Posttraumatic Stress Disorder

Abstract
A traumatic event affects many people in various ways. Posttraumatic Stress Disorder (PTSD) is a globally recognized disorder that is common among persons who have experienced traumatic events, but is also known as a normal response by normal persons in abnormal situations. Posttraumatic Stress Disorder can be caused by a multitude of reasons, not just from traumatic events. People with various personality traits can be associated with Posttraumatic Stress Disorder. People who suffer from poor health can also be associated with Posttraumatic Stress Disorder. People who suffer various life occurrences such as rape, natural disasters, military personnel, and victims of domestic abuse are just a few examples of who can experience Posttraumatic Stress Disorder. Posttraumatic Stress Disorder is a controllable disorder. The treatment is long, and will involve counseling, medication, desensitization, and possible support groups. Treatment will also include the victim, family members, and possibly friends of those diagnosed with the disorder.

Introduction
Posttraumatic Stress Disorder, more commonly referred to as PTSD, is defined by the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM_IV, 1994) in this way “…characteristic symptoms following exposure to an extreme traumatic stressor” (Diane Everstine & Louis Everstine, 2006, p. 153). PTSD affects millions of people every year and does not discriminate against culture, race, or age. It is an anxiety disorder that often results from a stressful event such as a natural disaster, rape, or war. Many times the symptoms last longer than a month (Ronald Comer, 2011). Lt. Col. Kevin Stevenson, chief of the Department of Social Work at Moncrief Army Community Hospital at Fort Jackson, S.C., notes that “PTSD is a normal physiological response to being in a traumatic event – war, natural disasters, car accidents or working in an emergency room,” he said. “The symptoms can manifest physically, emotionally and cognitively. In most cases, exhibiting signs of PTSD is not a cause for concern. After six to eight weeks the symptoms tend to disappear. If they persist for a prolonged period, that’s when we have concerns” (Glasch, Mike, A., 2007).

The American Psychiatric Association (2000) notes that PTSD is characterized by the re-experiencing of an extremely traumatic event that is accompanied by the symptoms of arousal and avoidance that is associated with the trauma. The event must “first, to qualify for a diagnosis of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994), the individual must have experienced, witnessed, or otherwise been confronted with an event that involved actual or threatened death, serious injury, or threat to physical integrity. Second, the individual’s response to the event must include intense fear, helplessness, or horror” (Patricia A. Resick & Karen S. Calhoun, 2001, p. 65). The events of the past trauma can be sudden and can come on sudden for the PTSD sufferer. This can be very dangerous because it can cause extreme fear, flashbacks, and anxiety. PTSD sufferers can no longer use normal coping skills and often times are a different person as a result of the traumatic event they have experienced.

PTSD sufferers may also suffer from panic attacks, numbness, and extreme distress. Those who also suffer from PTSD may also become substance abusers and suffer from chronic physical pain (in depth, 2013). One traumatic event that can onset PTSD is natural disasters. Natural disasters can be defined as “large-scale, not directly human-caused, injury-or –death-producing environmental events that adversely affect a significant number of people” (John N. Briere & Catherine Scott, 2013, p. 9). They are classified as such things as floods, fires, earthquakes, hurricanes, or tornadoes. Many natural disasters are devastating and the victim looses possessions, may loose loved ones or close friends, and many times end up having to also relocate due to their loss. Not all individuals are affected by these events. Those that are significantly affected usually have suffered a traumatic loss, witnessed death, or have had a serious injury (in depth, 2013). These factors can contribute to symptoms associated with PTSD.

Victims also referred to as survivors of natural disasters are aware of their losses and are affected in different ways, and many times this is due to their age and/or stage in life. The elderly often times feel they are too old to start over again and feel the loss of all their possessions, especially family possessions, pictures, and memories of children in the younger years is too much to overcome (Lee Ann Hoff, Bonnie Joyce Hallisey, & Miracle Hoff, 2009). For some survivors anger and frustration can set in. They also have feelings of guilt because they have survived the disaster. Survivors also have feelings of anxiety and flashbacks, especially if they hear or see things that trigger memories of the disaster. Children are especially susceptible to nightmares and often times do not want to be left alone after a disaster. Those who suffer from PTSD due to a natural disaster may have symptoms that are severe and last for a months or even a lifetime. Others may be able to overcome their symptoms and reconstruct a new life, a new home, and move forward. Some find comfort in rebuilding in the same area, while others need to move to a new area and find a fresh start.

