Post-Traumatic Stress Disorder as an Incurable Disease and Its Symptoms - Essay Example

Abstract While treating obvious and visible diseases or injury is not without difficulty, treating the invisible injuries are often more difficult. Society views illnesses that are outwardly visible with more acceptance, as one can see a broken arm or a broken leg, but what about the injuries that exist on the inside? Much like the difficulty involved in reading the thoughts of another, acceptance of invisible injuries has been just as challenging. Post traumatic stress disorder, which has been around since the 19th century, perhaps even longer, is a pervasive, destructive, yet invisible illness. While the names have been changed, it still remains an incurable disease. This paper will discuss the history, implications, treatment options, and how post traumatic stress disorder is conceptualized in society. What is PTSD? In April of 1980, a new diagnosis was added to the Diagnostic and Statistical Manual (DSM-III), however, the symptoms have been around since the 19th Century. With more people becoming aware of Post Traumatic Stress Disorder (PTSD), whose victims range from rape survivors to the wave of soldiers returning home from the wars in Iraq and Afghanistan, psychologists are unfortunately becoming more familiar with the disorder. However, clinicians are facing a difficult terrain, namely PTSD patients who self-medicate with drugs and/or alcohol. According to the present Diagnostic and Statistical Manual (DSM-IV), the diagnostic criteria for PTSD includes an exposure to a traumatic event and symptoms from each of three symptom clusters: Criterion B: intrusive recollections; Criterion C: avoidant/numbing symptoms; and Criterion D: hyperarousal. For the traumatic event to be directly linked as a causal factor to the development of PTSD (Criterion A), the person has to have either experienced it directly, witnessed it, or been threatened. Additionally, the person’s response has to have evoked an intense fear, helplessness, or horror. There are two other criteria to be considered when evaluating the diagnosis of PTSD, which include duration (Criterion E) of more than one month; and Criterion F: functional significance (APA, 2000). The International Statistical Classification of Diseases and Related Health Problems (ICD-10) has a similar diagnosis of post traumatic stress disorder under code number F43.1. Namely, the symptoms arise as a response to a stressful event or situation, which can either be brief or involve long-term exposure, of an exceptionally threatening nature. Some of the key differences between the DSM diagnosis of PTSD and that of the ICD include the ICD specifies that the situation would likely cause pervasive distress in a member of the general population, and that a probable diagnosis of PTSD should not be made if there is evidence the symptoms did not arise within 6 months of the traumatic exposure (ICD-10, 1992). So, now that we are aware of the differences and diagnostic criteria, how long has it been around? A brief history of PTSD Having been referred to by over 80 different names, the history is a bit challenging to track down. Over the years some of the names it has gone by include Nostalgia, Homesickness, Estar Roto (which means “to be broken” in Spanish), Soldier’s Heart, Neurasthenia/Hysteria (during the Victorian era), Compensation Sickness, Railway Spine (during the boom of the railway era, where horrific injuries were commonplace), Shell Shock (during WWI), Combat Exhaustion (during WWII and the Korean War), and Stress Syndrome, when it was finally introduced to the DSM in 1952. According to Gordon Holmes, one of the more influential members involved in diagnosing PTSD during the early 1900s, close to 15% of soldiers in the British Expeditionary Force suffered from ‘nervous and mental shock’ symptoms (Macleod, 2004). It was observed by Holmes that the incidence of what was then termed shell shock (present day PTSD), nearly crippled the British Army during the Battle of Somme in 1916, accounting for over 40%, or 24,000 soldiers. Common difficulties of diagnosis and treatment The prevalence of comorbidity is evident when considering that among individuals who are in inpatient substance abuse rehabilitation centers, roughly half of the patients also meet the criteria for PTSD (Brown & Ouimette, 1999). Such comorbidity makes diagnosis more difficult for the clinicians, since this is often a vicious cycle, consisting of racing thoughts and substance abuse to dull the feelings associated with the trauma, which can bring with it dangerous lifestyle choices (Cramer, 2002). As if experiencing the psychological effects of PTSD are not tough enough, from nightmares and flashbacks, to avoidant and hypervigilant behavior, another symptom has arose, namely impaired cognitive functioning. In a study consisting of over 2,000 United States