Mankind’s earliest literature tells us that a considerable proportion of military casualties are psychological and that witnessing the horror of war can leave chronic psychological symptoms.
Scientists linked over 60 years the combat trauma and PTSD (Post-Traumatic Stress Disorder) together. Most of the scientists thought that military combat was the primary cause of PTSD.
Post-Traumatic Stress Disorder (PTSD) can develop not only in people directly harmed by trauma but also by those witnessing such events. One of the triggering factors for PTST might be the survivor’s guilt. Also, soldiers who killed the enemy can develop PTSD due to the perpetrator’s trauma.
An important fact is that over the past thirty years, the criteria for PTSD have evolved. Currently, PTSD is linked not only to combat trauma but also to other traumatic events happening in normal life. For example, PTSD can be caused by car accidents, plane crashes, natural disasters, such as earthquakes and hurricanes, being taken hostages, domestic violence, and sexual abuse.
In the article, we provide a comprehensive description of Post-Traumatic Stress Disorder, its symptoms, diagnosis, and treatment options. For more information about treatment for PTSD, contact our specialists at CHMC.
The step preliminary to treatment is an in-depth diagnosis. The main reason for the diagnostic procedure is the exclusion of other psychiatric conditions appearing with symptoms similar to PTSD.
Signs and symptoms of PTSD
People with PTSD experience feelings of panic or extreme fear linked to the trauma. The most common PTSD symptoms are:
- The person relives the traumatic event through intrusive and recurring memories, in particular vivid images and nightmares. Those memories are causing usual intense emotional and physical reactions, such as extreme fears, heart palpitations, sweating, and other somatic symptoms.
- The person is overly alert or wound up, suffering from insomnia, irritability, or lack of concentration.
- The affected individual deliberately avoids activities, places, people, thoughts, or feelings associated with the traumatising event.
- In the chronic stage of the PTSD, other symptoms, such as loss of interest in day-to-day activities, social detachment, and a feeling of numbness, appear.
The individuals affected by PTSD often develop other mental health problems, most commonly depression, anxiety, and alcohol or drug abuse.
PTSD is a natural response to danger and is almost unavoidable in the short term. In the long term, it possesses self-correcting dynamics, reducing in most of the cases the severity of the symptoms. Only about 20 percent of people exposed to trauma react with long-term (chronic) PTSD.
Diagnosis and Classification of PTSD
DSM-V has made a number of important changes to the criteria of post-traumatic stress disorder. While DSM-IV classified PTSD under anxiety disorders, DSM-V created a new category called “Trauma- and stressor-related disorders,” in which PTSD is now classified. The diagnostic category for PTSD provides a psychiatric manual allowing to identify the disorder. However, quantifying the symptoms could not capture the human dimension of the individual’s suffering.
DSM V is the diagnostic manual predominantly used in the USA. The World Health Organisation (WHO) uses a different manual called “International Classification of Diseases,” or in its abbreviation, “ICD.” The current version of this manual is the ICD 10. The ICD-10 classification also provides guidelines for the diagnosis of PTSD. There are only minor differences between DSM V and ICD 10 regarding the PTSD criteria.
DSM V Classification
PTSD can be difficult to diagnose because numerous factors can lead to over-reporting and under-reporting symptoms, dysfunction, and distress. Such statistics manuals as ICD 10 and DSM V provide coherent and standardised diagnostic criteria. In the chapter below, we present the DSM V criteria helpful in identifying PTSD. The DSM-V Diagnostic Criteria of the American Psychiatric Association categorises the general criteria for diagnosing PTSD in adults.
The Role of Exposure in PTSD
A. exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
- Directly experiencing the traumatic event(s).
- Witnessing, in person, the event(s) as it occurred to others.
- Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Criteria for PTSD
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s). The symptoms begin or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
- Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).
- Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
- Intense or prolonged psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).
- Marked physiological reactions to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).
Avoidance
C. Persistent avoidance of stimuli associated with the traumatic event(s). The symptoms begin or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- Avoidance of or efforts to avoid distressing memories, thoughts, or feelings closely associated with the traumatic event(s).
- Avoidance of external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings closely associated with the traumatic event(s).
Negative Alterations
D. Negative alterations in cognitions and mood associated with the traumatic event(s). The symptoms begin or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
- Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
- Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) lead the individual to blame himself or others.
- Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
- Markedly diminished interest or participation in significant activities.
- Feelings of detachment or estrangement from others.
- Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Marked Alterations
E. marked alterations in arousal and reactivity associated with the traumatic event(s). The symptoms begin or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- Irritable behaviour and angry outbursts (with little or no provocation) are typically expressed as verbal or physical aggression toward people or objects.
- Reckless or self-destructive behaviour.
- Hypervigilance.
- Exaggerated startle response.
- Problems with concentration.
- Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
- The duration of the disturbance is more than 1 month.
Disturbances
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
Comorbidities Linked to PTSD
It’s not uncommon for people with PTSD to suffer from other mental illnesses. Such conditions may either develop directly as a result of the traumatic event or appear later, following the PTSD.