H. Norman Wright states (2011, p. 193) “the brain is a creation at the hand of G-d. It is unique in its design, purposeful in its creation and wonderfully made (see Ps. 139)”. Because the brain is split into two sides, right and left, we utilize the right side for pictures and memories. When one is suffering from PTSD, those flashbacks, or traumatic memories, play in the right side almost like a movie. The Bible (ESV) notes that Paul experienced posttraumatic stress disorder but overcame and as in 2 Corinthians 1:6, “If we are afflicted, it is for your comfort and salvation”. Paul continued to focus on helping people rather than focusing on his own distress. The Bible teaches us to focus on G-d and not to focus on our trauma. This will continue to help in the healing process and help those who are counseling those who are suffering from PTSD. The Bible tends to focus both on the realistic aspects of PTSD as well as how to live a complete and new life after the affects of PTSD. Assessment

There are several different assessments that can be used for victims of trauma to determine the level of stress and if a victim is suffering from Posttraumatic Stress Disorder. The best results will occur if the clinical work is directed at the symptoms expressed by the resulting trauma. When assessing the treatment plan, “the psychic injury caused by the event and its impact on the survivor’s normal life patterns and his or her worldview must be accounted for” (Everstine & Everstine, 2006, p.161). A person who has been raped should not be treated in the same manner as someone who has lost everything in a flood. It is important to remember that certain things will trigger memories for some and others will be numb and want to avoid memories of the event.

It is important to know how long ago the event occurred when devising a treatment plan. If the event is fairly recent, a counselor can work on adaptive and coping mechanisms that will help to relive the current symptoms. The more recent treatment is to the event the shorter the treatment will be. Our normal “flight and fight” mechanisms tend to build mechanisms of defense the longer a person has been dealing with the trauma. It is also important to remember that events such as natural disasters will have effects on people because they may think that their fate has been determined and that their lives are ruined forever. Even a witness to a trauma has to be treated differently than a victim. Witnesses tend to feel guilty because they were not affected like the victims.

It is very important when dealing with trauma victims to remember that some victims will think that the event was not traumatic. This is seen more in events such as physical abuse or incest (Everstine & Everstine, 2006), but can also be seen with natural disasters or other environmental traumas. Some people fear they will be perceived as weak if they admit they are having trouble dealing with the trauma. Many times social stigma can hinder treatment. Other times victims will feel they are shamed or an outcast if they admit they are having problems due to a trauma. Sometimes if a person has experienced a trauma before this will also play a factor when assessing a treatment plan for a victim.

There are various checklists that a counselor can use to assess a victim to help determine their state of crisis they are in or if they even recognize they are in a victim of a trauma. The questions should be prefaced by a phrase such as “a frightening thing has happened to you”. This lets the victim know that the counselor or interviewer is empathetic to their situation and is caring. Questions can range from “Did you feel angry?” to “Did you lose trust in people?” and questions should be different for adults than for children. There are also specific interview questions that can be asked in a disaster situation to determine if a person needs to be triaged and at risk for PTSD, for example: 1. Are you having flashbacks? 2. Do you feel numb, detached, estranged? (Everstine & Everstine, 2006).

It is always important when assessing the victim to remind them that PTSD symptoms do occur frequently in the general population yet be empathetic to the victim as well (Frueh, Christopher, Grubaugh, Anouk, Elhai, Jon D., & Ford, Julian D., 2012). One type of assessment that can be used is the Brief Interview for Posttraumatic Disorders (BIPD). This is used for those who do not want a very structured interview (Breiere & Scott, 2013). This particular interview will review all the symptoms that are reviewed in the DSM-IV definition for PTSD. Certain criteria must be met in order for the victim to be diagnosed with PTSD. One criteria is that the victim must have been exposed to a traumatic event prior to the last month in which both of the following were present: it involved death, potential death, serious injury, threat to physical integrity, developmentally inappropriate sexual experiences, and the victims response to he event involved intense fear, horror, or helplessness (Briere & Scott, 2013). If no is the answer to any of the criteria than the interview is stopped and the victim could be assessed for some other disorder.

Other assessments should also be made and it is important to include a generic psychological assessment because PTSD includes symptoms of anxiety, depression and psychosis. Some examples of these generic assessments are the Minnesota Multiphasic Personality Inventory, 2nd Edition, Psychological Assessment Inventory, and the symptom Checklist 90-revised. These tests are important because they can tell if a victim is under or over reporting symptoms (Briere & Scott, 2013). It is often found that those suffering from trauma may exaggerate their symptoms or even deny they have symptoms, but when using these scaled tests their higher scores can portray the effects of the trauma and possible symptoms of PTSD. Sometimes scores are skewed because symptoms that can be associated with PTSD can also be associated with anxiety and depression. This can be seen when someone is numb, has problems sleeping, or cannot concentrate (Frueh, Grubaugh, Elhai, & Ford, 2012).