Vietnam military veterans, those with both PTSD and a concurrent diagnosis of major depression, generalized anxiety disorder, alcohol dependence, or drug abuse were shown to have more cognitive impairment when compared with those who did not have an additional diagnosis (Barret, Green, Morris, Giles, & Croft, 1996). Those with dual diagnoses performed consistently was on immediate and delay recall. This may be due in part to the comorbid diagnosis having a synergistic effect on the cognitive functioning areas of the brain. It appears that the additional psychological stress associated with PTSD may be associated with memory recall in such individuals. Alcohol is the most common drug of choice among those diagnosed with both PTSD and a substance abuse disorder (Souza & Spates, 2008). Alcohol is a depressant, and when combined with the cluster of symptoms associated with PTSD, the effects can wreak havoc not only in the life of the patient, but those around the individual as well. The prevalence of depression in those who have been diagnosed with PTSD has been estimated to be as high as 53% (Holtzheimer, Russo, Zatzick, Bundy, & Roy-Byrne, 2005) when compared to the general population without the disorder. Individuals with PTSD are also roughly six times more likely to attempt suicide than those without the disorder (Kessler, McGonagle, & Zhao, 1994). Treatment options for comorbidity Often, patients who turn to alcohol and/or drugs, do so in hopes of escape from the terror that lives inside their own mind. As the patients experience rising anxiety levels, they reach for what makes them numb, making life more manageable. As the effects wear off, the patient again experiences anxiety, setting the vicious cycle into motion again (Coffey, Schumacher, Brimo, & Brady, 2005). Getting them to quit what once brought them comfort can be compared to taking the security blanket away from a child; both will be met with firm resistance. In a recent study, those who received treatment not only for PTSD, but substance abuse as well (when substance abuse disorders were present), were almost four times as likely to be clean 5-years later than those who received only treatment for PTSD (Ouimette, Moos, & Finey, 2003). Research into the field has shined a light on the importance of treating the comorbid diagnosis of PTSD and substance abuse, which has led to numerous treatment regimes, some being quite successful. One such treatment focuses on a probable cause of the perpetuation of the drug abuse cycle. Acceptance and Commitment Therapy (ACT), aims to address experiential avoidance, in which a person wishes to not experience a negative event and takes actions to reduce and/or numb the experiencing of said event, regardless of the possible negative consequences associated with their actions (Batten & Hayes, 2005). ACT works in a holistic fashion, focusing on the reduction of such avoidance, acceptance of the past events, and behavior change. The program seems like one of the most promising on the horizon for the treatment of PTSD and substance abuse, however, a long-term commitment, averaging over a year, is needed to achieve the desired outcome, which can be taxing not only on the patient, but on the provider as well. Substance abuse disorders Substance abuse disorders are pervasive, costly, life-altering, and without appropriate treatment, often lethal. The term substance abuse can be used to encompass a plethora of drugs, spanning from alcohol and cocaine, to marijuana and methamphetamines. Substance abuse can also cover everyday substances as well, including nicotine and over-the counter medications. According to a 2009 survey, of the 187,000 individuals incarcerated in the state prison system of the United States, over 50% (95,200) were serving time for drug-related offenses (West, Sabol, & Greenman, 2010), with prison terms averaging 15 months. The statistic demonstrates that substance abuse disorders not only affect the individual, but also their families and society as a whole. Substance abuse, addiction, and common complications According to the Diagnostic and Statistical Manual (DSM-IV-TR), substance abuse (and dependence) can be classified as meeting three of the following seven criteria over a 12-month period: Tolerance, as defined either by the need for increasing amounts of the substance to obtain the desired effect or by experiencing less effect with extended use of the same amount of the substance, Withdrawal, as exhibited either by experiencing unpleasant mental, physiological, and emotional changes when drug-taking ceases or by using the substance as a way to relieve or prevent withdrawal symptoms, Longer duration of taking a substance or use in greater quantities than was originally intended, Persistent desire or repeated unsuccessful efforts to stop or lessen substance abuse, A relatively large amount of time spent in securing and using the substance, or