The most frequent of the coocurring psychiatric disorders are depression and anxiety, especially when the PTSD has persisted for a long time. Many people attempt to “treat” their symptoms with alcohol or medication, trying to sleep better or block out intrusive thoughts. However, this approach is ineffective—in fact, over time, it only intensifies emotional distress, cognitive disturbances, and finally an addiction.
Treatment for Depression Associated with PTSD
Depression is a common mental health problem. In the industrialised countries, depression (mild, moderate, or severe) affects around one in ten individuals per year. The pre-existing depression adds to the risk of developing PTSD, and in reverse, PTSD can trigger depression in previously healthy individuals. It is a fact that prior to the trauma, people with PTSD are three to five times more likely to suffer from depression. On the other hand, individuals with PTSD are four times more likely to develop depression. PTSD also significantly increases the risk of suicide. The recommended treatment for depression associated with PTSD is the use of antidepressants.
Anxiety Treatment in PTSD
The American Psychiatric Association (APA) in the past classified PTSD as an anxiety disorder. Such association is understandable, as PTSD and anxiety disorders might cause the same symptoms. The common symptoms occurring in PTSD and in the anxiety disorders are fluctuating anxiety, panic attacks, and insomnia. On the other hand, the pre-existing anxiety disorders increase the risk of PTSD after trauma exposure. Also, coexisting anxiety disorders should be treated with medication.
PTSD and Substance Abuse
Mental healthcare providers noted that PTSD and substance abuse often coexist. A summary of several studies has shown that around half of patients suffering from PTSD fulfil the criteria for substance abuse disorders. PTSD and alcohol dependence in traumatised individuals often occur at the same time. The reason for alcohol over drug abuse is because of alcohol’s legal status and its availability.
Diagnosing Post-Traumatic Stress Disorder (PTSD)
The main criterion of PTSD diagnosis is the symptoms persistence for more than four weeks. Additionally, the condition should affect functioning in important areas of life. A chronic PTSD will be diagnosed if the symptoms persist for more than three months.
The first step in the diagnostic procedure is taking the patient’s medical history and identifying the symptoms and possible risk factors. In some cases, standardised questionnaires can be used, enabling a structured interview. It’s crucial that the conversation takes place in a trusting atmosphere so that the patient can open up and overcome any distrust towards the doctor.
The core of the diagnostic process involves carefully identifying the trauma that caused the disorder and its subjective significance to the individual. Each symptom of PTSD is systematically queried and evaluated in its severity. In addition, other mental health conditions occurring with symptoms similar to PTSD must be ruled out.
Risk Factors for PTSD
Risk and protective factors can mutually influence and/or compensate for each other. Some factors, like neurobiological traits, genetic predispositions, childhood, and environmental conditions, may increase the likelihood of developing PTSD.
Factors that promote the development of Posttraumatic Stress Disorder include:
- Lack of social support from family, friends, or colleagues after a traumatic experience.
- Adolescence or older age, female gender.
- Mental illnesses or traumas in one’s own history.
- Mental illnesses or traumas in the family.
- Prolonged duration and severity of the trauma.
Treatment for PTSD with Psychotherapy
Within four weeks after the appearance of the symptoms, the use of medication in the therapy for PTSD is not recommended, except in the more severe cases. The treatment of choice for PTSD is psychotherapy. The most effective psychotherapy methods for PTSD are CBT, EMDR, or trauma-focused psychotherapy. In some cases, especially those resistant to CBT, psychodynamic psychotherapy is indicated.
Raising Trauma Awareness
Trauma patients need to develop an awareness of their suffering, which helps them gradually incorporate the traumatic experience. Reducing the intensity of the underlying tension leads to symptom reduction.
The PTSD symptom reduction or even healing happens through bringing the unconscious feelings to light and making them conscious. In consequence, psychodynamic psychotherapy employs the ego (the conscious part of the psyche) in understanding the cause and its effect.
Our clinic in Dubai offers all below-listed forms of psychotherapeutic treatment for PTSD
Trauma-Focused Psychotherapy
TFP is the most effective evidence-based treatment for PTSD. “Trauma-focused” means that treatment focuses on the memory of the traumatic event and their associations. The three most effective forms of trauma-focused psychotherapy are: Eye Movement Desensitization and Reprocessing (EMDR) followed by two cognitive-behavioural therapy techniques: Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE).
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR is using sounds and hand movements while talking about trauma. This helps the brain process trauma memories. Eye movement desensitisation and reprocessing (EMDR) is a form of psychotherapy developed and studied by Francine Shapiro. This is a technique that uses eye movements to facilitate the emotional processing of memories. EMDR helps the brain deal with flashbacks and “unwind” the destructive effects of traumatic experiences. It changes the person’s memory to attend to more adaptive information.
Cognitive Model of CBT (Cognitive-Behavioral Therapy)
Cognitive-behavioural therapy (CBT) is based on the idea that people internally interpret situations, thoughts, and emotions differently. Such misinterpretation activates protective mechanisms that cause patients to act out through avoidance and social isolation.
