Treatment for PTSD

Mankind’s earliest literature tells us that a considerable proportion of military casualties are psychological, and that witnessing 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. An important fact is that over the past thirty years the criteria of PTSD has evolved. Currently PTSD is linked not also to combat trauma but also to other traumatic events happening in “normal live”. For example, PTSD can be caused by car accidents, plane crashes, natural disasters, such es earthquakes and hurricanes, by being taken hostages, domestic violence, and sexual abuse.

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 is the survivor’s guilt. Also, soldiers who killed the enemy might develop PTSD due to the perpetrator trauma.

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, lack of concentration.

• The affected individual deliberately avoids activities, places, people, thoughts or feelings associated with the traumatizing event.

• In the chronic stage of the PTSD other symptoms such as loss of interest in day-to-day activities, social detachment and feeling of numbness, appear.

The individuals affected by PTSD develop often 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 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.

PTSD. Diagnosis and Classification

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 use in the USA. The World Health Organization (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 standardized diagnostic criteria. In the chapter below we present the DSM V criteria helpful by identifying a PTSD. The DSM-V Diagnostic Criteria of American Psychiatric Association categorizes the general criteria in diagnosing PTSD in adults.

Exposure

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. 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.
4. 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).

PTSD Symptoms

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s). The symptoms beginn or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Avoidance

C. Persistent avoidance of stimuli associated with the traumatic event(s). The symptoms beginn or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings closely associated with the traumatic event(s).
2. 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 beginn or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. 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).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. 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 beginn or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behaviour.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
7. 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 coocuring 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.

PTSD and Depression

Depression is a common mental health problem. In the industrialized countries depression (mild, moderate, or severe) affects around one of ten individuals per year. The pre-existent 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 time more likely to develop depression. PTSD also significantly increases the risk of suicide.

PTSD and Anxiety

The American Psychiatric Association (APA) in the past classified PTSD as an anxiety disorder. Such association is understandble as PTSD and anxiety disorders might crate 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-existent anxiety disorders increase the risk of PTSD after trauma exposure.

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 patients suffering of PTSD fulfil the criteria for a substance abuse disorders. PTSD and alcohol dependence in traumatized individuals often occur at the same time. The reason for alcohol over drug abuse, it because of alcohol’s legal status and its availability.

Diagnosing Post-Traumatic Stress Disorder (PTSD)

The main creterion 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, identyfying the symptoms and possible risk factors. In some case standardized 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 occuring 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, childgood 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 the more severe cases. The treatment of choice for PTSD is psychotherapy. The most effective psychotherapy methods for PTSD are CBT, EMDR or trauma focus psychotherapy. In some cases, especially those resistent to CBT the 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 trough bringing the unconscious feelings to light and making them conscious. In consequence the 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-behavioral therapy technics: 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 desensitization and reprocessing (EMDR) is a form of psychotherapy developed and studied by Francine Shapiro. This is a technique which uses eye movements to facilitate the emotional processing of memories. EMDR helps the brain deal with flashbacks and “unwind” the destructive effect of traumatic experiences. It changes the person’s memory to attend to more adaptive information.

Cognitive Model of CBT (Cognitive-Behavioral Therapy)

Cognitive-behavioral 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-behavioral therapy for PTSD might use exposure therapy, stress-inoculation training, cognitive processing therapy, behavioral activation and 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 behavioral therapy that involves assisting trauma survivors to re-experience distressing trauma-related memories. The goal is to remind and to facilitate habituation and successful emotional processing of those memory. Exposure therapy programs include different technics. One of them is an imaginal confrontation with the traumatic memories. The other 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)

The 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) 

CPT belongs to cognitive-behavioral therapy technics 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, thought 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, the psychodynamic psychotherapy is the more effective method. CBT as therapeutic technique owes its roots to psychoanalytical psychotherapy. The conducted studies shown 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 good 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 the 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 diagnosis like depression or anxiety. The combination of PTSD with other psychiatric disorders requires more complex therapy plan, including the use of medication.