in recovering from the effects of the substance, Important work and social activities reduced because of the substance use, and/or Continued substance use despite negative physical and psychological effects of use. As indicated by the above criteria, substance abuse has the ability to touch every aspect of a user’s life. Due to the nature of addiction, many individuals are not able to quit cold-turkey by themselves. Substance abuse and addiction are often associated with disorganized thought processes, hallucinations, and unstable behavior. Substance abuse is often presented with an accompanying mental health disorder, the most common of which is an Axis I diagnosis of depression (Grant, 1995). The comorbidity may complicate treatment and influence which therapeutic options area taken, Addiction is more than the mere intake of a substance, but rather it encompasses the ritual involved in the seeking out, finding, and indulging in the substance. Fortunately, there have been great improvements in the therapeutic approaches used to treat substance abuse disorders. From the informal 12-step programs, to more traditional psychotherapeutic approaches, the field of substance abuse disorder research continues to grow. Therapeutic treatment approaches There are many different approaches when it comes to substance abuse treatment, ranging from drug replacement therapies (i.e., methadone and nicotine patches) two intense psychotherapeutic methods. While each treatment has their strengths, they also have their weaknesses and limitations. Some critics of drug replacement therapies wonder if replacing one drug with another is effective or ethical. Some have suggested that the medications that are used as replacements in cocaine addiction have an abuse potential since they activate the same reward pleasures in the brain (Rothman, Blough, & Baumann, 2007). Psychotherapeutic methods also have their shortcomings, including the importance of considering personality and cognitive characteristics of the client. Since it is unethical to treat every individual the same, there are several therapies to consider regarding substance abuse disorders. Cognitive-Behavior Therapy (CBT) The premise behind cognitive behavior therapy (CBT) is that the combination of both cognitive and behavioral principles in a time-limited setting would be effective at introducing and applying new tools that could be beneficial to a client. Studies have incorporated the methods of CBT into substance abuse treatments, to mixed reviews. The effectiveness of integrated CBT was examined in participants who had been diagnosed with both a substance abuse disorder as well as a depressive disorder (Brown et al., 2006). Previous studies have indicated that the comorbidity of depression and substance abuse usually results in poorer treatment outcomes. In order to effectively treat both conditions, Brown et al. (2006) implemented an integrated cognitive behavioral therapy (ICBT) that consisted of two phases over the course of 24 60-minute sessions that were held twice per week, in addition to weekly group sessions. The first phase covered acute treatment for current thoughts, activities, and people that could be triggers for the participant. Homework was assigned in the first phase as a means of providing feedback and insight into how the participants were able to put these new skills to the test in real-life situations. The second phase, lasting 12 sessions, covered relapse prevention techniques that pertained to the triggers that were identified in the previous phase of treatment. The ICBT combined two different interventions that have shown to be effective in studies conducted in the past; Cognitive-Behavioral Depression Treatment and Cognitive-Behavioral Coping Skills Training. The latter program was developed for Project MATCH, which was designed around the theory of matching individuals based on their personal characteristics, two approaches. According to the study, a comorbid diagnosis with ICBT is promising; participants were able to maintain improvement in both substance abuse and depression episodes six months after the termination of treatment. Researchers have suggested that the positive outcome may be due to the participants being able to draw upon the skills they learned during the first phase of treatment. Twelve-Step Facilitation Therapy (TSF) Researchers in the aforementioned ICBT study also compared an augmented form of a traditional 12-step substance abuse program, which consisted of two phases conducted over 24 60-minute sessions, as in the ICBT condition. However, the phases focused on quite different topics, namely, acceptance and surrender. Participants in the group were also encouraged to attend community 12-step meetings (i.e., AA, NA, and CA). Phase two consisted of aftercare and relapse prevention topics. During the course of therapy, both the ICBT and the TSF conditions