CBT used in the treatment of PTSD tries to change the way a trauma victim feels and acts by influencing his patterns of thinking and behaviour. It uncovers the negative emotions, helping the individual to identify thoughts and feelings making him feel afraid.
Examples of CBT in Treatment of PTSD
The cognitive-behavioural therapy for PTSD might use exposure therapy, stress-inoculation training, cognitive processing therapy, behavioural activation, acceptance, and commitment therapy. Many of these therapy methods have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms. Exposure therapy is a type of cognitive behavioural therapy that involves assisting trauma survivors to re-experience distressing trauma-related memories. The goal is to remind and facilitate habituation and successful emotional processing of those memories. Exposure therapy programs include different techniques. One of them is an imaginary confrontation with the traumatic memories. The other is real-life exposure to trauma reminders.
Short-term treatment typical of CBT is often the only option in military settings. This attitude with limited treatment time greatly reduces the chances of recovery.
Prolonged Exposure (PE) in Treatment for PTSD
Prolonged Exposure (PE) therapy involves repetitive talking about the trauma until the memory is no longer a hindrance. This gives the patient more control over his trauma-related thoughts and feelings. It helps to bring the traumatic memories to “the light,” making them conscious and decreasing their destructive effect.
Cognitive Processing Therapy (CPT) in Treatment for PTSD
CPT belongs to cognitive-behavioural therapy techniques described below. Along with EMDR and PE, CPT is the most effective evidence-based psychotherapy for PTSD. CPT focuses on thoughts and emotions caused by the traumatic events. It builds a bridge between bodily sensations and the associated thoughts and feelings. It helps to understand how the trauma changes feelings, thoughts, and behaviour, relieving the person from the vicious circle triggered by the event.
PTSD Treatment with Psychodynamic Psychotherapy
The CBT it’s the most well-researched PTSD treatment method, but it doesn’t help all patients. In some cases, psychodynamic psychotherapy is the more effective method. CBT as therapeutic technique owes its roots to psychoanalytical psychotherapy. The conducted studies show that psychodynamic psychotherapy can have several benefits. It is more effective for the individuals who were the victims of violence. The other group of patients responding well to psychodynamic psychotherapy are the perpetrators.
Methods of In-Depth Therapy in PTSD Treatment
Psychodynamic psychotherapy (counselling) places a large emphasis on the exploration of the unconscious. The main approach of psychodynamic psychotherapy is uncovering and making conscious the hidden upsetting feelings and thoughts. Such suppressed and unconscious content influences the patient’s current behaviour. That’s why the psychodynamic psychotherapy focuses not only on the encapsulated trauma content but also on the current conflicts with roots in the past.
Group Therapy. Treating PTSD with Interpersonal Psychotherapy
Interpersonal Psychotherapy is an effective group therapy treatment for PTSD involving meeting with a group of other people sharing the same or a similar traumatic event. It is easier to talk about traumatic events with other people who have been through a similar experience. An open trial of interpersonal psychotherapy reported high rates of remission from PTSD symptoms without using exposure.
Medication in Treatment for PTSD
The use of medication for PTSD treatment is not the first method of choice. However, PTSD is frequently associated with other psychiatric diagnoses like depression or anxiety. The combination of PTSD with other psychiatric disorders requires a more complex therapy plan, including the use of medication.
In such situations, a combination of psychotherapy and pharmacotherapy in treatment for PTSD can improve the positive therapy outcome.
The use of anti-depressants can be effective, especially in the treatment of severe and/or residual PTSD and/or co-existing psychiatric comorbidities such as depression. In such cases, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are helpful in reducing the intensity of the PTSD symptoms.
Supportive Treatment for PTSD
Traumatised people frequently feel stigmatised and might avoid seeking professional help. They worry about confidentiality breaches or potential professional repercussions if they disclose their psychological distress.
Social Support in PTSD
Among post-traumatic factors, the extent of social support is the most extensively researched factor. Perceived social support appears to influence the strength of the relationship between trauma severity and PTSD symptoms.
Family Support in Treatment for of PTSD
After a traumatic experience, it’s crucial for the affected individual to be supported by their family members. This includes actively listening and taking the other person’s feelings seriously. Especially in cases of suicidal statements, immediate medical assistance should be sought.
Encourage the affected individual to start therapy and be willing to be involved if the therapist deems it helpful. Accept any support offers yourself so you can better assist and stay healthy at the same time.
Complementary Therapy for PTSD
The overall treatment plan often incorporates creative approaches such as music therapy or art therapy, as well as movement therapy and other methods to improve posture and movement patterns (Feldenkrais, Qi Gong, occupational therapy).
Through relaxation techniques (Yoga, autogenic training) or biofeedback, the patient learns to better control their symptoms. If necessary, as part of therapy, the individual receives support for career or social reorientation, grief processing, or relationship issues.
