with absolute certainty and may be confused with normal childhood injuries, such as bruises. Behavioral Clues That May Indicate Child Abuse
Although there are many other potential indicators, the abused child may: Be aggressive, oppositional, or defiant Cower or demonstrate fear of adults Act out, displaying aggressive or disruptive behavior Be destructive to self or others Come to school too early or not want to leave school²indicating a possible fear of going home; Show fearlessness or extreme risk taking Be described as "accident prone" Cheat, steal, or lie (may be related to too high expectations at home) Be a low achiever (to learn, children must convert aggressive energy into learning; children in conflict may not be able to do so) y Be unable to form good peer relationships y Wear clothing that covers the body and that may be inappropriate in warmer months (be aware that this may be a cultural issue as well) y Show regressive or less mature behavior y Dislike or shrink from physical contact²may not tolerate physical praise such as a pat on the back) Since children typically receive bruises during the course of play or while being active, the leading or bony edges of the body, such as knees, elbows, forearms, or brows, are most likely to be bruised. The soft tissue areas, such as cheeks, buttocks, and thighs, are not normally injured in such circumstances. Additionally, bruises received during the normal course of childhood activity are rarely in distinct shapes, such as a hand, belt buckle, or adult teeth marks. Bruises in soft tissue areas or in distinct shapes are much more indicative of physical abuse.
y y y y y y y y y
Unlike bruises, abuse directed to the abdomen or the head, which are two particularly vulnerable spots, often are undetected because many of the injuries are internal. Injuries to the abdomen can cause swelling, tenderness, and vomiting. Injuries to the head may cause swelling in the brain, dizziness, blackouts, retinal detachment, or even death. Referred to more recently as the "shaken baby" syndrome, violent shaking can cause severe damage in children at any age. PTSD is an anxiety disorder that some people get after seeing or living through a dangerous event. When in danger, it¶s natural to feel afraid. This fear triggers many split-second changes in the body to prepare to defend against the danger or to avoid it. This ³fight-or-flight´ response is a healthy reaction meant to protect a person from harm. But in PTSD, this reaction is changed or damaged. People who have PTSD may feel stressed or frightened even when they¶re no longer in danger. PTSD can cause many symptoms. These symptoms can be grouped into three categories: 1. Re-experiencing symptoms: Flashbacks²reliving the trauma over and over, including physical symptoms like a racing heart or sweating Bad dreams Frightening thoughts. Re-experiencing symptoms may cause problems in a person¶s everyday routine. They can start from the person¶s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger reexperiencing. 2. Avoidance symptoms: Staying away from places, events, or objects that are reminders of the experience Feeling emotionally numb Feeling strong guilt, depression, or worry Losing interest in activities that were enjoyable in the past Having trouble remembering the dangerous event. Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.
y y y
y y y y y
y y y
3. Hyperarousal symptoms: Being easily startled Feeling tense or ³on edge´ Having difficulty sleeping, and/or having angry outbursts. Hyperarousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic event. They can make the person feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating. It¶s natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a few weeks and become an ongoing problem, they might be PTSD. Some people with PTSD don¶t show any symptoms for weeks or months.
The main treatments for people with PTSD are psychotherapy (³talk´ therapy), medications, or both. Everyone is different, so a treatment that works for one person may not work for another. It is important for anyone with PTSD to be treated by a mental health care provider who is experienced with PTSD. Some people with PTSD need to try different treatments to find what works for their symptoms. If someone with PTSD is going through an ongoing trauma, such as being in an abusive relationship, both of the problems need to be treated. Other ongoing problems can include panic disorder, depression, substance abuse, and feeling suicidal.
After a traumatic experience, it¶s normal to feel frightened, sad, anxious, and disconnected. Usually, as time passes, the upset fades and you start to enjoy life again. But sometimes the trauma you experienced is so overwhelming that you find that you can¶t move on. You feel stuck with painful memories that don¶t fade and a constant sense of danger. If you went through a traumatic experience and are having trouble getting back to your regular life, reconnecting to others, and feeling safe again, you may be suffering from post-traumatic stress disorder (PTSD). When you have PTSD, it can seem like you¶ll never get over what happened or feel normal again. But help is available²and you are not alone. If you are willing to seek treatment, reach out to others for support, and work on developing new coping skills, you will be able to overcome the symptoms of PTSD and move on with your life.