In such sases 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 peaple frequently feel stigmatized 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 Therapy 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 case 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 case 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 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 a sucessful 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 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 so 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 traumatizing events exceeds the psychological defence not allowing to neutralize 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 of 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 a trauma will develop the symptoms of PTSD. The people more vulnerable to trauma tend to be individuals suffering from pre-existent 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 proof that the psychiatric comorbidities increase the risk for PTSD. According to a study published 1989 in the British Journal of Psychiatry individuals who were exposed to traumatizing events in the childhood have much higher risk for PTSD. On the other hand, also people which normal childhood development and without prior exposure to traumatizing 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 level 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. Hyper-responsiveness in the norepinephrine system ist most probably caused by continued exposure to high stress level.

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 amygdala and the hippocampus belongs to the limbic system. It’s the limbic system, which is involved in forming emotional memories, especially those fear related. 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 soldier but also to other individuals struck by a sudden trauma causing the same symptoms initially observer only by the military personnel.

The modern sciences became aware of the psychological combat damage caused by the traumas of World Wars I. The term “Shell Shock” was created during the WW I, describing psychological impact of the soldiers living for years in the trenches, under constant shelling and seeing the massacred bodies of their brothers in arms. At the beginning of the 20th century military doctors called the condition “shell shock”.

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 in 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 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 the WW I and between the wars the combat trauma was called “shell shock” or “war neurosis”. Later, during the WW II, the diagnosis was changed into “battle fatigue”.

The scientifically documented history of PTSD started during the WW I. During the “Great War” many analysts have experienced the trauma of “shell shock” in treating traumatized soldiers. Matthew Eder ran a hospital for shocked soldiers in Malta. Sandor Ferenzi worked with traumatized soldiers in Budapest; Max Eitingon and Karl Abraham in Berlin.

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 the WW II everyone was hoping that war will never happen again. The research on the war trauma (synonymous to PTSD) stagnated. It started again in the 60ties during the Vietnam war. Since then, the trauma related to war or other severe traumatizing events has been called “Post Traumatic Stress Disorder” (PTSD). Along with establishing the diagnosis of PTSD also different therapeutic methods for this condition have been developed. Until today the most effective treatment for war trauma is the psychotherapy which has its roots in the Freudian psychoanalysis.

Psychoanalysis in Treatment for PTSD

The formative figure in 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. Midst 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 realized how thin the layer of civilization 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 traumatized soldiers with his own method, the 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 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 the opposition to the “life instinct”. With this acknowledgment 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 is 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 to destruct the civilization. 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 is a way of freeing humankind from the aggression and threat of war? Taking in consideration the destructive drive in humans, Freud presented 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, men 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 the WW I in a nursery for children. She continued her work during and after the WW II treating the war orphans. She became one of the founders of the psychoanalytic child psychology alongside Melanie Klein. During WW II she observed the effect of deprivation of parental care in 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 day-dreams 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 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 recognized or acknowledged by the mother. The false self is a facade that the child presents to the world not being able to recognize 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, being in touch with oneself and other was essential to life. The feeling of being alive and authentic in mind and body, 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 psychiatrist and psychoanalyst. At the outbreak of 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 the child psychology. It was the “milestone” in the history of PTSD treatment.

The Attachment Theory

Newborns develop strong bonds with their care takers, which reflects the child’s need for safety, security and protection. Such affectional 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 caregivers 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, decreases trough the access to a secure figure.

Separation Trauma

The quality of the emotional relationship between caregivers and children overweighs the importance of time amount spent. The biological mother is usually the primary caregiver, but anyone who behaves “like a mother” can fulfil this role. This means that the bond between child and caregiver is not defined by “blood”. The primary caregiver 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 caregiver is unavailable or unresponsive. John Bowlby established that the profound grief exhibited by children upon losing their primary caregiver 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 self-reliant. 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 emphasized 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 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, the psychoanalysis was the first, early method for the treatment of “war neurosis”.

After the WW 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 utilizing 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 for PTSD raised as a consequence of the Vietnam war and 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.

Since World War I, the war trauma has been described in military terms. During World War I, it has been called “shell shock”; during World War II, “battle fatigue.”. During WW I and WW II, psychiatrists called the disorder “war neurosis.”.

Post-Traumatic Stress Disorder may occur in people who were exposed to traumatic events. 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. 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: the 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)

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.

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 great distress and interfering with people’s personal lives. The symptoms can also fluctuate in severity over the years.

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.