Course of PTSD
The progression of post-traumatic stress disorder (PTSD) varies. Some symptoms may appear during the traumatic event itself or shortly afterward. In some cases, the symptoms surface after a latency period lasting weeks or even months. This delayed onset of symptoms is often observed in soldiers after combat missions.
After the onset of PTSD, the symptoms may subside after a few weeks, while for others, they can persist for many years and even become chronic. Often, phases of milder symptoms alternate with periods of more severe ones.
The prognosis of successful treatment of PTSD has improved in recent years. The long-term prognosis for PTSD is good, and symptoms often disappear or lessen with treatment. Such positive therapeutic effects can be achieved with treatment initiated soon after trauma and with healthy social support. The prognosis is good, especially in high-functioning individuals without pre-traumatic psychiatric disorders. About half of those affected even recover without treatment (spontaneous remission).
Many people manage to overcome and handle the trauma-related memories after a few months. However, for about 30% of those affected, the symptoms persist for at least three years. With appropriate treatment, PTSD typically lasts an average of 3 years, while without therapy, it lasts around twice as long and can get chronic.
Causes of PTSD
The main factor contributing to the onset of PTSD is the sudden appearance of a severe trauma, which breaks the psychic balance of the affected individual. The quick and massive influx of traumatising events exceeds the psychological defence, not allowing to neutralise the harmful feelings. Violent traumatic events such as accidents, abuse, and disasters break through the Ego defence mechanisms. As a result, people store traumatic memories in their raw, unprocessed form.
Despite the formative role of the trauma in triggering the onset of PTSD, there are several other factors modulating the development of the condition. One of the most important factors is the neurobiology of the brain followed by genetic, environmental, and psychosocial factors.
Trauma, the Main Cause in PTSD
PTSD is believed to be caused by the experience of a wide range of traumatic events. PTSD is likely to be triggered if the trauma is extreme and occurs suddenly. In a survey done after the first Gulf War, combat veterans reported that killing an enemy soldier—or even witnessing one getting killed—was more distressing than being wounded oneself. But the very worst experience, by a significant margin, was witnessing a friend dyeing.
Factors Adding to PTSD
Not every person exposed to trauma will develop the symptoms of PTSD. The people more vulnerable to trauma tend to be individuals suffering from pre-existing psychological disorders. According to a study on twins and combat-related PTSD, a twin brother of a person who was not exposed to war trauma but suffers from a psychiatric disorder is more likely to develop PTSD. This is proof that the psychiatric comorbidities increase the risk for PTSD. According to a study published in 1989 in the British Journal of Psychiatry, individuals who were exposed to traumatising events in childhood have a much higher risk for PTSD. On the other hand, people with normal childhood development and without prior exposure to traumatising events can develop PTSD. The probability of developing PTSD correlates to the intensity of the trauma and the time of the exposer.
Persons considered at risk include, for example, combat military personnel, victims of violent crime or natural disasters, concentration camp survivors, and victims of violent crime. Individuals frequently experience “survivor’s guilt” for remaining alive while others died.
Neuroendocrinology
Dysregulation of the stress system, including the hypothalamic-pituitary-adrenal (HPA) axis and the locus caeruleus/norepinephrine-sympathetic nervous system (SNS), is involved in the pathophysiology of PTSD. The HPA axis that coordinates the hormonal response to stress, which activates the LC-noradrenergic system, is implicated in the over-consolidation of memories that occurs in the aftermath of trauma.
During traumatic experiences, the release of high levels of stress hormones suppresses hypothalamic activity. Most people with PTSD show a low secretion of cortisol and high secretion of catecholamines in urine, with a norepinephrine/cortisol ratio consequently higher than comparable non-diagnosed individuals.
Such finding shows the difference between PTSD and the normative fight-or-flight response, in which both catecholamine and cortisol levels are elevated after exposure to a stressor. Brain catecholamine levels are high, and corticotropin-releasing factor (CRF) concentrations are high. Other studies demonstrated in individuals with PTSD an elevated corticotropin-releasing hormone and increased plasma catecholamines. PTSD can be the effect of a maladaptive learning pathway to fear response through a hypersensitive and hyper-responsive HPA axis. Hyperresponsiveness in the norepinephrine system is most probably caused by continued exposure to high stress levels.
Neuroanatomy and PTSD
In the PTSD patients, the brain areas being affected are the prefrontal cortex, amygdala, and hippocampus. The prefrontal cortex is responsible for planning complex cognitive behaviour, decision-making, and moderating social behaviour. PTSD patients have inhibited brain activity in such areas of the prefrontal cortex as the dorsal and rostral anterior cingulate cortices and the ventromedial cortex. These brain areas are involved in the process of experiencing and regulating emotions.
A part of the brain called the amygdala and the hippocampus belong to the limbic system. It’s the limbic system that is involved in forming emotional memories, especially those fear-related ones. The hippocampus plays important roles in the consolidation of information from short-term memory to long-term memory. During high stress, the hippocampus is suppressed, which can explain the later occurrence of flashbacks.