indicated similar decreases in depressive symptoms, however, the follow-up results of the TSF condition were not as positive when compared to the ICBT treatment group; those who received the TSF treatment demonstrated a gradual increase in both depressive symptoms as well as substance use six months after the end of treatment. Researchers have debated the reasons behind the increase in substance use that were found in the TSF condition. The differences may not be due to the programs, but rather individual differences in the social skills of the participants. Due to the need for social interaction involved in TSF, it would not be a good therapeutic method for individuals who are experiencing depressive symptoms (i.e., poor eye contact, flat affect). Still, other possible explanations for the less than positive outcome from TSF could be a result of the skills which were incorporated into one of the ICBT conditions, which included identifying and changing dysfunctional cognitions, and incorporating role-play techniques for high-risk relapse situations. Acceptance and Commitment Therapy (ACT) A more recent addition to substance abuse treatment is acceptance and commitment therapy (ACT), which emphasizes an observation of the thinking process rather than trying to change the content, reducing the experience of avoidance through distress coping and acceptance skills. By recognizing and acknowledging negative cognitions as they arise, as opposed to trying to change them, a greater level of acceptance and being open to the reality of being “in the moment” will arise (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). The six core processes behind the ACT principle include: acceptance, cognitive defusion, being present, self as context, values, and committed action. The application of ACT to methamphetamine addiction was tested by Smout et al. (2010) over the course of 12 sessions. The sessions covered topics which included values clarification, acceptance and diffusion exercises, and an examination of how the actions of the participants, namely their use of methamphetamines, interfered with their daily life activities. The results indicated that ACT produces similar outcomes when compared to more traditional CBT treatments. In a separate study, ACT was implemented in an alcohol dependence relapse prevention program (Vieten, Astin, Buscemi, & Galloway, 2010). Working on the principle that negative affect is often cited as the most common reason for relapse among adults and adolescents, the treatment focused on improving the mindfulness and strengthening of coping skills, which would theoretically lead to lower relapse rates. Treatment consisted of eight weekly group sessions, where the central focus included an introduction to mindfulness; learning how to observe and accept internal experiences without trying to change or judge them; developing a willingness to experience rather than avoid distressing states; and cultivating the ability to recognize that thoughts are not always an accurate representation of reality. As with the previous study conducted by Smout et al., the results indicated that ACT is as effective as the more traditional CBT methods. How society views mental illness Just like schizophrenia, depression, and anxiety, substance use disorders and PTSD are categorized as mental illnesses and need to be treated as such. Sadly, just like with other mental illnesses and disorders, there is a large, negative stigma associated with even being suspected of having a mental illness. Researchers have examined the scientific reasoning behind the existence of stigma, despite a wealth of disproving facts. One such conceptualization was developed by Jones et al. (1984), which identifies six dimensions of stigma. These include concealability (which is high in the case of many mental illnesses); course (reversible over time); disruptiveness (the level which the illness interferes with daily interactions), aesthetics (the level of potential disgust society may have), and origin (how it came to being). Society has often shared their thoughts about mental illness, choosing to believe the unfounded stigma, rather than the science-based theories and results that have come about from thorough research. This very stigma often drives those experiencing distress, away from seeking help, for fear of being labeled as dangerous or insane, when the reality is that they just are in need of help. There are many different treatment options available, but if the pervasive stigma proceeds to exist and thrive, then the individuals who could benefit the most, will be missing out, and so will society as a whole. Therapeutic limitations and future directions As with most psychotherapeutic interventions, there are some limitations to keep in mind when considering an appropriate method. In ACT and CBT, it is imperative to assess the cognitive ability of the client, as clients