Post-traumatic stress disorder

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Classification according to ICD-10
F43.1 Post-traumatic stress disorder
ICD-10 online (WHO version 2019)

The posttraumatic stress disorder (PTSD), English. posttraumatic stress disorder (PTSD), is one of the mental illnesses from the chapter on stress and somatoform disorders. By definition, post-traumatic stress disorder is preceded by one or more stressful events of exceptional or catastrophic proportions ( psychological trauma ). The threat does not necessarily have to affect yourself directly, but can also have been observed and experienced by others (e.g. as a witness to a serious accident or an act of violence).

PTSD usually occurs within six months after the traumatic event and is associated with various psychological and psychosomatic symptoms. Often, in the course of PTSD, additional accompanying illnesses ( comorbidities ) and complaints occur (in up to 90% of cases). In addition to the typical PTSD basic symptoms of vegetative overexcitability and reliving traumatic memories (or memory fragments ) , so-called flashbacks , there is often a feeling of " emotional numbness " ( numbing ) and helplessness and a shaking of the ego Understanding the world through traumatic experience.

Are more synonyms for PTSD Post-traumatic stress disorder (PTBR) , posttraumatic stress disorder , post-traumatic stress syndrome , psycho-traumatic stress disorder , basal psycho-traumatic stress disorder or posttraumatic stress disorder (English, abbr. PTSD ).

Note: Special features of PTSD in children and adolescents are presented in the article Post-traumatic stress disorder in children and adolescents .

causes

Basically the cause is a psychological trauma , whereby not every trauma necessarily leads to a stress disorder (ergo PTSD is a trauma experience plus a subsequent reaction with illness value ). As the number of trauma experiences increases, the likelihood of developing PTSD increases.

Traumatic experiences

People seek refuge in the Louisiana Superdome from Hurricane Katrina (August 2005) - many were later diagnosed with PTSD.

According to the definition of the AWMF , which also created treatment guidelines for PTSD, the

"Post-traumatic stress disorder [...] a possible follow-up reaction to one or more traumatic events (such as experiencing physical and sexual violence , including in childhood (so-called sexual abuse ), rape, violent attacks on oneself, kidnapping, Hostage-taking , terrorist attack, war, captivity, political imprisonment , torture , imprisonment in a concentration camp , natural or man-made disasters , accidents or the diagnosis of a life-threatening illness) that can be experienced in oneself, but also in strangers. "

This definition has been formulated jointly by the German-speaking Society for Psychotraumatology (DeGPT), the German Society for Psychotherapeutic Medicine and Medical Psychotherapy (DGPM), the German College for Psychosomatic Medicine (DKPM) and the German Society for Psychoanalysis, Psychotherapy, Psychosomatics and Depth Psychology .

According to the current status of the ICD-10 classification system, the diagnosis should only be made if all the symptoms required for the diagnosis of post-traumatic stress disorder are present (full picture of post-traumatic stress disorder), and a traumatic event is also reported in the patient's biography and this event is also reported to the patient corresponds to the severity required by the ICD-10. If the symptoms of a post-traumatic stress disorder are incomplete or if no traumatic event with the required severity is reported in the biography, the diagnosis key for the disease is a F. 43.2 (adjustment disorder ) .

Violent trauma in childhood and adolescence - regardless of whether it is one-off or long-term - often leads to profound disorders in the personality of the victims that go beyond the symptoms of general post-traumatic illnesses. When growing up for a long time in a violent family or social environment, the traumatization often has an effect in the form of an educational character, which is later reflected in a specifically formed structure of thought, feeling, action, communication and values.

It is believed that the classic symptoms of post- traumatic stress disorder (overexcitation, avoidance, intrusion) often occur after monotraumas . Complex disorders (impaired affect regulation, self-destructive behavior, attention disorders, disorders of consciousness, dissociative disorders, changes in the systems of meaning) are more likely to result from man -made disaster , chronic trauma or multitrauma and are also post-traumatic as complexes Called stress disorder .

Post-traumatic stress disorder does not arise due to increased psychological instability, nor is it an expression of a (mental) illness - even mentally healthy and stable people can develop PTSD. However, there are certain risk factors that make a person more likely to develop the full picture of PTSD (see below).

PTSD is an attempt by the organism to survive a traumatic, sometimes life-threatening situation. Therefore the PTB reactions are not caused by a disturbance (malfunction), but rather a "healthy" one, ie. H. normal and appropriate reaction to better protect people from a threatening dangerous situation. Neuroscientists at Utrecht University were able to show that PTSD patients react unusually weakly to physical pain. The term " post- traumatic stress reaction ", which is also common, points to this distinction; at the same time, its conceptual alignment makes it clear the difference to the so-called acute stress reaction , which can occur as a short-term reaction aimed at ensuring survival and not as a lasting impairment like PTSD leads.

Risk and protective factors

Risk factors are stressful life events or circumstances that, individually or in combination, favor the development of PTSD. Risk factors can either precede the trauma (pretraumatic risk factors), be based on the traumatic experience itself (peritraumatic risk factors) or occur after the trauma (post-traumatic risk factors). Risk factors include long duration and severe severity of the trauma.

Compared to accidents or natural disasters, the experience of human violence (e.g. through rape , war , political persecution or torture) usually has more profound consequences. Atrocities that people experienced during a war or in prisons, both as eyewitnesses and as victims, cannot be reconciled with their previous view of the world . What remains is "a nameless horror that is incompatible with the original belief in the existence of humanity". People who already suffered from mental health problems before the trauma are particularly often affected. People without a social network are also particularly vulnerable.

The experience of "mental defeat" (in German: mental defeat) is associated with an increased likelihood of post-traumatic symptoms. Professional helpers (e.g. firefighters, police officers) develop PTSD less often in the event of a disaster than people who are not specially trained.