History of PTSD. War and Psychology
The term called today PTSD and its diagnostic criteria changed over the past hundred years. The diagnosis was initially referring to the combat trauma. In the past half century, the diagnosis relates not only to soldiers but also to other individuals struck by a sudden trauma causing the same symptoms initially observed only by the military personnel.
The scientifically documented history of PTSD started during World War I. During the “Great War,” many analysts were confronted with the trauma of “shell shock” in treating traumatised soldiers. During WW I, Sandor Ferenzi worked with traumatised soldiers in Budapest; Max Eitingon and Karl Abraham in Berlin.
Traumatic War Neurosis
At the same time, psychiatrists coined for the combat trauma the term “Traumatic War Neurosis,” following the terminology of Freud’s psychoanalysis. The psychoanalysis became also the first psychotherapy method used for PTSD treatment. Later, more effective therapy methods such as Eye Movement Desensitization and Reprocessing (EMDR), Cognitive Processing Therapy (CPT), and Prolonged Exposure (PE) followed.
During WW II, the combat trauma remained, but it was renamed into the less shocking term “Battle Fatigue.” For a long time, the military establishment neglected the psychological impact of the combat trauma. During WW II, the American general George Patton struck two soldiers, finding them at evacuation hospitals away from the front lines without visible physical injuries.
“Shell Shock” and “War Neurosis”
Firstly, during World War I and between the wars, the combat trauma was called “shell shock” or “war neurosis.” Later, during World War II, the diagnosis was changed to “battle fatigue.”
The trauma of World War II influenced many of the founders of psychodynamic psychology. Paradoxically, contact with war victims, including children, helped develop theoretical foundations and effective treatment methods for PTSD.
Establishing PTSD Diagnosis
After World War II, everyone was hoping that war would never happen again. The research on the war trauma (synonymous to PTSD) stagnated. It started again in the 1960s during the Vietnam War. Since then, the trauma related to war or other severe traumatising events has been called “Post Traumatic Stress Disorder” (PTSD). Along with establishing the diagnosis of PTSD, different therapeutic methods for this condition have also been developed. Until today, the most effective treatment for war trauma is psychotherapy, which has its roots in Freudian psychoanalysis.
Psychoanalysis in Treatment for PTSD
The formative figure in the history of PTSD treatment and research was Sigmund Freud, who developed the first psychotherapeutic treatment method called psychoanalysis. For Freud, the “Great War” was a traumatic experience. He was worrying not only about his three serving sons. The Spanish Flu pandemic struck Freud with tragic results. Sophie, Freud’s beloved daughter, died suddenly from the influenza while pregnant with her third child. In the middle of such devastating events, Freud worked on his paper “Beyond the Pleasure Principle.” The deprivation and losses of the war raised his scepticism about human nature. He realised how thin the layer of civilisation in advanced European societies was.
Freud worked with soldiers returning from World War I. He and other psychoanalysts described the symptoms of combat trauma as war neurosis. Freud treated the traumatised soldiers with his own method, psychoanalysis, at that time the only available psychological treatment.
Freud observed repetitive dreams and memories by the victims of war related to the traumatic experiences. He wrote: “Dreams occurring in traumatic patients have the characteristic of repeatedly bringing the patient back into the situation of his accident.” This phenomenon observed by Freud is one of the diagnostic criteria for today’s PTSD diagnosis.
“Beyond the Pleasure Principle”
The outbreak of shell shock among the soldiers challenged Freud’s thinking. On the one hand, it demonstrated that neurotic symptoms such as stuttering, convulsions, and paralysis are of psychological nature. On the other hand, he challenged the main pilar of Freud’s early psychoanalytic theory, the purely sexual origin of neurosis.
The experience of World War I and his research on the war neurosis modified Freud’s position. Initially, he assumed that the origin of neurosis was purely of sexual nature. In 1920, in his book “Beyond the Pleasure Principle,” he added the existence of the “death instinct,” called also “‘Thanatos,”‘opposite to the “life instinct” or “Eros.” At first, Freud was sceptical about the existence of the “death instinct.” The first concept assuming the existence of the “death instinct” was already published in 1912. A Russian psychoanalyst and Freud’s collaborator Sabina Spielrein emphasised in her paper “” the importance of the destructive tendencies in human psyche. By a paradoxical coincidence, Spielrein and her two daughters became later victims of WW II.
Freud’s Change of Paradigm
In his book “Beyond the Pleasure Principle,” Freud put forward the concept of the “death instinct” standing in opposition to the “life instinct.” With this acknowledgement, he changed the paradigm of his own psychoanalytic theory, in which initially he identified only one “instinct” called “libido.” Freud defined libido as the vital energy or driving force of all human desires and actions and was convinced of its exclusively sexual nature.
Freud created an important landmark in the history of research on the war neurosis, respectively, PTSD. He concluded that the self-preservation and the tendency toward creative, life-producing drives are contradicted by the death drive. He wrote, “The purpose of all life is death.”