What is post-traumatic stress disorder (PTSD)?
Post-traumatic stress disorder (PTSD) is a disorder that can develop following a traumatic event that threatens your safety or makes you feel helpless. Most people associate PTSD with battle±scarred soldiers±and military combat is the most common cause in men±but any overwhelming life experience can trigger PTSD, especially if the event feels unpredictable and uncontrollable. Post-traumatic stress disorder (PTSD) can affect those who personally experience the catastrophe, those who witness it, and those who pick up the pieces afterwards, including emergency workers and law enforcement officers. It can even occur in the friends or family members of those who went through the actual trauma.
PTSD develops differently from person to person. While the symptoms of PTSD most commonly develop in the hours or days following the traumatic event, it can sometimes take weeks, months, or even years before they appear.
Traumatic events that can lead to PTSD include:
The difference between PTSD and a normal response to trauma
The traumatic events that lead to post-traumatic stress disorder are usually so overwhelming and frightening that they would upset anyone. Following a traumatic event, almost everyone experiences at least some of the symptoms of PTSD. When your sense of safety and trust are shattered, it¶s normal to feel crazy, disconnected, or numb. It¶s very common to have bad dreams, feel fearful or numb, and find it difficult to stop thinking about what happened. These are normal reactions to abnormal events. For most people, however, these symptoms are short-lived. They may last for several days or even weeks, but they gradually lift. But if you have post-traumatic stress disorder (PTSD), the symptoms don¶t decrease. You don¶t feel a little better each day. In fact, you may start to feel worse.
A normal response to trauma becomes PTSD when you become stuck
After a traumatic experience, the mind and the body are in shock. But as you make sense of what happened and process your emotions, you come out of it. With post-traumatic stress disorder (PTSD), however, you remain in psychological shock. Your memory of what happened and your feelings about it are disconnected. In order to move on, it¶s important to face and feel your memories and emotions.
Signs and symptoms of post-traumatic stress disorder (PTSD)
The symptoms of post-traumatic stress disorder (PTSD) can arise suddenly, gradually, or come and go over time. Sometimes symptoms appear seemingly out of the blue. At other times, they are triggered by something that reminds you of the original traumatic event, such as a noise, an image, certain words, or a smell. While everyone experiences PTSD differently, there are three main types of symptoms: 1. Re-experiencing the traumatic event 2. Avoiding reminders of the trauma 3. Increased anxiety and emotional arousal
Symptoms of PTSD: Re-experiencing the traumatic event
Intrusive, upsetting memories of the event Flashbacks (acting or feeling like the event is happening again) Nightmares (either of the event or of other frightening things) Feelings of intense distress when reminded of the trauma
War Natural disasters Car or plane crashes Terrorist attacks Sudden death of a loved one
Rape idnapping Assault Sexual or physical abuse Childhood neglect
Intense physical reactions to reminders of the event (e.g. pounding heart, rapid breathing, nausea, muscle tension, sweating)
Symptoms of PTSD: Avoidance and numbing
Avoiding activities, places, thoughts, or feelings that remind you of the trauma Inability to remember important aspects of the trauma Loss of interest in activities and life in general Feeling detached from others and emotionally numb Sense of a limited future (you don¶t expect to live a normal life span, get married, have a career)
Symptoms of PTSD: Increased anxiety and emotional arousal
Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance (on constant ³red alert´) Feeling jumpy and easily startled
Other common symptoms of post-traumatic stress disorder
Anger and irritability Guilt, shame, or self-blame Substance abuse Feelings of mistrust and betrayal
Depression and hopelessness Suicidal thoughts and feelings Feeling alienated and alone Physical aches and pains
Symptoms of PTSD in children and adolescents
In children²especially those who are very young²the symptoms of PTSD can be different than the symptoms in adults. Symptoms in children include:
Fear of being separated from parent Losing previously-acquired skills (such as toilet training) Sleep problems and nightmares without recognizable content Somber, compulsive play in which themes or aspects of the trauma are repeated New phobias and anxieties that seem unrelated to the trauma (such as a fear of monsters). Acting out the trauma through play, stories, or drawings. Aches and pains with no apparent cause Irritability and aggression
Post-traumatic stress disorder (PTSD) causes and risk factors
While it¶s impossible to predict who will develop PTSD in response to trauma, there are certain risk factors that increase your vulnerability. Many risk factors revolve around the nature of the traumatic event itself. Traumatic events are more likely to cause PTSD when they involve a severe threat to your life or personal safety: the more extreme and prolonged the threat, the greater the risk of developing PTSD in response. Intentional, human-inflicted harm²such as rape, assault, and torture² also tends to be more traumatic than ³acts of God´ or more impersonal accidents and disasters. The extent to which the traumatic event was unexpected, uncontrollable, and inescapable also plays a role.