Egle et al. were able to identify a number of pretraumatic risk factors. These include, among other things, a lack of emotional support from parents or relatives, growing up in poverty , a poor school education of the parents, growing up in a large family with little living space, criminality or dissociality of at least one parent, poor family harmony, mental disorders at least one Parents, authoritarian parental behavior, illegitimacy , growing up with a single mother or a single father, short age gap to the next sibling and poor contacts with peers.

In the most cited study on risk and protective factors of PTSD, a meta-analysis by Brewin et al. (2000), lack of social support and post-traumatic stress were identified as the most important risk factors (mean effect size) and with decreasing relevance: severity of trauma, previous traumatisation, low intelligence, sexual abuse, low social class, psychiatric history, female gender and a different previous trauma than Risk factors with a small effect size.

The National Vietnam Veterans' Readjustment Study , carried out in 1983, provided important insights into risk and protective factors in soldiers. In the course of their lives, 30.9% of the men surveyed and 26.9% of the women surveyed had suffered from PTSD. At the time of the survey, however, only 15.2% of the male and 8.5% of the female veterans still suffered from PTSD. The following risk factors were identified:

  • Risk factors before the combat mission : Depression , punishing upbringing style of the parents, origin from unstable family relationships
  • Risk factors during combat : Peritraumatic dissociation (this is understood to mean dissociation directly after the trauma)
  • Risk factors after combat : stressful life events (such as divorce , loss of loved ones, illness), further trauma

Conversely, corrective factors and living conditions protect against trauma despite potentially traumatic events and situation factors. The following protective factors were identified:

Resilience and salutogenesis

Aaron Antonovsky examined a group of women who had been in a Nazi concentration camp . Their emotional state was compared with that of a control group. The proportion of women whose health was not impaired was 51 percent in the control group, compared to 29 percent of the concentration camp survivors. Not the difference per se, but the fact that in the group of concentration camp survivors 29 percent of women were judged to be physically and mentally healthy despite the unimaginable agony of living in a camp followed by a refugee life was an unexpected result for him.

This observation led him to the question of which qualities and resources had helped these people to maintain their physical and mental health under the conditions of the concentration camp imprisonment and in the years afterwards. So Antonovsky created (in contrast to the pathogenesis concept of traditional medicine) the concept of salutogenesis - the emergence of health.

Under resilience is meant the ability to cope with difficult life successful. Resilient people typically have a number of characteristics:

  • You deal effectively with stress.
  • You have good problem solving skills.
  • If you have any problems, ask for help.
  • They believe that there are ways to deal with life problems.
  • Your relationships with friends and family members are close.
  • You tell people you trust that you have experienced trauma.
  • They are often spiritual or religious.
  • Rather than "victims" ( victim ) they see themselves as "survivors" ( survivor ) - relates to this distinction in English, whether the traumatized person experiences himself as passive and helpless ( "sacrifice") or as a strong and self-determined, usually in Connection with a conscious handling of the trauma (“survivor”).
  • You help others.
  • They are trying to get something positive out of the trauma.

PTSD and genes

There is evidence that the susceptibility to developing antisocial symptoms after abuse may be influenced not only by trauma but also by genetic predisposition . According to several studies, boys with an X-linked low MAO-A activity are more likely to develop behavioral disorders as a result of traumatic experiences than boys without this genetic variant. The gene-environment interaction in this area is highly complex and (as of 2020) only very poorly understood.

frequency

50 to 90 percent of adults and children in the USA experience trauma in their life, mostly in the context of a traffic accident, which does not necessarily have to lead to post-traumatic stress disorder (PTSD). The lifetime prevalence of PTSD in the US is around 8%. In an epidemiological study in Germany in 2008, the one-month prevalence was 2.3%. There were no differences in terms of gender, but there were significant differences in terms of age group (3.4% for those over 60 compared to 1.9% for those aged 30 to 59). The authors identified this as the late effects of WWII .

In exposed persons such as rescue workers, doctors, police officers, soldiers or refugees, the prevalence can rise to over 50%. According to a German sample, abuse led to the development of PTSD in 30% of cases, and rape in every second person affected. According to a 2011 study by the University of California of women with PTSD, PTSD is more likely to have chronic inflammation associated with PTSD, which can lead to heart disease and other chronic, life-shortening diseases.

According to Guido Flatten and Arne Hofmann 2001, the probability of PTSD occurring after political imprisonment and persecution is significantly higher than stated here, namely 50–70%. However, these numerical values ​​cannot be directly compared with the other data because the authors use different criteria for the diagnosis than those required by the World Health Organization.

According to a study from 2004, 38.8% of soldiers experience combat situations in which they develop PTSD. After the experience of the Vietnam War, quotas of more than 30% of the combatants had to be expected. Ten years after the start of the war in Afghanistan and Iraq , unexpectedly few American soldiers suffer from PTSD. In a review article from 2012, the psychologist Richard McNally from Harvard Medical School reports that, depending on the study, 2.1 to 13.8% of those involved in the war are sick. In the methodologically most reliable study, 7.6% of the soldiers involved in combat showed the typical symptoms of PTSD. A new British study by King's College in London concludes that the public has a wrong view of the numbers of soldiers affected. Two thirds of respondents believed that post-traumatic stress disorder was much more common in soldiers than in civilians. The scientists lead this perception u. a. back to the numerous reports in the media about the traumatic stress suffered by soldiers and to the actions of charities that raise awareness of PTSD and its consequences.

In November 2015, general physician Bernd Mattiesen , officer in charge of post-traumatic stress disorders in the Bundeswehr, announced that 2.9% of German soldiers who are usually on duty for four to six months were diagnosed with PTSD according to current studies.