More specific Posttraumatic Stress Disorder tests are geared to measure and evaluate certain criteria specific to certain symptoms of PTSD. The Posttraumatic Stress Diagnostic Scale (PDS) evaluates the exposure to the trauma and how it interferes with the victim’s daily life (Briere & Scott, 2013). The Davidson Trauma Scale (DTS) evaluates and measures such aspects as the victim’s intrusion, numbness, avoidance, and hyper arousal to certain events. It can also be used to test and retest when the victim is going through therapy (Briere & Scott, 2013). The Detailed Assessment of Posttraumatic Stress (DAPS) measures and evaluates lifetime exposures to traumatic events and immediate responses to specified traumas (Briere & Scott, 2013). The Trauma symptoms Inventory-2 (TSI-2) measures and evaluates exposure to trauma over a certain period of time. These tests are very important when assessing what types of treatment are needed and how severe one is suffering from PTSD.

When assessing one for PTSD it is also important to evaluate their current health status. The counselor needs to be aware of any medications the victim is currently taking; this includes vitamins and herbal supplements. The victim should also disclose if they have any current medical conditions because those who suffer from trauma may experience physical problems and it is important to know which are medically related and which are trauma related. Some medical problems can be similar to PTSD symptoms and it is important to know a full medical history before treating a victim for PTSD physical symptoms. (Briere & Scott, 2013).

G-d does not let us suffer more than one can endure. The pain and suffering from PTSD gives one the strength to look forward and find trust and hope in G-d. As the symptoms of PTSD arise one can remember that G-d never gives a person more than they can handle. One needs to remember how Abraham was willing to sacrifice Jacob or the Israelites oppression until Esther became queen. It is important not to focus on ones self and own suffering, but to remember that G-d wants one to focus one why there is suffering and how he is bringing his people back to him. Wright (2011) notes that Spiritual journaling, or just journaling, can help one work through the symptoms of PTSD. It allows one to focus on their suffering and work through the healing process. Treatment

Various treatments are available to those who suffer from PTSD. The most important treatment is early intervention. If a counselor or clinician can see a victim at the scene of the disaster or shortly after, there is a better chance to reduce the severity and duration of PTSD. It is very important to provide the victims with educational information about posttraumatic stress, what they can expect, how long it may last, and where they can seek help (Everstine & Everstine, 2006). It is important to start the traumatized person towards the recovery as soon as possible. At times early intervention will not work for those who have been severely traumatized. These people are not always able to function intellectually. They may have trouble just doing the basics of life and cannot think beyond getting through their normal daily lives. They will not be able to cognitively process what has happened to them and if they are asked too, they will only become confused and frustrated when asked to explain what has happened to them. This can cause them to “shut down” (Everstine & Everstine, 2006). It is important to stabilize the victim.

By stabilizing the victim, the counselor or clinician will help the victim reconnect with reality. They need to become safe again in their surroundings and begin to function intellectually. Sometimes this will take long periods of time and require psychotherapy, and other times, this will take a short period of time, and no drastic therapy steps are needed. It is also important to remember to use short answer questions when working with PTSD victims. Asking open-ended questions can cause confusion and frustration because many times these victims cannot explain their feelings or express deep feelings (Everstine & Everstine, 2006). Various other therapies can also help those who suffer from PTSD. One therapy that is successful is cognitive therapy. This therapy allows the victim to understand their thoughts about the trauma and what causes the stressors and makes the symptoms worse (US Department of Veterans Affairs, 2014). Through cognitive therapy the victim learns to deal with their fears, replace those fearful thoughts with thoughts that cause less stress, and also learn to stop feeling thoughts of anger and guilt(US Department of Veterans Affairs, 2014).

Many times a victim feels guilty for surviving and the victim needs to understand that they cannot change what has happened and they were not selected to live versus someone who might have passed in a natural disaster or some other traumatic event. Exposure therapy also assists those with PTSD. This therapy assists those victims with their fear about their memories and/or flashbacks they may be experiencing. The victim spends time in their therapy session speaking about their trauma. By the continual talking they learn to control their thoughts and feelings about the trauma and learn to be no longer be afraid of their memories (US Department of Veterans Affairs, 2014). It is important for the victim to understand that their flashbacks can be in any of the sensory modes, including auditory, tactile, and olfactory (Everstine & Everstine, 2006). It helps for the victim to understand that flashbacks can come at anytime because they are stimulated by their surroundings. As they practice techniques, such as relaxation, these flashbacks should subside.