Other risk factors for PTSD include:
Previous traumatic experiences, especially in early life
History of depression, anxiety, or another mental illness
Family history of PTSD or depression History of physical or sexual abuse History of substance abuse
High level of stress in everyday life Lack of support after the trauma Lack of coping skills
etting help for post-traumatic stress disorder (PTSD)
If you suspect that you or a loved one has post-traumatic stress disorder (PTSD), it¶s important to seek help right away. The sooner PTSD is confronted, the easier it is to overcome. If you¶re reluctant to seek help, keep in mind that PTSD is not a sign of weakness, and the only way to overcome it is to confront what happened to you and learn to accept it as a part of your past. This process is much easier with the guidance and support of an experienced therapist or doctor. It¶s only natural to want to avoid painful memories and feelings. But if you try to numb yourself and push your memories away, post-traumatic stress disorder (PTSD) will only get worse. You can¶t escape your emotions completely ± they emerge under stress or whenever you let down your guard ± and trying to do so is exhausting. The avoidance will ultimately harm your relationships, your ability to function, and the quality of your life.
Why Should I Seek Help for PTSD?
Early treatment is better. Symptoms of PTSD may get worse. Dealing with them now might help stop them from getting worse in the future. Finding out more about what treatments work, where to look for help, and what kind of questions to ask can make it easier to get help and lead to better outcomes. PTSD symptoms can change family life. PTSD symptoms can get in the way of your family life. You may find that you pull away from loved ones, are not able to get along with people, or that you are angry or even violent. Getting help for your PTSD can help improve your family life. PTSD can be related to other health problems. PTSD symptoms can worsen physical health problems. For example, a few studies have shown a relationship between PTSD and heart trouble. By getting help for your PTSD you could also improve your physical health.
Source: National Center for PTSD
Treatment for post-traumatic stress disorder (PTSD)
Treatment for PTSD relieves symptoms by helping you deal with the trauma you¶ve experienced. Rather than avoiding the trauma and any reminder of it, you¶ll be encouraged in treatment to recall and process the emotions and sensations you felt during the original event. In addition to offering an outlet for emotions you¶ve been bottling up, treatment for PTSD will also help restore your sense of control and reduce the powerful hold the memory of the trauma has on your life. In treatment for PTSD, you¶ll:
Explore your thoughts and feelings about the trauma Work through feelings of guilt, self-blame, and mistrust Learn how to cope with and control intrusive memories Address problems PTSD has caused in your life and relationships
Types of treatments for post-traumatic stress disorder (PTSD)
Trauma-focused cognitive-behavioral therapy. Cognitive-behavioral therapy for PTSD and trauma involves carefully and gradually ³exposing´ yourself to thoughts, feelings, and situations that remind you of the trauma. Therapy also involves identifying upsetting thoughts about the traumatic event±particularly thoughts that are distorted and irrational²and replacing them with more balanced picture.