The inspiration and turning point for Freud’s “modified version” of psychoanalytic theory was the assumption of two opposing tendencies in human nature. The drive to unfold and preserve life contrasts with the urge to destroy others, ourselves, and even civilisation. Human history, consisting of epochs of creation interrupted by violence, war, and destruction, seems to support Freud’s pessimistic hypothesis.
A Letter from Freud to Einstein
Why war? In 1932, Freud received an anxious letter from Albert Einstein asking him if there was a way of freeing humankind from the aggression and threat of war. Considering the destructive drive in humans, Freud presented a rather pessimistic outlook for the future of mankind. Freud wrote in his letter to Einstein: “Conflicts of interest between man and man are resolved, in principle, by recourse to violence. It is the same in the animal kingdom, from which man cannot claim exclusion; nevertheless, humans are also prone to conflicts of opinion, touching, on occasion, the loftiest peaks of abstract thought.
Anna Freud, PTSD Treatment for Children
Freud’s daughter, Anna Freud, worked during WW I in a nursery for children. She continued her work during and after World War II, treating the war orphans. She became one of the founders of psychoanalytic child psychology alongside Melanie Klein. During WW II, she observed the effect of deprivation of parental care on children. She set up a centre for young war victims called “The Hampstead War Nursery.” The underlying idea was to give children the opportunity to form attachments by providing continuity of relationships.
Melanie Klein
Melanie Klein’s first attempts at child analysis coincided with the violent revolution in Hungary in 1919. During this time, her son Erich’s play and daydreams were full of scenes with murdering soldiers and maimed fathers returning from the front.
Donald Winnicott
Winnicott (born 1896) was a paediatrician and psychoanalyst and a leading figure in the field of object relation theory. Winnicott received his medical degree in 1920 and worked as a paediatrician and child psychoanalyst at Paddington Green Children’s Hospital in London. Trained at a military hospital in Cambridge and serving in the Navy, he described the confrontation with death as a defining trait of his generation.
A mother “good enough”
Winnicott’s ideas were derived from Melanie Klein’s theories. He believed that the psyche of a child develops in relation to a real, influential parent. His emphasis on the mother as a “good-enough mother” who relates to the child with “primary maternal preoccupation” is central to the healthy development of the child’s self. Winnicott argues that “the foundations of a child’s health are laid down by the ordinary mother in her ordinary loving care of her own baby.” According to Winnicott, a failure of the mother to provide a “holding environment” can lead to the development of a “false self.” The false self is a defence mechanism that is created when the child’s real self is not recognised or acknowledged by the mother. The false self is a facade that the child presents to the world, not being able to recognise its true self.
Holding environment
Winnicott became one of the key figures in the history of PTSD treatment. During World War II, he served as a paediatrician for the Child Evacuation Program. Winnicott’s paediatric research on traumatized children led to the development of his concept of a “holding environment.”.
In contrast to other psychoanalysts using Freudian terms such as “Ego” and “Id”, Winnicott used the term “Self” to refer to both. The term “Self” was previously established by Carl Gustav Jung. However, Winnicott used it in a different context. For Winnicott, feeling real and being in touch with oneself and others was essential to life. The feeling of being alive and authentic in mind and body and expressing spontaneous emotions allows people to connect with others and develop their creativity.
John Bowlby, PTSD and the Child Trauma in WW II
The war affected not only adults but also children like John Bowlby, who became later a psychiatrist and psychoanalyst. At the outbreak of World War II, Bowlby, at the age of seven, was sent away to boarding school. Over this time, he barely saw his father. Bowlby’s childhood experiences influenced his later studies on child development. Bowlby’s research leading to his “attachment theory” became one of the most formative discoveries related to child psychology.
The Attachment Theory
Newborns develop strong bonds with their caretakers, which reflect the child’s need for safety, security, and protection. Such an affectionate bond is the crucial prerequisite for the formation of a sound child’s personality. It creates for the child the safe base from which it can explore the world.
Bowlby’s attachment theory holds that children instinctively attach themselves to their carers to survive. The presence of a supportive attachment figure is of crucial importance during the early years of a child’s development. The fears in children exposed to danger decrease through access to a secure figure.
Separation Trauma
The quality of the emotional relationship between carers and children overweighs the importance of time spent. The biological mother is usually the primary carer, but anyone who behaves “like a mother” can fulfil this role. This means that the bond between child and carer is not defined by by “blood.” The primary carer may also be a father, grandmother, or another person who provides the necessary social involvement and most of the childcare.
Separation stress occurs when a carer is unavailable or unresponsive. John Bowlby established that the profound grief exhibited by children upon losing their primary carer is a natural reaction to their innate dependence on her presence. In infants, physical separation causes fear and anger, followed by sadness and despair.
Although children usually manage to endure this ordeal, they often do so by adopting a defensive stance of emotional detachment. They tend to become excessively self-absorbed and dependent. As a result, they may harbour lingering doubts about their ability to elicit care and affection, and their demean or may appear odd and aloof. Such behaviour can make it difficult for them to form close relationships with others.