Diagnosis

It is believed that Samuel Pepys suffered from PTSD after the Great London Fire.

history

The symptoms of PTSD have likely been around for as long as people have been around. They can be found time and again in historical reports, for example that of Samuel Pepys , who witnessed the great fire of London in 1666 . Six months after the catastrophe he wrote in his diary: “How strange that to this day I have not been able to sleep at night without being gripped by a great fear of the fire; and that night I lay awake until almost two o'clock in the morning because the thoughts of the fire did not let me go. "

The concept of rape trauma syndrome (Rape trauma syndrome RTS) developed in the 1970s with regard to the traumatic effects of rape is now considered to be PTSD. The theory was first proposed by Ann Wolbert Burgess and sociologist Lynda Lytle Holmstrom in 1974. The same applies to the description of the consequences of sexual violence developed in the 1980s. A number of other syndromes (was sailor syndrome, trench foot, abused child syndrome) are now counted as PTSD.

However, PTSD has only recently received attention in medicine. The symptoms of PTSD have only been the subject of scientific research since the middle of the 19th century; At the end of the 19th century, the German psychiatrist Emil Kraepelin coined the term shock neurosis (or "shock psychosis") to describe the symptoms that occurred in victims of serious accidents and injuries, especially conflagrations, derailments or collisions on the railroad.

At the time of the First World War one spoke of the "bomb-shell disease"; in Germany, PTSD patients were called " war tremors " at the time. After the Second World War, the so-called concentration camp syndrome was described in Holocaust survivors . According to the Federal Agency for Civic Education, little research has been carried out on the consequences of the traumatization of people in Germany after the Second World War .

Although the symptoms of PTSD have been scientifically investigated for over 100 years, the diagnosis was first included in the American Diagnostic and Statistical Manual of Mental Disorders (current version: DSM-5 ), published by the American Psychiatric Association (APA) in 1980 is issued. This development was significantly shaped by American soldiers returning from the Vietnam War and the description of the Post Vietnam Syndrome (PVS) , which is especially known in the English-speaking world .

In the DSM-5, the syndrome is now listed under 309.81 as a form of trauma and stressor-associated disorders. According to the ICD-10 (International Classification of Diseases) of the WHO, PTSD has the code F43.1.

According to ICD-10

For the diagnosis of PTSD according to ICD-10 , the following criteria must be met:

  • The victim was exposed (short or long-term) to a stressful event of exceptional threat or of catastrophic proportions that would arouse profound despair in almost everyone.
  • There must be persistent memories of the traumatic experience or the repeated experience of the trauma in intrusive memories (reverberation memories, flashbacks , dreams, or nightmares) or an inner distress in situations that are similar or related to the stress.
  • The person concerned avoids (actually or as far as possible) circumstances that are similar to the stress.
  • At least one of the following criteria (1st or 2nd) is met:
  1. a partial or complete inability to remember some important aspects of the stressful experience; or
  2. persistent symptoms of increased psychological sensitivity and arousal, with at least two of the following characteristics:
  • Difficulty falling asleep and staying asleep
  • increased jumpiness
  • Hypervigilance
  • Difficulty concentrating
  • Irritability and outbursts of anger
  • Symptoms must have appeared within six months of the stressful event (or period of stress). Otherwise, it is referred to as PTSD with a delayed onset. This can only occur after many years.

Social withdrawal, a feeling of numbness and emotional dullness, indifference to other people and an impaired mood are also common.

According to DSM-5

For the PTSD diagnosis according to DSM-5 , the following criteria must be met:

A. Traumatic Event: The individual faced one of the following events: death, threat of death, serious injury, threat of serious injury, sexual violence, threatened sexual violence, in any of the following ways (at least one):

  1. Directly exposed
  2. As eyes witness
  3. Indirectly; learn that a close relative or friend has been exposed to a traumatic event. If this event was a death or a fatal threat, then it must have been the result of violence or an accident.
  4. Confrontation with details of traumatic events (e.g. as a first aider, police officer ...), possibly also as a confrontation through electronic media.

B. Reliving: The traumatic event is relived in one of the following ways (at least one):

  1. Recurring, involuntary and haunting stressful memories (children older than 6 years can potentially express these in repetitive play).
  2. Traumatic nightmares (children can have nightmares without the content directly relating to the traumatic event).
  3. Dissociative reactions (e.g. flashbacks), varying in duration from a short episode to loss of consciousness (children can recreate the traumatic experience in play)
  4. Intense or prolonged stress after the person is reminded of the traumatic experience (regardless of the cause of the memory).
  5. Distinctive physiological response after the person was exposed to a stimulus related to the traumatic experience.
The left soldier has the look referred to as Two Thousand Yard Stare . This can be a precursor or symptom of PTSD.

C. Avoidance: Persistent strong avoidance behavior of trauma-associated stimuli after the traumatic experience (at least one):

  1. Trauma-associated thoughts or feelings
  2. Trauma-associated external stimuli (e.g., people, places, conversations, activities, objects, or situations).

D. Negative changes in thoughts and mood: The negative changes in thoughts and mood began or worsened after the traumatic experience (at least two):

  1. Inability to remember important features of the traumatic experience (usually dissociative amnesia; not due to a head injury, alcohol, or other drugs )
  2. Persistent (and often distorted) negative assumptions about yourself or the world (e.g. "I am bad", "The whole world is dangerous")
  3. Persistent distorted accusations against yourself or others of being to blame for the traumatic experience or its negative consequences
  4. Persistent negative trauma-associated emotions (e.g. fear, anger, guilt, or shame)
  5. Significantly reduced interest in important (non-trauma-associated) activities
  6. The feeling of being a stranger to others (e.g. detachment or alienation)
  7. Limited affect: persistent inability to experience positive emotions

E. Changes in arousal and responsiveness: Trauma-associated changes in arousal and responsiveness that started after the traumatic experience or worsened afterwards (at least two):

  1. Irritable or aggressive behavior
  2. Self-harming or careless behavior
  3. Increased vigilance
  4. Excessive startle reaction
  5. Difficulty concentrating
  6. sleep disorders

F. Duration: The disorder (all symptoms in B, C, D and E) lasts longer than a month.

G. Functional Significance: The disorder causes suffering or impairment in a clinically significant way in social, professional or other important functional areas.