Family therapy. Since PTSD affects both you and those close to you, family therapy can be especially productive. Family therapy can help your loved ones understand what you¶re going through. It can also help everyone in the family communicate better and work through relationship problems. Medication. Medication is sometimes prescribed to people with PTSD to relieve secondary symptoms of depression or anxiety. Antidepressants such as Prozac and Zoloft are the medications most commonly used for PTSD. While antidepressants may help you feel less sad, worried, or on edge, they do not treat the causes of PTSD. EMDR (Eye Movement Desensitization and Reprocessing). EMDR incorporates elements of cognitive-behavioral therapy with eye movements or other forms of rhythmic, left-right stimulation, such as hand taps or sounds. Eye movements and other bilateral forms of stimulation are thought to work by ³unfreezing´ the brain¶s information processing system, which is interrupted in times of extreme stress, leaving only frozen emotional fragments which retain their original intensity. Once EMDR frees these fragments of the trauma, they can be integrated into a cohesive memory and processed.
Helping a loved one with PTSD
Be patient and understanding. Getting better takes time, even when a person is committed to treatment for PTSD. Be patient with the pace of recovery and offer a sympathetic ear. A person with PTSD may need to talk about the traumatic event over and over again. This is part of the healing process, so avoid the temptation to tell your loved one to stop rehashing the past and move on. Try to anticipate and prepare for PTSD triggers. Common triggers include anniversary dates; people or places associated with the trauma; and certain sights, sounds, or smells. If you are aware of what triggers may cause an upsetting reaction, you¶ll be in a better position to offer your support and help your loved one calm down. Don¶t take the symptoms of PTSD personally. Common symptoms of post-traumatic stress disorder (PTSD) include emotional numbness, anger, and withdrawal. If your loved one seems distant, irritable, or closed off, remember that this may not have anything to do with you or your relationship. Don¶t pressure your loved one into talking. It is very difficult for people with PTSD to talk about their traumatic experiences. For some, it can even make things worse. Never try to force your loved one to open up. Let the person know, however, that you¶re there when and if he or she wants to talk.
Posttraumatic Stress Disorder (PTSD)
SYMPTOMS
Post-Traumatic Stress Disorder (PTSD) is a debilitating condition that follows a terrifying event. Often, people with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. PTSD, once referred to as shell shock or battle fatigue, was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. These include kidnapping, serious accidents such as car or train wrecks, natural disasters such as floods or earthquakes, violent attacks such as a mugging, rape, or torture, or being held captive. The event that triggers it may be something that threatened the person's life or the life of someone close to him or her. Or it could be something witnessed, such as mass destruction after a plane crash. Whatever the source of the problem, some people with PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They may also experience sleep problems, depression, feeling detached or numb, or being easily startled.
They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Seeing things that remind them of the incident may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the event are often very difficult. PTSD can occur at any age, including childhood. The disorder can be accompanied by depression, substance abuse, or anxiety. Symptoms may be mild or severe--people may become easily irritated or have violent outbursts. In severe cases they may have trouble working or socializing. In general, the symptoms seem to be worse if the event that triggered them was initiated by a person--such as a rape, as opposed to a flood. Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A flashback may make the person lose touch with reality and reenact the event for a period of seconds or hours or, very rarely, days. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, usually believes that the traumatic event is happening all over again. Not every traumatized person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month. In those who do have PTSD, symptoms usually begin within 3 months of the trauma, and the course of the illness varies. Some people recover within 6 months, others have symptoms that last much longer. In some cases, the condition may be chronic. Occasionally, the illness doesn't show up until years after the traumatic event.
Specific Symptoms of PTSD:
The person has been exposed to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person's response involved intense fear, helplessness, or horror. The traumatic event is persistently reexperienced in one or more of the following ways: y y y Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Recurrent distressing dreams of the event. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
y y
The individual also has persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more of the following:
y y y y y y y
Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma Significantly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect (e.g., unable to have loving feelings) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2 or more of the following: y y y y y Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response
The disturbance, which has lasted for at least a month, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Definition
Post-Traumatic Stress Disorder (PTSD) is classified as acute, chronic, and with delayed onset. For pension purposes, acute PTSD, i.e. when duration of symptoms is less than 3 months, will not be pensioned. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) has defined PTSD as a psychiatric condition if it meets the following 6 criteria: A. The person has been exposed to a traumatic event in which: i. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and ii. The person's response involved intense fear, helplessness, or horror; and B. The traumatic event is persistently re-experienced in one or more of the following ways: i. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions; ii. Recurrent distressing dreams of the event; iii. Acting or feeling as if the traumatic event were recurring (including a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awaking or when intoxicated);
C.