must have the capacity to think abstractly and to identify and assess their own cognitions. As mentioned previously, impaired cognition has been associated with both PTSD and substance abuse disorders, further stressing the importance of effective evaluation methods in place by the counselor or another member of the health care team. The presence of a comorbid diagnoses is also a confounding factor when assessing a client and their needs, as it may be inappropriate to administer ACT to a client who has a dual diagnosis of alcoholism and major depression. As the field of psychotherapy continues to grow, research will uncover more therapeutic applications, which will inevitably contain strengths and weaknesses. Regardless of the therapeutic intervention, it is important to consider the individual characteristics of the client and their motivation to participate in treatment. A more individualized approach to therapy may yield more positive results, as documented in the aforementioned studies. Conclusion While society may hold onto their unfounded stigma associated with the illnesses they cannot see, outreach programs have started to spread the message that there is no shame in seeking help. Perhaps with continued effort, society will drop their ill conceived notions, in favor of a more open view that will not only help them to grow, but allows those seeking treatment to come out from under the veil of judgement. There are many different approaches to treatment, so finding the right one for an individual is important to the outcome of the process. Reference List American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association. Barrett, Green, Morris, Giles, & Croft (1996). Cognitive functioning and post traumatic stress disorder. American Journal of Psychiatry, 153(11), 1492-1494. Batten, & Hayes (2005). Acceptance and commitment therapy in the treatment of comorbid substance abuse and post-traumatic stress disorder: A case study. Clinical Case Studies,4(3), 246-262. Brown, & Ouimette (1999). Introduction to the special section on substance use disorder and post traumatic stress disorder comorbidity. Psychology of Addictive Behavior, 13(2), 75-77. Brown, S., Glasner-Edwards, S., Tate, S., Chalekian, J., & Granholm, E. (2006). Integrated cognitive behavioral therapy versus twelve-step facilitation therapy for substance-dependent adults with depressive disorders. Journal of Psychoactive Drugs, 38(4), 449-460. Coffey, Schumacher, Brimo, & Brady (2005). Exposure therapy for substance abusers with PTSD: Translating research into practice. Behavior Modification, 29, 10-38. Cramer (2002). Under the influence of unconscious process: Countertransference in the treatment of PTSD and substance abuse in women. American Journal of Psychotherapy,56(2), 194-210. Grant, B., & Harford, T. (1995). Comorbidity between DSM-IV alcohol use disorders and major depression: Results of a national survey. Drug and Alcohol Dependence, 39, 197-206. Hayes, S., Luoma, J., Bond, F., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behavior Research and Therapy, 44, 1-25. doi:10.1016/j.brat.2005.06.006 Holtzheimer, Russo, Zatzick, Bundy, & Roy-Byrne (2005). The impact of comorbid posttraumatic stress disorder on short-term clinical outcome in hospitalized patients with depression. American Journal of Psychiatry, 162(5), 970-976. Jones, E. E., Farina, A., Hastorf, A. H., Marcus, H., Miller, D. T., & Scott, R. A. (1984).Social stigma: The psychology of marked relationships. New York: W.H. Freeman. Kessler, McGonagle, & Zhao (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey.Archives of General Psychiatry, 51, 8-19. Ouimette, Moos, & Finney (2003). PTSD treatment and 5-year remission among patients with substance use and post-traumatic stress disorders. Journal of Consulting and Clinical Psychology, 71(2), 410-414. Rothman, R., Blough, B., & Baumann, M. (2007). Dual dopamine/serotonin releasers as potential medications for stimulant and alcohol addictions. The AAPS journal, 9(1), E1-E10. Smout, M., Longo, M., Harrison, S., Minniti, R., Wickes, W., & White, J. (2010). Psychosocial treatment for methamphetamine use disorders: A preliminary randomized controlled trial of cognitive behavior therapy and acceptance and commitment therapy.Substance Abuse, 31, 98-107. doi:10.1080/08897071003641578 Souza, & Spates (2008). Treatment of PTSD and substance abuse comorbidity. The Behavior Analyst Today, 9(1), 11-26. Vieten, C., Astin, J., Buscemi, R., & Galloway, G. (2010). Development of an acceptance-based coping intervention for alcohol dependence relapse prevention. Substance Abuse,31, 108-116. doi:10.1080/08897071003641594 West, H. C., Sabol, W. J., & Greenman, S. J. (2010, December). Prisoners in 2009. Bureau of Justice Statistics (BJS). Retrieved from http://bjs.ojp.usdoj.gov/content/pub/pdf/p09.pdf World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization. Read More