H. Exclusion: The symptoms are not the result of medication, substance use or other illnesses.

To be specified for dissociative symptoms: In addition to the diagnosis, a person may have a high degree of either of the following two reactions:

  1. Depersonalization: The feeling of being outside of your own body or of being detached from yourself (e.g. feeling as if “this didn't happen to me” or of being in a dream).
  2. Derealization: The feeling of unreality, distance or distortion of reality (e.g. "these things are not real").

To be specified in the case of delayed onset of the clinical picture: Complete diagnostic criteria are not met in the first six months after the traumatic event (some symptoms can, but do not have to be present immediately after the traumatic event).

Demarcation

PTSD is just one of several possible sequelae of trauma . Related disorders are:

Further trauma-related disorders can include:

Other disorders that can be largely caused by traumatic stress:

Connection with borderline disorder in childhood trauma

The extent to which trauma suffered in childhood can later lead to other disorders, such as borderline personality disorder (BPD), is controversial in science. People with a borderline disorder report more than average experiences of sexual violence (around 65 percent), physical violence (around 60 percent) and severe neglect (around 40 percent), cumulative over 85 percent and more of rememberable, relevant traumatic childhood experiences , mostly multiple traumas. It should be noted, however, that the most severe trauma often arose in early childhood (the first two years of life are most sensitive to trauma) and that memories of such events can usually no longer be recalled ( infantile amnesia often extends well beyond the second year of life).

On the other hand, many scientists criticize the claim that “the borderline disorder is a chronic post-traumatic stress syndrome.” This statement finds “no evidence on a scientific level”.

Symptoms

General symptoms

General symptoms of post-traumatic stress disorder:

  • lasting memories of the traumatic experience or repeated, to aufdrängendes ( intrusive ) (re) experiencing the trauma, flashbacks , nightmares , with the traumatic experience in connection (available here may often small-timer ( trigger ), for example einschießende awareness images, perceptions , evoke intrusive thoughts or ideas or arouse violent emotions to the traumatic experience, as if it were happening in the present, even if some of those affected can no longer consciously remember what actually happened)
  • Avoidance behavior (those affected avoid (actual or possible) circumstances that are similar to the stress and discussions about topics related to the trauma)
  • Partial amnesia (partial or complete inability to remember some important aspects of the stressful experience)
  • physical symptoms of vegetative overexcitation ( hyperarousal ) and increased psychological sensitivity:
  • emotional numbness (also emotional numbness symptom or numbing (English 'numbness'), lack of interest and feelings, feeling of alienation towards fellow human beings, the world, one's own life
  • emotional and social withdrawal

More symptoms

Feelings of helplessness and being exposed

Maslow hierarchy of needs.svg

According to Abraham Maslow , the need for security is one of the basic human needs . People prefer a safe, predictable, controllable environment to an environment that is dangerous, uncontrollable, and unpredictable. Normally, people learn in the course of their childhood and adolescence that their needs for security and protection from danger are met - an exception are children who have been neglected (also emotionally), abused or abused by their parents , children who grow up in war and children in similar exceptional situations. A person whose security needs have been met comes to the following basic beliefs:

  • The world is a safe place, most people are well-meaning.
  • The things that happen in the world happen for certain reasons.
  • Good things will happen to good people.

After trauma, these core beliefs often seem to be in question. The world now appears hostile, unpredictable and chaotic. The conviction that the world is reliable is lost.

The occurrence of symptoms is variable; for example, they can occur immediately after experiencing the trauma or with a delay of many years or decades.

Loss of previous beliefs about the world and yourself

A trauma can permanently damage a previously existing feeling of basic security and security in life and the basic trust in life and fellow human beings and occasionally even call into question earlier basic beliefs about the world and oneself and the meaning of life. Traumatized people often find the world and those around them suddenly threatening and no longer trustworthy.

Many of them also blame themselves and develop a negative image of themselves based on the mistaken assumption that they could have positively influenced the catastrophic outcome of the event through different behavior if they had not made a mistake themselves or were stronger, more determined , braver or smarter. This often creates excruciating feelings of guilt and shame. Often, a supposed weakness is also seen in one's own trauma and the resulting (and for many inexplicable) symptoms of PTSD and in the slow progress in coping with the trauma.

Difficulty finding your way back into later life

Many people have difficulty resuming their old lives after trauma. It is often difficult to maintain relationships and social contacts, as well as hobbies and previous interests. After severe trauma, there is an increased risk of long-term disability. Statistics show that one in four homeless people on America's streets is a veteran of war. According to the Ministry of Veterans Affairs, almost 200,000 ex-soldiers are without permanent residence. Many of them are Vietnam War veterans , but there are also an increasing number of unemployed and homeless Iraq War veterans .

"Speechless terror"

Trauma patients repeatedly report speechless terror that comes over them when they remember the trauma. They are often unable to express how they feel or think about the events and are unable to use words to describe the trauma.

Comorbidities

Possible accompanying illnesses, so-called comorbid disorders :

Physical complaints

Traumatized people are in a kind of constant alarm mood because the excitation threshold in the CNS is lowered after a trauma and even small stresses can trigger a more lasting and stronger arousal. Little things that are reminiscent of the trauma, key stimuli such as B. Photos, people, news, films, sounds, smells, surroundings or anniversaries that trigger memories, so-called triggers can cause physical symptoms such as palpitations, tremors, sweat, shortness of breath, nausea and fainting attacks.

Increased mortality

Wolff (1960) found in a study of former prisoners of the Second World War that within the first six years after their release, nine times as many of these people died of tuberculosis as would be expected in civil life. The rates for death from gastrointestinal disease, cancer, and heart disease were also increased. Bullmann and Kang (1997) found an association between PTSD and an increased risk of death from external causes (such as accidents or overdoses ) in Vietnam War veterans.

