Acute and Post-Traumatic Stress

This is a quickie on differential diagnosis, but I think it's important. It's sometimes nice to know what you have and the prognosis for symptom alleviation.

I had a deposition a few weeks ago, did an expert witness thing for about four hours in my little office with a court stenographer and two lawyers.

It was just like on TV.

Towards the end of the deposition (4 hours later, not 2 as promised), the defense lawyer asked me how long I could expect my client to need therapy.

I said that he'd be over the really serious psychological stuff in a couple of years.

But I regretted that statement later on because the DSM-IV really doesn't specify the two years. I said that based upon reading the research on rape and recovery.

The DSM is correct, however, in that although the severe symptoms of post traumatic stress usually resolve within two years, many people have PTSD and other Axis I disorders which are related to the trauma and stress for many years following an initial trauma. They also are prone to avoidant behaviors, too, that change their lives, along with irrational anxiety in safe contexts.

I call it the trauma to the trauma.

A person who (a) has severe nightmares, flashbacks, recurring thoughts, avoidance, and a host of related symptoms (b) following a very stressful event that persist longer than 2 months is diagnosed with PTSD, POST TRAUMATIC STRESS DISORDER. Recurrence of symptoms becomes less frequent and less intense over the years.

ACUTE STRESS DISORDER only lasts 2 months, same symptoms.

So if you see a terrible car crash or a murder from a distance, you'll probably have flashbacks or recurring thoughts about it for only a few months. If you are mistakenly thrown into jail but aren't raped, yet feel humiliated and angry,and can't get it out of your head initially, the intensity of these symptoms, too, will probably actually resolve in under 8 weeks no matter what you do, with or without therapy.

But go and talk about it with a therapy doc anyway. Exposure therapies (and talking is a form of exposure) really can speed things along and are the way to go with acute and post traumatic stress. We have all kinds of tools in our toolboxes for these disorders. By the way, they are considered anxiety disorders.

Copyright 2006, TherapyDoc


Mark said…
Good to know and very interesting. Question, do you find that these disorders sometimes last longer than expected or excellerate because the person in therapy begins to enjoy the attention?
deb said…
Dear Doc, thanks,....even George said thanks.
Therapy Doc said…
To Mark: Nah. Nobody likes PTSD and truthfully? As long as someone wants to come to therapy we don't say, oh, you're all better, what are you doing here, anyway? If ever there was a place to get attention, therapy's that place. So resolving a disorder doesn't jeopardize a therapeutic relationship.

Of course, with HMO and PPO medicine, insurance will not cover therapy that is not considered "medically necessary."
Therapy Doc said…
Your welcome, George and Deb.
How does PTSD related to incidents which occur over a long enough period to create new behavior - such as long term torture, concentration camps, prostitution against one's will and such - Is therapy effective in resolving or only lessening in such cases?
Therapy Doc said…
It's multivariate and much depends upon a person's family/social experience and psychological development prior to trauma, and adaptation varies also post-trauma depending upon the trauma itself. The PTSD can't possibly resolve over night.

AND personality, as you suspect, does change over the course of long-term trauma as does world view.

The diagnoses we have for both Axes I and II (although again, generalizing with this population will get you into trouble)include: borderline disorder or features, anxiety and depressive disorders, PTSD, paranoia, sexual dysfunction, schizo-affective, schizo-typal, social phobia, and more. Treatment is very difficult due to the intensity of the trauma and longevity.

The brain changes slowly, for better or for worse, and there's certainly reason to think that without treatment, as a survivor ages, symptoms and disorders only get worse. Personality gets more exaggerated, not better.

Yet, we people out there like Tante Tela (read the post on Yom Kippor under "holidays").

Am open to comments here.

Thanks for a great question, Elizabeth,

Therapy Doc said…
A resident expert sent me the following email (thanks Mi):

There's a study published in Israel after the first Scud missiles landed in Tel Aviv in the '80's. (Figure some social workers were right there, coming up with study ideas as the Scuds were falling).

Anyway, one missile landed on a senior building in Tel Aviv and the residents were totally freaked. (One was killed.)

The data showed higher anxiety levels and renewed PTSD as compared to a control group of non-Holocaust-Survivors. In general, data on Holocaust-Survivors showed strong efforts in acclimating to their new surroundings but lots of pathology, as would also be expected.

However, does the data really show this or do we find data to prove what we think? You gotta' think that anyone interested in this topic has a vested interest in it - most likely is a survivor-family child or whatever. Who else cares?

Now, based on life and everything else I know, I would think that therapy would reduce the pathology, being PTSD or anything else. The more you talk it through, the more you can revise and fix things. Holocaust-Survivers had no therapy, no one to help them through trauma except other survivors. When asked, they will tell you that no one understands what they went through except someone who went through it also. And since each experience was so different, they essentially survived by themselves. That's why aging is so darn challenging- who else experienced anything like they are going through?

Finally, I think people adapt to trauma the way they adapt to life in general. If they have good coping skills, they will cope with trauma, too. If they have less-then-helpful coping skills, they will have less-than helpful skills to cope with trauma. I don't think it matters if the trauma was last week or thirty years ago. Although, after therapy, a survivor of trauma of thirty years ago might wonder why the heck he didn't go for treatment sooner!

I'd have to read the study to check it's validity, but assuming you're correct, that survivors don't get treatment, then it's likely they are very sensitive to re-traumatization.

I can't imagine fending off that much anxiety. Thanks for sharing!
Ella said…
Still love finding old posts on such interesting topics.
In my case, you'd have to tell the lawyer - "Well, it happened in 1982, and she suffered in silence since then, so how much time do you think is fair?"
The Dr. Judith Herman book "Trauma and Recovery..." has given me so much understanding of the vastness of trauma. I know that I'm imprinted for life, but the print will fade.
I can celebrate my survival, my thriving in spite of it.
UnmotheredChild said…
I suffer from chronic PTSD and for me talking is very very difficult and slow and often has the opposite affect that I get worse.
Rachmawaty said…
good experience... i am still in Clark ship n medical student. Hope your experience give me inspiration and more social knowledge before i am going to be a doctor.