D.
E. F.
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; v. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; and Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before trauma), as indicated by three or more of the following: i. Efforts to avoid thoughts, feelings, or conversations associated with the trauma; ii. Efforts to avoid activities, places, or people that arouse recollections of the trauma; iii. Inability to recall an important aspect of the trauma; iv. Markedly diminished interest or participation in significant activities; v. Feeling of detachment or estrangement from others; vi. Restricted range of affect (e.g. unable to have loving feelings); vii. Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span); and Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following: i. Difficulty falling or staying asleep; ii. Irritability or outbursts of anger; iii. Difficulty concentrating; iv. Hypervigilance; v. Exaggerated startle response; and Duration of the disturbance (indicated by the relevant symptoms set out in paragraphs (b), (c) and (d)) is more than one month; and The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
iv.
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Diagnostic Standard
A diagnosis from a qualified medical practitioner or a psychiatrist or a registered/licensed psychologist is required. The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible and should satisfy the requirements for diagnosis as outlined in the DSM-IV diagnostic criteria. Back to Top
Anatomy and Physiology
PTSD is a condition that can develop as a result of an individual's exposure to an extremely traumatic stressor, especially if the individual response involves intense fear, helplessness, or horror. The disorder may be particularly severe or long-lasting when the stressor is of human design (e.g. torture, rape), and trust is lost. Trauma may be personal trauma or witnessed trauma, examples of which are as follows: y The direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or
y
Witnessing an event that involves death, injury or threat to the physical integrity of another person.
Such personal trauma events include, but are not limited to: y y y y y y y y y y Military combat violent personal assault (sexual assault, physical attack, robbery, mugging) being kidnapped being taken hostage a terrorist attack torture incarceration as a prisoner of war or in a concentration camp being required to exhume a dead body or body parts natural or man-made disasters severe automobile accidents, of a nature which meets the above-noted criteria or equivalent
Witnessed events include, but are not limited to: y y y y y observing serious injury or unnatural death of another person due to violent assault accident war disaster unexpectedly witnessing a dead body or body parts
Studies indicate that the prevalence of PTSD for at risk populations (e.g. Vietnam veterans, rape victims, Rwandan peacekeepers, and Armenian children after an earthquake) ranges from 14 - 75%. It is considered that the wide range of prevalence rates reflects the variety of measurement criteria used to diagnose PTSD. Epidemiological studies show that PTSD often remains chronic, with a significant number of persons remaining symptomatic several years after the event. The disorder cannot exist unless the individual has been exposed to a traumatic stressor with a particular set of properties. While trauma is a necessary factor, few would consider it to be sufficient to cause PTSD. The relative importance of the traumatic event, predisposing factors, and environmental factors shortly before or after the trauma must all be considered in understanding the etiology of PTSD. In most instances, occurrence of the disorder represents the outcome of an interaction amongst these three groups of factors. Predisposing factors include the identification of genetic vulnerability to the development of PTSD. Because of different reactions to the same traumatic event, it cannot be said that psychological models alone fully account for the development of PTSD. Other than genetics, premorbid vulnerability factors include a prior history of psychiatric disorder, a family history of psychiatric disorder, a pre-existing personality disorder or traits, poor peer and social support, and a prior history of trauma. Normal adaptive mechanisms for processing life experiences may eventually become overwhelmed by psychological trauma, if the trauma is sufficiently severe. There are 3 psychological theories of PTSD, which are briefly described as follows:
1. Psychodynamic Theory y When faced with an overwhelming traumatic experience, the mind mobilizes defences in order to survive. In order to make sense of the trauma, the survivor develops intrusive and avoidance symptoms, and through the use of repetition and compulsion attempts to master the memories. This is adaptive in Adjustment Disorder and Acute Stress Disorder, but in PTSD the process is overwhelmed and symptoms persists. 2. Cognitive/Behavioural Theory y Fears associated with PTSD develop through classical conditioning, i.e. an unconditioned stimulus produces an unconditioned response which becomes associated with a conditioned stimulus. For example, a person is robbed in an elevator by a man in a yellow raincoat. The robbery (unconditioned stimulus) produces fear (unconditioned response), and the sight of a yellow raincoat (conditioned stimulus) becomes associated with the same fear. These new, classically-condition fears are maintained through operant conditioning. Escape or avoidance behaviours are reinforced by their anxiety-relieving effects. Over time, increasing numbers and types of stimuli may become elicitors of anxiety, and symptoms of PTSD are maintained. 3. Cognitive Network Theory y Original traumatic events conflict with prior beliefs. For example, a person who grows up to believe that women and children are to be protected may find this principle challenged when placed in a combat situation. New information that is congruent with prior beliefs about self or the world is assimilated quickly and without effort because the information matches current schemas. When schema-discrepant effects occur, as in trauma, individuals must reconcile the effect with their beliefs about themselves and the world. Accordingly, their schemas must be altered or accommodated to incorporate this new information. Because of the strong effect associated with the trauma, this process is often avoided. Thus, rather than accommodating beliefs to incorporate the trauma, victims may distort the trauma to ensure that their beliefs remain in tact. PTSD has been shown to have a number of unique biological features, separate from other mental disorders. These include changes to the hypothalmic-pituitary axis (which regulates the body's response to stress), decreased cortisol levels, and higher glucocorticoid receptor sensitivity. These factors demonstrate that the body's response to traumatic stress in PTSD differs from other mental health disorders. Despite exposure to the same trauma, it is only those who suffer from PTSD who undergo biological changes in response to the trauma. Subsequent stressors may also contribute to biological alterations. Back to Top
Clinical Features
For pension purposes, PTSD is classified as "chronic" or "with delayed onset". Chronic PTSD is used when symptoms last 3 months or longer. PTSD of delayed onset is used when at least 6 months have passed between the traumatic event and onset of symptoms. To make a diagnosis of PTSD for pension purposes, it is required that symptoms last for a minimum period of 3 months and that the disturbance causes an impairment or clinically significant distress.
The characteristic symptoms of PTSD are as follows: y y y y Re-experiencing the traumatic event, Avoidance of stimuli associated with the event, Numbing of general responsiveness, Increased arousal.
i.
Re-experiencing the traumatic event The traumatic event can be re-experienced in a variety of ways. Commonly, the person has recurrent and intrusive recollections of the event or recurrent distressing dreams during which the event is re-experienced. In rare instances there are dissociative states lasting from a few seconds to several hours or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment. There is often intense psychological distress when the person is exposed to a situation that resembles an aspect of the traumatic event or that symbolizes the traumatic event, e.g. an anniversary of the event.
ii.
Avoidance of stimuli There is persistent avoidance of any stimuli associated with the traumatic event or a numbing of general responsiveness that was not present before the trauma. The person commonly makes deliberate efforts to avoid thoughts or feelings about the traumatic event and about activities or situations that arouse recollections of it. This may include psychogenic amnesia for an important aspect of the traumatic event.
iii.
Numbing of general responsiveness Diminished responsiveness to the external world, referred to as "psychic numbing" or "emotional anesthesia", usually begins soon after the traumatic event. A person may complain of feeling detached or estranged from others, that he or she has lost the ability to become interested in previously enjoyed activities, or that the ability to feel emotions of any type, especially those associated with intimacy, tenderness and sexuality, is markedly decreased.
iv.
Increased arousal At least one of the five of the following symptoms not present before the trauma is required: i. Difficulty falling or staying asleep (recurrent nightmares during which the traumatic event is relived are sometimes accompanied by middle or terminal sleep disturbance) Irritability or anger Poor concentration Hyper-vigilance Exaggerated startle response
ii. iii. iv. v.