Parents and ancestors with PTSD

In the bond research showed a link between trauma of the parents and a bond uncertainty of small children there. Because of this transgenerational transmission of trauma, it is important when examining children with attachment disorders (e.g. "secure base distortion") or who are brought up by traumatized parents to include parent-child interaction through anamnesis and detailed direct and video observation analyze and take a two-generation perspective. In such a case, parent-child psychotherapy can be helpful.

The parenting program SAfE - Safe Education for Parents for Parents- to-be, developed by child psychiatrist Karl Heinz Brisch , aims to develop parental sensitivity . This is intended, among other things, to prevent one's own negative attachment experiences from being passed on to the next generation. Otherwise, a disorder of attachment to adulthood can influence social behavior and relationship-based attachment behavior (e.g. insecure-ambivalent, insecure-avoidant or disorganized BV instead of secure BV). ( See also: Trauma and Attachment and Childhood Trauma : Life Disadvantages , and Identity-Oriented Psychotrauma Therapy .)

The psychologist and social worker Joy DeGruy postulates the existence of a Posttraumatic Slave Syndrome PTSS , which is caused by the collective trauma of slavery and also affects the generation of African-Americans who have never been slaves. Among other things, it expresses itself in rejection of the school system and devaluation of one's own ethnic group.

Prevention through "debriefing"

Psychological “de briefing ” should support the processing of a traumatic experience within a time frame of 1–2 days to around 2–3 weeks after the traumatic situation and thus prevent the development of PTSD. It was developed for those affected and for helpers such as rescue workers or police officers. Debriefing consists of a relief talk through which those affected deal directly with the event and share their feelings with a therapeutically trained person in order to structure the memories of the event. However, overview studies found that psychological debriefing cannot be helpful and even counterproductive by reinforcing memories of the traumatic experiences. In 2017, the American Psychological Association rated the method as unsupported and potentially harmful.

Trauma therapy

PTSD is often chronic , but can usually be treated relatively well with psychotherapy , so that a cure or at least a significant alleviation of the stress symptoms and a recovery in quality of life can often be achieved; Mild PTSD often improves spontaneously, but more severe PTSD can also improve on its own over time. Social support , especially from family and friends, is important in overcoming traumatic experiences .

The basic prerequisite for the psychotherapeutic processing of a trauma is always that the traumatisation (and also the traumatic threatening or dangerous situation and possibly the contact with the perpetrator) has to be ended, since it is not possible with the actual psychotherapeutic processing of the traumatic memory and the trauma-related disorders to begin while the person concerned is still in a traumatizing situation (nevertheless, a trauma-therapeutic help to stabilize and better cope with the stressful situation can be useful or necessary here, as this often counteracts the development of more severe PTSD or chronification and has a favorable effect on the course of the disease can be).

In most cases, at least after moderate or severe trauma, or if more severe post-traumatic complaints and symptoms occur (see above), it is advisable to consult a psychotraumatologically experienced doctor or psychotherapist as soon as possible and to get expert advice and to discuss the next steps (even if the traumatizing situation should still persist). The time factor (i.e. the time between the trauma and the start of trauma therapy) plays an essential role for the success of the treatment and for the symptoms to improve as quickly as possible. Particularly after severe trauma, it is important as early as possible (if possible within the first few weeks) to provide suitable trauma therapy (tailored to the needs of the patient, concrete psychotherapeutic support measures to cope with the stress, behavioral therapy exercises and assistance that helps to deal with the Relieve symptoms (psychoeducation and stabilizing treatment included) to reduce the risk of long-term effects and chronic residual complaints . According to the findings of psychotraumatology and the recommendation of guidelines, trauma treatment should only be carried out by psychotherapists with well-founded specialist training and experience in trauma therapy; if severe dissociative symptoms or CPTBS develop, the therapist should also have additional qualifications in these areas. It should be borne in mind that in Germany there is a considerable shortage of psychotherapists with specialist training in trauma therapy who have sufficient experience in the treatment of severe trauma-related disorders and who usually have long waiting times. If the traumatic stressful situation persists, psychotherapeutic stabilization and support for better coping with traumatic stresses should be started, if necessary, in order to support the person concerned in dealing with their acute complaints and internal and external stresses and to stabilize them mitigate the consequential damage caused by trauma.

With regard to a suitable therapy (selection of a suitable psychotherapeutic method, possibly medical support to alleviate symptoms, in severe cases also partial or full inpatient treatment), the treatment decision should be based on the severity and type of trauma, the main symptoms, as well as any clinical Comorbidity of the person concerned can be made dependent. For these decisions, the person concerned should seek qualified advice (e.g. from a specialist doctor or psychologist, trauma therapist or an appropriate counseling center) and discuss which treatment options are sensible and which therapy methods are recommended in the specific case. In doing so, advice can also be given about the most sensible further course of action and possibly also a combination of the measures mentioned (if this should be necessary) and information about other offers of help for traumatized people. So the patient can z. B. as part of a psycho-education about his difficulties and give him a better understanding of his symptoms and their causes, as well as strategies and techniques for better handling his complaints. If the traumatic complaints also severely impair everyday life, the person concerned cannot take care of himself or go to work and suffers from severe complaints or there are concomitant diseases (comorbidities), medical treatment of the symptoms can be considered, which according to the prevailing opinion Cannot replace trauma therapeutic treatment (but may make it easier) in order to alleviate stressful symptoms (e.g. sleep disorders, anxiety and panic attacks, overexcitation, etc.) and to achieve better coping with life and therapeutic ability. In some cases, day-care treatment can be useful at the beginning of treatment. Full inpatient treatment can be considered for stabilization in the case of severe panic reactions and other very severe symptoms and severe comorbidities. As a rule, full or partial inpatient treatment should be followed by more extensive outpatient trauma therapy.

Psychotherapies

There are many different methods available for treating psychotraumas. Many of these procedures have been developed specifically for trauma treatment and are based on different results of research on the effects of trauma . Every major psychotherapy school has developed its own approaches to treating traumatic disorders, such as: B. Methods of cognitive behavioral therapy or behavioral therapy and psychodynamic methods.