Bowlby’s research emphasised the devastating effect of child separation contributing to the understanding of PTSD.
From Shell Shock to PTSD
At the end of the war, a debate about the origin of PTSD arose between Freud’s followers and the military psychiatrists engaged. The first were downplaying the emphasis on the external stimuli causing the “shell shock,” respectively, “battle fatigue,” defending its infantile origins. This discussion continues until today.
Today we forgot the fact that psychoanalysis helped to understand the close and complex relation of physical illnesses to states of mind. In the history of PTSD research, psychoanalysis was the first, early method for the treatment of “war neurosis.”.
After World War II, the interest and the research on war trauma stagnated. First, the Vietnam War shifted again the attention to the combat-related trauma. The American Psychiatric Association (APA) coined the term “Post Traumatic Stress Disorder””and integrated it as a psychiatric diagnosis into the diagnostic system (DSM). In fact, much of the available published research regarding PTSD is based on studies done on veterans of the war in Vietnam.
Establishing the PTSD Diagnosis
The 1952 edition of the DSM-I includes the diagnosis of “Gross Stress Reaction”, which was similar to the modern definition and understanding of PTSD. “Gross Stress Reaction” was defined as a “normal personality utilising established patterns of reaction to deal with overwhelming fear” as a response to “conditions of great stress.”.
The term “Post Traumatic Stress Disorder, (PTSD)” came into use in the 1970s. The new awoken interest in PTSD was raised as a consequence of the Vietnam War and the high number of traumatised US military veterans. PTSD was officially recognised as a psychiatric disorder by the American Psychiatric Association in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
PTSD Treatment. Summary
The history of PTSD is the history of wars, but at the same time the history of psychology dealing with the war trauma. The first psychological treatment for PTSD during World War I was Freudian psychoanalysis. Psychoanalysts did much of the research in the treatment of war trauma.
The modern sciences became aware of the psychological combat damage caused by the traumas of World War I. The war trauma has been described in military terms. During World War I, it has been called “shell shock,” describing the psychological impact of the soldiers living for years in the trenches, under constant shelling, and seeing the massacred bodies of their brothers in arms. The combat trauma during World War II was named by military experts “battle fatigue.” During WW I and WW II, psychiatrists called the same condition “war neurosis.”.
Today, the PTSD diagnosis is used not only for the veterans of wars but also for civilians who, after being affected by a suddenly occurring traumatic event, develop intense, disturbing thoughts and feelings.
The essential steps for overcoming Post-Traumatic Stress Disorder are early diagnosis and treatment.
Treatment for PTSD
At CHMC Dubai, the therapy for PTSD starts with an in-depth diagnostic procedure such as psychiatric evaluation, physical exam, and laboratory test. In the second step, a thorough psychological interview follows. In some cases, the psychometric testing might be indicated to secure the diagnosis.
Psychotherapy Treatment of Choice for PTSD
Typically, treatment can be done in an outpatient setting. The treatment primarily involves trauma-focused psychotherapy, if necessary, with medication support. Our psychiatric clinic in Dubai offers effective trauma processing methods, including cognitive behavioural therapy (CBT), eye movement desensitisation, and eye movement desensitisation and reprocessing (EMDR), as well as other techniques.
Treatment Goals
The goals of treatment include helping the individual gain control over involuntary memories and reducing accompanying symptoms such as anxiety, depression, sleep disturbances, and concentration problems. We assist our patients in integrating the trauma into their life story and finding new meaning in life.
FAQ (Frequently Asked Questions)
In the below Frequently Asked Questions section, we provide the answers to the most common concerns of our patients about PTSD.
We are specialised in the therapy of psychiatric disorders; among them, we also treat PTSD.
For more information, contact CHMC, the German Clinic for Psychiatry and Psychology in Dubai:
What is PTSD?
PTSD, known as Post-Traumatic Stress Disorder, emerges following exposure to or witnessing a traumatic event. It elicits profound and unsettling emotions, thoughts, and responses associated with the trauma.
What Are the Symptoms of PTSD?
PTSD symptoms usually begin shortly after the traumatic event; sometimes they can appear months or years later. Typical for PTSD is when the symptoms persist for more than 4 weeks, causing severe distress and interfering with people’s personal lives. The symptoms can also fluctuate in severity over the years. Symptoms of PTSD:
Re-experiencing symptoms: Memories of the event appearing repeatedly. This can be nightmares or trauma memories (“flashbacks”) related to the event.
Avoidance: The person avoids things reminding him of the trauma. They can avoid places or people related to the event, or even suppress talking and thinking about such an event.
Negative feelings and thoughts: After the event, the person experiences negativistic thinking. He might feel numb and unable to express emotions, even towards the loved ones.
Hyperarousal: The hyperarousal is frequently associated with insomnia, lack of focus, and an unhealthy lifestyle such as overeating, excessive smoking, or abusing alcohol or drugs.