The victim needs to be patient as they are not going to go away immediately and the victim will need to work at it to make them diminish. Another treatment that can help a victim of PTSD is family therapy. Many times a family has experienced some form of trauma as a result of a natural disaster. A victim of PTSD may show anger, depression, or anxiety at times and family members may not understand why. This may scare some members, especially young children. The key to family therapy is that everyone needs to be honest. They need to express their fears, concerns, and the symptoms of PTSD and what triggers them (US Department of Veterans Affairs, 2014). Treatment can vary in length. Treatments can vary from three months to as long as a year or longer. If a victim has other mental health issues the treatment could be longer. While a victim is in treatment they will work to reduce their symptoms, learn to live with their symptoms, and learn to cope with any other problems that arise due to their PTSD symptoms. Victims will go through stages of healing through their treatment.

They will experience shock/disarray, denial, blaming, pain/anguish, anger, and integration/acceptance (Young, Trina, (n.d)). Some of the stages my bring on anxiety, such as the first stage. They may not know what to feel after a trauma. It may be hard for a victim to even realize that the disaster has even occurred. They may blame themselves even though the disaster was due to an environmental cause. They may feel they could have done something to prevent it even though they may have not even known it was going to occur. They may even feel anger towards G-d for letting this disaster happen and ruining things they can no longer possess or fix.

Each stage could take hours or months to process through, but it is important for them to move through each stage in order to heal and continue to a sense of normalcy. The victim also needs to plan for ongoing recovery. Once they have moved through the stages of healing they cannot consider themselves completely healed. They need to ensure that they have access to social support and are prepared for continued ongoing therapy. They need to be aware of any symptoms such as fatigue or chest pains that may be signs of reoccurring PTSD. Although they may feel they are “normal” they may experience triggers that bring back memories or flashbacks and they have to be ready to seek therapy. Conclusion

Any type of trauma can cause PTSD. Natural disasters are a form of trauma that usually cannot be controlled by mankind. The Bible reminds us that G-d loves all his people and that he has not failed us. G-d creates these natural disasters in order to remind us to come back to him. Assessing and treating PTSD is not an easy task. Each victim suffers from trauma in different ways and it is important to remember that each must be treated uniquely. There are various assessments that can help determine the severity of PTSD but even those assessments can be inconclusive if the victim is numb or in denial. Treatment can be long and tedious, and some may refuse treatment. It is important as counselors or clinicians to remember that these victims are fragile and not to push the victims as this can shut them down. PTSD is a true illness that affects many, regardless of age, sex, or culture.

References
American Psychiatric Association. (2000). Arlington, VA. Retrieved from http://www.psych.org
Briere, J. & Scott, C. (2013). Principles of trauma therapy and treatment (2nd ed.). Thousand Oaks, CA: Sage Publications.
Comer, Ronald J. (2011). Fundamentals of abnormal psychology. (6th ed). New York, NY: Worth Publishing.
Everstine, D. S., & Everstine, L. (2006). Strategic interventions for people in crisis, trauma, and disaster (Revised Edition). New York, NY: Routledge Frueh, Christopher, Grubaugh, Anouk, Elhai, Jon D., Ford, Julian D., (2012). Assessment and treatment planning for PTSD. Hoboken, NJ: John Wiley & Sons. Glasch, M. A. (2007). Battling PTSD. Soldiers, 62(8), 28-31. Retrieved from http://search.proquest.com/docview/205327424?accountid=12085 Hoff, L.A., Hallisey, B.J., & Hoff, M. (2009). People in crisis: Clinical and diversity Perspectives (6th ed.). New York, NY: Routledge. In depth. Treating PTSD. (2013). PN, 67(8), 13-14.

Resick, Patricia, A., Monson, Candice, M. & Rizvi, Shireen, L. (2001). Posttraumatic Stress Disorder. Clinical Handbook of Psychological Disorders. New York, NY. Guilford Press. U.S. Department of Veterans Affairs. (2014). PTSD: National center for PTSD. Washington, DC. Retrieved from http://www.ptsd.va.gov/public/treatment/therapy- med/treatment-ptsd.asp

Wright, H. N. (2011). The complete guide to crisis and trauma counseling: What to do and say when it matters most!.Ventura, CA: Regal Books. Young, Trina. (n.d) Responding to rape and sexual assault. [CRDC 106]. Domestic and Community Crisis Response Video. Lecture retrieved from http://learn.liberty.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2Fw ebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_50809_1 %