Cop­ing with CATAS­TRO­PHE

Once thought to strike only soldiers, PTSD di­ag­noses are in­creas­ingly com­mon

201 Health - - Health Care Philosophy - WRIT­TEN BY BROOKE PERRY

In the post-World War I era, it was called “shell shock.” By the end of World War II, it was dubbed “com­bat fa­tigue.” In our more mod­ern times, it’s post-trau­matic stress dis­or­der, or PTSD, a moniker that took hold as soldiers re­turned from Viet­nam.

It first ap­peared in the Amer­i­can Psy­chi­atric As­so­ci­a­tion’s Di­ag­nos­tic and Sta­tis­ti­cal Man­ual of Men­tal Dis­or­ders in 1980. In gen­eral, ex­perts say, it arises from ex­po­sure to a life-threat­en­ing event – any­thing from a nat­u­ral disas­ter to an episode of do­mes­tic abuse or as­sault – in short, an event that changes the body’s re­sponse to stress. In Ber­gen County, “we saw a spike af­ter 9/11 and again af­ter Hur­ri­cane Sandy,” says Michael J. Toz­zoli, MSW, LCSW, chief ex­ec­u­tive of­fi­cer of West Ber­gen Men­tal Health­care and a prac­tic­ing ther­a­pist.


Though ex­perts some­times dis­agree on whether a per­son can have PTSD and be un­aware of it, most agree that de­layed onset PTSD is a re­al­ity, with symp­toms ma­te­ri­al­iz­ing at least six months af­ter the life-threat­en­ing event. Even in text­book cases of PTSD, the dis­or­der is not di­ag­nosed un­til at least 30 days af­ter the trau­matic event.

Dr. Gabriel Ka­plan, med­i­cal di­rec­tor for Be­hav­ioral Health Ser­vices at Ber­gen Re­gional Med­i­cal Cen­ter in Para­mus, says PTSD is de­fined as one of sev­eral anx­i­ety dis­or­ders with one very im­por­tant char­ac­ter­is­tic.

“It de­vel­ops when you are ex­posed to a very stress­ful stim­u­lus,” Ka­plan says. “It has to be a ma­jor trau­matic event, such as a car ac­ci­dent, war and ter­ror, for which symp­toms then cause sig­nif­i­cant dis­rup­tion to your life. Women who were abused as chil­dren and chil­dren who have been abused, par­tic­u­larly when the abuse is sex­ual or phys­i­cal and is un­known to the rest of the world, can have de­layed onset PTSD.”

“Any range of events can cause symp­toms of PTSD,” Toz­zoli says. “Gen­er­ally, the event is a psy­cho­log­i­cally sig­nif­i­cant event that causes on­go­ing anx­i­ety, de­pres­sion and other feel­ings. This can

in­clude los­ing a baby, phys­i­cally abus­ing re­la­tion­ships and, of course, a pe­riod of time away from one’s fam­ily in a war zone.”

Ac­cord­ing to the Amer­i­can Psy­chi­atric As­so­ci­a­tion, symp­toms of PTSD can in­clude vivid flash­backs or night­mares in which they re­live the ex­pe­ri­ence, as well as feel­ings of de­tach­ment, of­ten avoid­ing close re­la­tion­ships or sit­u­a­tions that might trig­ger painful mem­o­ries. Those who suf­fer from PTSD are of­ten highly ir­ri­ta­ble and hy­per­aroused.

“PTSD symp­toms gen­er­ally come on slowly but can es­ca­late rapidly,” Toz­zoli says. “It can be a mat­ter of months, or it can take even longer than that. Symp­toms can range from de­pres­sion and sig­nif­i­cant anx­i­ety to avoidant be­hav­iors. Of­ten th­ese symp­toms are co-min­gled with cop­ing mech­a­nisms that can be mal­adap­tive, like al­co­hol or drug use.”

One of the most vex­ing ques­tions about PTSD is why some peo­ple get it and oth­ers don’t.