Other PTSD symptoms: shattered self-image and worldview, enduring distrust in others, intense guilt, shame, or self-loathing. Performance in significant life areas is impaired, and coping with daily life becomes a struggle.
What types of events can cause PTSD?
PTSD can be triggered by various traumatic events, such as combat exposure, physical or sexual assault, natural disasters, serious accidents, or witnessing a traumatic event happening to others.
How is PTSD diagnosed?
Diagnosis of PTSD involves a thorough evaluation by a qualified mental health professional, which may include a review of symptoms, medical history, and assessment of how the symptoms are impacting daily functioning.
What are the risk factors for developing PTSD?
Risk factors for PTSD include experiencing intense or prolonged trauma, having a history of mental health conditions, lacking a strong support system, experiencing additional stressors after the trauma, and having a family history of PTSD or other mental health disorders.
Is PTSD treatable?
Yes, PTSD is treatable with various forms of therapy, such as cognitive-behavioural therapy (CBT), exposure therapy, eye movement desensitisation and reprocessing (EMDR), and medication. Treatment aims to reduce symptoms, improve coping skills, and enhance overall quality of life.
How long does PTSD last?
The duration of PTSD can vary greatly among individuals. Some people may experience symptoms for a few months, while others may struggle with symptoms for years. Early intervention and appropriate treatment can help reduce the duration and severity of symptoms.
Can PTSD go away on its own?
Without treatment, PTSD symptoms may persist or worsen over time. Seeking professional help and participating in therapy can significantly improve outcomes.
I suffer from sleeplessness, mood swings, and the same memories from the past coming repeatedly. Do you think I have PTSD?
PTSD is a mental health problem people develop after being exposed to a life-threatening event or witnessing such an event happening to someone close to them. Sometimes the symptoms occur directly after the trauma, sometimes even years later. Typical for PTSD are memories, called “flashbacks,” insomnia, and anxiety. The diagnosis requires in-depth investigation, which must be done by an experienced psychiatrist or psychologist.
I was involved in a severe car accident…
Later, I developed anxiety and intrusive memories related to the accident. Now I’m scared to drive a car. My GP suspects that I might have PTSD. Can you treat it with medication?
Your GP can be right, but before talking about treatment, the diagnosis of PTSD must be secured. In some cases, PTSD counselling alone can be sufficient. The counselling (psychotherapy) methods used for PTSD treatment are called trauma-focused psychotherapies. The most effective among them is Eye Movement Desensitization and Reprocessing (EMDR)
Are PTSD and Borderline Personality Disorder similar?
PTSD (Post-Traumatic Stress Disorder) and BPD (borderline personality disorder) share some similarities, such as emotional dysregulation and difficulties in relationships. However, they are distinct conditions with different underlying causes and diagnostic criteria. PTSD typically develops in response to a traumatic event, while BPD involves pervasive patterns of instability in self-image, relationships, and emotions.
Are PTSD and trauma the same?
PTSD (Post-Traumatic Stress Disorder) and trauma are distinct concepts. Trauma signifies an event or experience that profoundly disturbs or distresses an individual, often surpassing their coping abilities. In contrast, PTSD is a mental health disorder that may arise following exposure to or witnessing such traumatic events. While trauma can precede PTSD development, not all individuals who experience trauma will develop PTSD.
Can PTSD cause memory loss?
Yes, PTSD (Post-Traumatic Stress Disorder) can cause memory problems, including memory loss or difficulty recalling specific details of the traumatic event. This can occur due to the intrusive nature of traumatic memories as well as the impact of stress hormones on memory encoding and retrieval processes.
Why do PTSD patients relive trauma?
Individuals with PTSD frequently experience trauma re-experiencing through intrusive memories or flashbacks. These vivid and distressing recollections of the traumatic event can be triggered by various cues or reminders. These memories can be triggered by reminders of the trauma, such as sights, sounds, or smells, and can feel as though the event is happening again in the present moment. This re-experiencing of the trauma is a hallmark symptom of PTSD and can lead to significant distress and impairment in daily life.
How can I recognise that I have PTSD?
After a trauma, people might develop upsetting memories, called “flashbacks,” and feel easily irritable. It is a fact that other symptoms typical for PTSD are insomnia, anxiety, and depression. PTSD affects your social and professional activities like going to work, being effective at work, seeing friends, and enjoying the social interactions. Some people develop PTSD symptoms immediately after the trauma. By others, the symptoms may come over time. If the symptoms and thoughts related to the trauma persist over months, upsetting you and causing problems in your life, it’s likely that you have PTSD.
Who can develop PTSD?
Another PTSD fact is that anyone can develop PTSD at any age. Several factors make people more likely to get PTSD, most of which are beyond the person’s control. For example, an intense or prolonged traumatic event makes a person more likely to develop PTSD. Also, personal factors such as previous traumatic experiences, age, and gender can influence the risk for PTSD.
DR. GREGOR KOWAL
Senior Consultant in Psychiatry,
Psychotherapy And Family Medicine
(German Board)
Call +971 4 457 4240