Some persons complain of difficulty in concentrating or in completing tasks. Many report increased aggression. In mild cases, this may take the form of irritability with fear of losing control. In more severe forms, particularly in cases in which the survivor has actually committed acts of violence (as in war veterans), the fear is conscious and pervasive and the reduced capacity for expressing angry feelings may lead to unpredictable explosions of aggressive behaviour. Avoidance of stimuli, numbing of general responsiveness, and hyperarousal symptoms must occur after the exposure to trauma if they are to be valid diagnostic symptoms. This can be a difficult judgment to make in cases in which PTSD has arisen from an ill-defined set of early childhood traumas or even a clearly defined event some 20 or 30 years earlier. A detailed summary of symptoms and manifestations of PTSD includes the following: Cognitive Symptoms anticipation of misfortune distrust of others inattentiveness intrusive memories memory impairment self-criticism trouble concentrating worry Behavioral and Physiologic Symptoms angry outbursts compulsive, repetitive acts diarrhea faintness headaches hyper alertness hyperventilation impatience insomnia nausea numbness nightmares palpitations withdrawal The long term course of PTSD is variable. Recovery varies from permanent recovery to no resolution of symptoms and deterioration with age. There may exist a relatively unchanging course with only mild fluctuations, or obvious fluctuations with intermittent periods of wellbeing and recurrences of major symptoms. The startle response, nightmares, irritability, and depression have been noted to increase with time in many persons. These symptoms often represent a poor prognostic sign. Affective Symptoms anger crying emotionally reliving the trauma guilt irritability loss of control low self-esteem sadness Identity Changes alienation from self, others work discontinuity from the past feelings of inadequacy or unworthiness sense of foreshortened future sense of pervasive unreality
It is important to remember that there are diseases other than PTSD which can result from trauma, e.g. mood disorders, other anxiety disorders, dissociative disorders, eating disorders, and substance abuse. It should also be noted that PTSD is unlikely to occur alone. Psychiatric comorbidity is the rule rather than the exception, and a number of studies have demonstrated that in both clinical and epidemiological populations a wide range of disorders is likely to occur. These include some depression disorders, all of the anxiety disorders, alcohol and substance abuse disorders, somatization disorders, schizophrenia and schizophreniform disorder. Schizophrenia and schizophreniform disorders are not commonly observed in the military, having been screened out early in an individual's military career. It should also be noted that PTSD may overlap with impulse control disorders in view of the anger, irritable outbursts and periodical recourse to violence that occur in PTSD. Back to Top
Pension Considerations
A. Causes and / or aggravation B. Medical conditions which are to be included in Entitlement / Assessment C. Common medical conditions which may result in whole or in part from PostTraumatic Stress Disorder and / or its treatment
A. Causes and/or Aggravation
The timelines cited below are not binding. each case should be adjudicated on the evidence provided and its own merits. 1. Exposure to a traumatic stressor prior to clinical onset or aggravation PTSD need not have its onset during combat. For example, vehicular or airplane crashes, large fires, floods, earthquakes, and other disasters could evoke significant distress in most involved persons. Trauma may be experienced alone (e.g. rape or assault), or in the company of groups of persons (e.g. military combat). A stressor should not be limited to one episode. A group of experiences may lead to PTSD. In some circumstances, for example, assignment to a grave registration unit/burn care unit, or liberation/internment camps could have the cumulative effect of powerful, distressing experiences essential to a diagnosis of PTSD. PTSD can be caused by events which occur before, during, or after service. The relationship between stressors during service and current problems/symptoms will govern the question of service- connection.
PTSD can occur hours, months, or years after a service-related stressor. Despite this long latent period, service-connected PTSD may be recognizable by a relevant association between the stressor and the current presentation of symptoms. 2. Inability to obtain appropriate clinical management B. Medical Conditions Which are to be Included in Entitlement/Assessment y Anxiety disorders y Mood disorders y Schizophrenia and other psychotic disorders y Adjustment disorders y Personality disorders y Eating disorders y Substance-related disorders y Dissociative disorders y Pain disorders/chronic pain syndromes
Common Medical Conditions Which may Result in Whole or in Part From Post-Traumatic Stress Disorder and/or its Treatment y Sexual dysfunction (e.g. erectile dysfunction) y Irritable bowel syndrome