“There is some re­search,” Toz­zoli says, “that sug­gests there is a ge­netic com­po­nent to all anx­i­ety dis­or­ders, in­clud­ing PTSD. How­ever, the lev­els of PTSD that are ex­pe­ri­enced in a war zone far out­weigh any ge­netic pre­dis­po­si­tion.”

“We don’t know with cer­tainty what the risk fac­tors are,” Ka­plan says. “But it’s gen­er­ally be­lieved that the health­ier you are emo­tion­ally, the less likely you are to de­velop it, and con­versely, if you have had pre­vi­ous stresses in your life, you are more likely to de­velop PTSD.”

Ka­plan notes that the sever­ity of the trauma is also a fac­tor.

“The the­ory now is that there is a con­nec­tion be­tween a per­son’s ge­netic vul­ner­a­bil­ity to it and their ex­po­sure,” he says.


A for­mer Vet­er­ans Af­fairs physi­cian with con­sid­er­able ex­pe­ri­ence treat­ing vet­er­ans with PTSD, Ka­plan says, “Men­tal health di­ag­noses are never

“We no longer be­lieve that the will to get bet­ter makes you get bet­ter. But the will to get bet­ter makes you more mo­ti­vated to re­ceive care, and if that’s the case, you will prob­a­bly have a bet­ter out­come.”


“Any range of events can cause symp­toms of PTSD. Gen­er­ally, the event is a psy­cho­log­i­cally sig­nif­i­cant event that causes on­go­ing anx­i­ety, de­pres­sion and other feel­ings." MICHAEL J. TOZ­ZOLI,




easy to make. But for ex­perts fa­mil­iar with PTSD, it can be rel­a­tively easy to rec­og­nize.”

Treat­ing PTSD is a process. In most cases, Ka­plan uses a two-pronged ap­proach to treat­ment.

“Psy­chother­apy [cog­ni­tive be­hav­ioral ther­apy] helps pa­tients re­frame their thoughts,” he says. “It’s a very prag­matic ther­apy, but it’s not al­ways ef­fec­tive.

In ad­di­tion, Ka­plan uses med­i­ca­tion to ad­dress spe­cific symp­toms, in­clud­ing anx­i­ety and de­pres­sion. “There is no one medicine for PTSD,” he says. “The spe­cific pro­to­col,” Toz­zoli says, “uses cog­ni­tive be­hav­ioral ther­apy, a struc­tured process that in­volves, in the broad­est sense, chang­ing neg­a­tive thoughts to neu­tral ones. In ad­di­tion, med­i­ca­tion is of­ten use­ful as an ad­di­tional modal­ity but is of­ten not the main fo­cus of treat­ment.”


The odds of beat­ing PTSD are good. “We no longer be­lieve that the will to get bet­ter makes you get bet­ter,” Ka­plan says. “But the will to get bet­ter makes you more mo­ti­vated to re­ceive care, and if that’s the case, you will prob­a­bly have a bet­ter out­come.”

In ad­di­tion, Ka­plan notes that though there no real break­throughs in treat­ment, med­i­cal re­search at VA hos­pi­tals is on­go­ing.

“Be­cause re­turn­ing com­bat­ants have a high fre­quency of PTSD,” he says, “the VA is at the fore­front of re­search.” The bright­est spot on the hori­zon? “Many peo­ple with PTSD will get well,” says Ka­plan, who rec­om­mends suf­fer­ers adopt a low­stress life­style, as stud­ies re­veal a risk as­so­ci­ated with a re­peat episode. “Ac­cord­ing to var­i­ous re­search, 30 to 50 per­cent of PTSD pa­tients will re­solve their symp­toms.”

Toz­zoli says the du­ra­tion of treat­ment de­pends of the level of symp­toms.

“Some level of treat­ment may be needed for a num­ber of years,” he says, “but the in­ten­sity of the cog­ni­tive be­hav­ioral ther­apy can last 12 to 18 months. As with all emo­tional ill­nesses, we en­cour­age peo­ple to seek treat­ment sooner rather than later. Small fires are eas­ier to put out than big fires.”

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