The aim of psychotherapeutic procedures is to come to an orderly processing of the trauma or trauma and thereby either limit or control or resolve the symptoms typical of trauma. The various methods can in part be used as complementary multidimensional approaches.

Cognitive behavioral therapy

The cognitive behavioral therapy has been further developed for the treatment of trauma consequences. The emergence and maintenance of symptoms is explained in behavior therapy with the behavioral model by Foa and Kozak from 1986 or the cognitive-behavioral model by Ehlers and Clark from 2000. As a particularly effective method of behavior therapy that has been here exposure therapy emerged, which in turn was modified specifically for the treatment of PTSD. The affected person should get used to the traumatic situation through the protected reminder. According to the AWMF guideline , behavioral therapies that also include trauma confrontation have been the most widely studied and have consistently shown positive effects on effectiveness. However, this is only possible if the patient is sufficiently stable. With the current state of knowledge, no general clinical treatment recommendations can be derived. In these cases, metacognitive therapy could be a possible alternative, which is currently still being investigated in more detail in studies. The treatment decision should be based on the severity and type of trauma (e.g. natural disaster, major accident or man-made disaster) , such as combat deployment, observation of the violent death of others, or victim of torture, terrorism, rape or other crimes ) and the main symptoms, as well as the clinical comorbidity of the person affected. There are also studies that suggest that prolonged exposure is particularly effective when fear is the dominant emotion, while it is only of limited effectiveness when feelings of shame, guilt or anger are in the foreground. From the point of view of Boss and Schönfeld (2014), in the case of pronounced feelings of guilt and rather low dissociative symptoms, a cognitive disputation of your fears seems most promising, since the cognitive factors in maintaining PTSD played a greater role than avoiding fear. In contrast to this, the authors consider exposure therapy to be sensible, even with pronounced dissociation, since it usually serves to avoid fear.

Narrative exposure therapy (NET)

The Narrative Exposure Therapy (NET) is also associated with cognitive behavioral therapy and is applied especially in Mehrfachtraumatisierung and after organized violence treatment. The procedure was developed on the basis of testimony therapy, which was developed for the treatment of those persecuted by the Pinochet regime . The effective understanding of the process is that the specific memory problems of the traumatized result in a lack of localization and historiography of the traumatic scene and emotional memory contents remain unconnected. In order to achieve a spatio-temporal connection of the traumatic experiences, the patient positions himself together with the therapist in the present and, telling the story in chronological order, relives his entire life story. The focus is on negative and traumatic events, with positive experiences being (re) discovered as a resource . Through the intensive re-experiencing, the past is actualized on all levels in the present (thoughts, feelings, meanings, sensations, posture, etc.). In the narrative approach, this is worked on until the experience can be classified, named, understood, and localized autobiographically and relief occurs through habituation and integration. In the treatment sessions, the patient gradually creates a detailed and consistent, written narration of his life events in dialogical contact with the counterpart , which is intended to serve as a testimony and recognition of the injustice suffered. There is now good empirical evidence for the effectiveness of NET in simple and multiple trauma. The therapy method is recommended internationally.

Prolonged Exposure (PE)

Also Prolonged Exposure (PE), German prolonged exposure therapy is emerged from the cognitive behavioral therapy. It consists of two main components: First, in vivo exposure , that is, repeated exposure to situations, activities, and places that are avoided due to traumatic memories. These confrontations are intended to reduce trauma-related fears and enable the patient to realize that avoided situations are not dangerous and that they can deal with the suffering. In addition, there is the imaginative exposition , ie the repeated retelling and processing of the traumatic experience. The imaginative exposure is intended to promote the processing of the trauma memory and help to gain a realistic perspective on the trauma. Prolonged Exposure typically takes 8–15 sessions to deal with trauma. PE is performed worldwide to treat patients with a variety of traumatic experiences such as rape, assault, child abuse, war, traffic accidents and natural disasters.

Psychodynamic procedures

In addition, there are also some psychodynamic procedures that have been specially tailored to the treatment of PTSD. In Germany, the Psychodynamic Imaginative Trauma Therapy ( PITT ) developed by Luise Reddemann should be mentioned, which is mainly used to treat a complex post-traumatic stress disorder . The multidimensional psychodynamic trauma therapy (MPTT) by Gottfried Fischer and Peter Riedesser is a method used to treat this disorder. The Ego-State-Therapy developed by John Watkins and Helen Watkins is a resource-oriented, imaginative psychotherapy procedure that is particularly suitable for the reintegration of traumatically separated personality parts. In the group of imaginative procedures, different treatment procedures are usually combined (often also in connection with EMDR), which enable the person affected to achieve a careful integration of the traumatic experience. For this they can withdraw to an inner, safe place if the emotions that accompany the traumatic memories become too strong. The integrative trauma therapy , developed by Willi Butollo at LMU Munich, is also a combination of different treatment methods that have proven to be useful for the psychotherapy of PTSD. All modern treatment approaches have in common that they are designed to be integrative, i.e. mostly combine several procedures.

EMDR

The eye movement desensitization and reprocessing is a form of treatment that has been specifically developed for the treatment of trauma and the other within the framework therapy method can be applied. In the EMDR, elements of psychodynamic imaginative trauma therapy (PITT) and cognitive behavioral therapy were integrated and expanded through the approach of intersphere communication. In the EMDR, the affected person is introduced to the traumatizing situation in a protected setting through discussions. The core element of the EMDR treatment is that when remembering, the traumatic experience is to be integrated by quickly changing the direction of gaze or another form of alternating stimulation of both halves of the brain (intersphere communication). While there is multiple evidence of the effectiveness of EMDR, the mechanism of action of intersphere communication has now been refuted several times. The eye movements do not seem to have any additional positive effect. EMDR is also assessed as an effective treatment method for PTSD in the AWMF guidelines, but the treatment should be carried out by well-trained and experienced therapists and with a sufficiently high number of treatment sessions (Sack et al. 2001)

Further treatment approaches

A biologically oriented approach ( Somatic Experiencing ) for the treatment of shock and trauma effects was developed by Peter Levine. Through the dosed and consciously executed completion of biological self-protection and orientation reactions, the energy fixed in the trauma is released and the nervous system returns to its natural balance.

Nightmares can be combated with the “ imagery rehearsal ” procedure: During the day, the person concerned imagines that the nightmare will end well. It is not important to visualize every single nightmare. The patient uses a typical recurring dream action, paints it out in every detail and invents a good ending. This procedure can relieve not only nightmares but other symptoms as well.

In inpatient, semi-inpatient and other holistic treatment settings, creative therapy methods, such as B. Art therapy is used.

Pharmacotherapy

From a certain severity of the symptoms, drug therapy for the trauma-related disorders can be considered. In this case, psychotropic drugs are used in addition to psychotherapy . Psychotropic drugs influence the balance of neurotransmitters in the brain and thereby interfere with the patient's brain functions. However, since none of the previously available drugs have a causal effect, they cannot replace psychotherapeutic trauma therapy, but in some cases they can prepare or accompany it. The selection of the respective drug is symptom-oriented and depends on the complaints that are in the foreground.

Critics complain that medication in trauma patients is often a helpless reaction by doctors to relieve the symptoms of the suffering patient with medication and that a subsequent discontinuation of the medication after the crisis has been overcome is often no longer risked. Drug treatment can also lead to the fact that trauma-focused psychotherapy is not started or is only started too late, thus increasing the risk of post-traumatic stress disorder with chronic residual symptoms.

Current study situation

Little has changed in recent years in the rather cautious assessment of pharmacotherapy in the treatment of PTSD. Trauma-focused psychotherapy is the method of choice. The study situation on the use of psychopharmacotherapy, on the other hand, is still inconsistent. Nonetheless, psychotropic drugs are often used in everyday clinical practice for PTSD. This may be due, on the one hand, to the fact that further psychological symptoms occur to a large extent with PTSD, and especially in complex and chronic forms, and, on the other hand, because trauma-specific psychotherapy places are too rarely available promptly. Tormenting symptoms such as sleep disorders and overexcitation often make those affected crave calming or depressant medication, which can also lead to self-medication through alcohol or drug abuse.

In recent years a variety of substances were examined for their potential efficacy, it could the substances trazodone , quetiapine , mirtazapine , gabapentin , desipramine , prazosin , alprazolam , clonazepam , nefazodone , brofaromine, bupropion , citalopram , Divalproat, risperidone , tiagabine and topiramate however, do not show convincing efficacy in controlled studies.

Statistically significant findings for their effectiveness, albeit with low effect sizes , which were clearly below those of trauma-focused psychotherapeutic treatment and sometimes only slightly more effective than placebo, were only found for individual substances such as venlafaxine , paroxetine , sertraline , phenelzine .

Benzodiazepines

The use of medication should be reserved for specialist treatment, who must consider possible side effects as well as a differentiated approach to possible withdrawal from medication. This is especially true when dealing with benzodiazepines . Their use in PTSD, even in insomnias , is clearly discouraged. An extensive meta-analysis showed that benzodiazepines are ineffective for the treatment and prevention of PTSD. The risks associated with ingestion outweigh the potential short-term benefits. Unfavorable therapy results, aggression, depression, substance use, and a generally higher degree of PTSD severity were observed in connection with the use of benzodiazepines.

The administration of benzodiazepines immediately after the stressful event, with the aim of positively influencing the course of the disease, proved in clinical studies to be unsuitable or possibly even disadvantageous for the people being treated. We therefore advise against the early use of benzodiazepines. There are also results from animal experiments which indicate that the use of a benzodiazepine favors the development of symptoms.

Approval and guideline recommendation in Germany

In Germany, only sertraline and paroxetine are approved for the treatment of PTSD.

The current S3 guideline comes to the following recommendations against the background of the evidence described :

  • Psychopharmacotherapy should neither be used as the sole nor as the primary therapy for post-traumatic stress disorder (recommendation 8).
  • If, after an informed and participatory decision-making process, despite the minor effects, medication is preferred, only sertraline, paroxetine or venlafaxine should be offered (recommendation 9).
  • Benzodiazepines should not be used (recommendation 10).

The economic calculation showed that pharmacotherapeutic treatment of PTSD (with SSRI) is less cost-effective than short trauma-focused cognitive behavioral therapy , EMDR or self-help with support.

History

The French philosopher, psychiatrist and psychotherapist Pierre-Marie-Félix Janet (1859–1947).

For the first time, the psychological consequences of trauma were discovered in 1900 BC . . Chr described by an Egyptian doctor. In 1859, Pierre Briquet noted hysterical symptoms in many patients after traumatic experiences and in 1867 Jean-Martin Charcot was the first to describe psychological concepts for the development of " traumatic hysteria ". While Joseph Babinski (1886) reduced these hysterical phenomena to simulation and suggestibility and thus paved the way for a problematic treatment of the later war neuroses (see below) and thus helped to shape the later development of psychoanalysis by S. Freud, Pierre Janet , the founder of modern dynamic, developed Psychiatry , as early as 1889 a theory that is still valid today about the processing of traumatic experiences. Janet viewed the trauma response basically as a memory disorder that prevented the integration of traumatic memories into existing cognitive structures, leading to their separation from consciousness and volitional control, and dissociation and amnesia , and causing the psychological and somatoform trauma symptoms. He developed a therapeutic approach for traumatized patients in order to achieve the reduction of post-traumatic stress and a cognitive reintegration of traumatic memories with a systematic, phase-oriented treatment. As early as 1889, Janet anticipated important findings of modern psychotraumatology and therapy, as well as dissociation, in essential parts, which were largely forgotten for almost 100 years.

Josef Breuer and Sigmund Freud pursued another theory in their " Studies on Hysteria " (1895) and described the possible long-term consequences of trauma as a subclass of hysterical illness (see " Traumatic hysteria ") and thus determined further trauma research for a long time public perception. At the end of the 19th century, the German psychiatrist Emil Kraepelin coined the term shock neurosis to describe the symptoms that showed up in victims of serious accidents and injuries, especially conflagrations, derailments or collisions on the railroad. The Freud student Abram Kardiner also described the symptoms of PTSD in more detail. The PTSD symptoms were given various other names in the last century, for example, when referring to the war victims of the First World War , one spoke of “ grenade shock ”, “grenade fever” or one (in the First World War with a kind of electrical shock like the Kaufmann method treated) "war neurosis". The so-called war tremors became known in this context . Some of the “war neuroses” (according to Maja Möller, Monika Pritzel and Reinhard Steinberg: Diagnostics for “war neurotics” ) today have to be diagnosed and treated as post-traumatic stress disorder.

The British Army alone counted 80,000 soldiers by the end of the war who had reached their “breaking point”, who were burned out and no longer operational. However, the doctors' knowledge, which was established relatively quickly, that they were dealing with an independent clinical picture, did not prevail either in the military leadership or in the civilian population. The latter often greeted psychologically traumatized returnees with the deepest contempt. The soldiers were made to feel that they were considered cowards. Several hundred of these patients never returned to Great Britain: the army command had them shot for cowardice. In Germany, the number of executions is said to have run to around two dozen.

With the term survivor syndrome , the psychiatrist William G. Holland used the psychological consequences of persecution and concentration camp imprisonment under the National Socialist regime. In more than a hundred appraisal processes, he also had to deal with the reports of the conservative German psychiatrists, who in almost all cases were unable to determine any disease value in the concentration camp survivors, attested a pension neurosis or attributed the disease to the survivors' "weak constitution". Even Kurt Eissler criticized the German post-war psychiatry. In his article The murder of how many of his children must a person be able to endure symptom-free in order to have a normal constitution? from 1963 he deals with the feud that took place between the US and the German reviewers regarding the recognition of a post-traumatic stress disorder. Milton Kestenberg examined various discriminatory aspects of German compensation practice and emphasized that it was not until 1965 that German courts recognized the possibility of a causal connection between psychiatric conditions and persecution.

The term PTSD was mainly introduced by the American psychologist Judith Lewis Herman as a consequence of her work with Vietnam War veterans as well as women affected by domestic violence . Other pioneers of research on war trauma are Robert Lifton and later Jonathan Shay .

The German psychologist David Becker , who worked for many years in Chile with extremely traumatized people from the Pinochet dictatorship , presented his experiences with these patients in his book Without Hatred No Reconciliation . He also described the introduction of the PTSD diagnosis as being related to the veterans of the Vietnam War, but was critical of the diagnosis insofar as it initially served as a defense against compensation payments to the soldiers.

Representation in literature and media

The diagnosis of post-traumatic stress disorder was first included in the Diagnosis Manual DSM III (currently DSM IV ) in 1980 , but there are already references to PTSD in older literary works. Jonathan Shay recognizes symptoms of PTSD in the portrayal of Sir Henry Percy ("Hotspur") in William Shakespeare's Henry IV . Hotspur has trouble sleeping and nightmares, loses interest in pursuits that previously gave him pleasure, and becomes jumpy and moody. In the depiction of Achilles , Shay recognizes clear characteristics of PTSD. Poets have repeatedly described traumatizing living conditions and highlighted the possibilities of those affected to survive in them. Often the presentation has shaken the reader or even had socially changing effects. One example is the novel Oliver Twist by Charles Dickens . This describes the psychological situation of a boy who has lost his parents. Dickens shows how social institutions, which are supposed to alleviate the boy's plight, instead contribute to further trauma. Books that deal explicitly with PTSD include the autobiographical A Rumor of War by Philip Caputo , In the Lake of the Woods by Tom O'Brian, and the National Book Award- winning Paco's Story by Larry Heinemann .

Post-traumatic stress disorder has been featured in films such as Waltz with Bashir by Ari Folman , Rambo by Ted Kotcheff , Birdy by Alan Parker , Coming Home - They're Returning Home by Hal Ashby , Going Through Hell by Michael Cimino and Born on July 4th and Between Heaven and Hell by Oliver Stone .

In 2005, Klaus Dörner complained that post-traumatic stress disorder had become a fashion diagnosis. After existentially drastic experiences, people could in very rare cases break so deep inside that they were marked for their entire life and needed help. But this thought, correct in itself, is being completely overstretched at the moment.

After two films were released in 2008 that deal with the syndrome in connection with the war effort in Afghanistan ( night before eyes and welcome home ), politicians in the German Bundestag demand that the care of soldiers affected be strengthened and further developed. The then German Defense Minister Franz Josef Jung (CDU) thanked the ARD for the broadcast of the film Welcome home . The 2011 documentary Hell and Back Again deals with a US soldier who is returning from the war in Afghanistan and struggling with post-traumatic stress disorder.

Since 2017, the topic has also been dealt with in “ Babylon Berlin ”. In the series set after the First World War, various war returnees can be seen who have the so-called "Flattermann" (war tremors). They are treated with various sedatives and barbiturates.

Chronology of the names

Popular saying:

See also

literature

General

Psychoanalysis

  • David Becker: Without hatred, there is no reconciliation. The trauma of the persecuted . With a foreword by Paul Parin . In cooperation with medico international and the Stiftung Buntstift eV, Federation of Grünnaher state foundations and educational institutions. Kore, Freiburg (Breisgau) 1992, ISBN 3-926023-27-9 .

Web links

Individual evidence

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  2. ↑ Classification of post- traumatic stress disorder according to ICD-10 F43.1
  3. ↑ S3 guideline on post-traumatic stress disorder, AWMF register number 051/010. P. 3.
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