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Medical Articles »Gordon Baumbacher, M.D.
Post Traumatic Stress Disorder Claims: Accurate Diagnosis is Critical
Gordon Baumbacher, M.D.
Psychiatry
Once a diagnosis of the battlefield, Post-Traumatic Stress Disorder (PTSD) has increasingly become a diagnosis of civilian life and the workplace. PTSD may be both under and over diagnosed in the industrial setting with poor outcomes expectable in either case affecting an injured worker's length of temporary total disability, level of permanent disability, and medical treatment costs. Historically, acceptance of the idea that profound and sometimes lasting psychological damage can result from exposure to physical trauma has been resisted. Although "Soldier's Heart" was recognized at the time of the Civil War, and "Shell Shock" in World War I, attitudes toward victims of these conditions were frequently infused with moral judgments such as cowardliness. Not until the anti-war movement that followed WWI did a political and social context develop that stripped away the veil of glorification, which had hidden the horror faced by combatants, and supported an awareness of the resultant emotional carnage. Since that time, a large clinical and research literature has developed regarding the deleterious effects of such exposure; effects that have come to be diagnosed as Post-Traumatic Stress Disorder.
Diagnostic Criteria for PTSD
The diagnosis of Post Traumatic Stress Disorder is now defined by a primary criteria and three essential characteristics in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The primary criteria for the disorder is that it must be precipitated by exposure to real trauma in which the individual is threatened with severe injury or death, or is witness to the same in others, and simultaneously the person feels a sense of terror / horror. Subsequent to the event, the worker must develop objective findings or essential characteristics in all of the following three areas: 1) reexperience of the trauma, for example, as in dreams, intrusive images, or flashbacks; 2) numbing and avoidance, for example, as in turning away from reminders of the trauma; and 3) hyperarousal as, for example, in excessive vigilance. These symptoms when less than a months duration are termed an acute stress reaction. The symptoms involve disordered perception of reality and time sequencing, although not necessarily disordered reality testing. Intrusive ideation or flashbacks, for example, are experienced as real (disordered perception of reality) and as present in real time (disordered temporal sequencing). The capacity, however, to understand intellectually that the experiences actually occurred in another time and place may not be lost (retained reality testing). In such circumstances, modulation of attention is almost always disrupted.
Anatomic and Physiologic Basis for PTSD
We now know that true PTSD is a real disorder with actual anatomic and physiologic alterations of brain function. Current thinking in regard to the understanding of the underlying dysfunction suggests that exposure to severe trauma results for some in an ongoing dysregulation of the limbic system and in particular, a specific locus in the limbic system, the amygdala. The limbic system is located in a portion of the brain that is situated between the cortexes, which house executive mental functions such as logical thought, speech, and associative and integrative capacities, and the brain stem, which is responsible for regulation of many automatic processes such as heart rate, respiration, temperature control, and circadian cycles such as sleep-wake patterns. The limbic system is a complex circuitry that generates and mediates emotional response, provides integration of information from the cortical and brain stem areas, and provides feedback to those areas. The limbic system thus generates emotion shaped by perception, memory, judgment, and basic body experiences, which provide quality, intensity, and predictive meaning to the resultant feelings: Is the resultant feeling, for example, one of mild anxiety calling for a calm but alert state or is it one of terror calling for full activation of all body systems necessary for survival? Of particular importance to this process in the limbic system is the amygdala, a neural center essential to the regulation of response to danger and mediation of aggression. PTSD seems to involve dysregulation of the amygdala resulting in disordered perception of danger and aggressive response. The individual becomes overly attuned to signals of danger while under attuned to other stimuli. Consequently, aggressive responses may be exaggerated and other motivations diminished.
How dysregulation of the limbic system occurs is uncertain. Some evidence indicates that exposure to severe trauma results in lasting physiologic changes in the limbic system. In addition, exposure to trauma results in images of the event and an altered self-perception, which cannot be integrated with other experiences and self-view, resulting in an ongoing source of stimulation to the limbic system. Because of the disconnected status of these images and memories, they signal present, severe danger without the attenuation, which would accompany integration into patterns of memory, temporal sequence, and over all self-image. Consistent with these proposed mechanisms, neuroimaging studies such as PET scans demonstrate altered brain functioning in cases of PTSD.
Onset and Prognosis of PTSD
Onset and outcome to PTSD are variable and have differing effects upon workers' compensation benefits such as temporary total disability, permanent disability, future medical treatment, and return to work. The time between trauma and development of overt symptoms may range from weeks to years. Issues of assessment, especially in the determination of causation, becomes complex, particularly in regard to meeting the current labor code threshold of "substantial cause" in cases of employees whose injuries result from being a victim of a violent act or direct exposure to a significant violent act, when the traumatic event may have occurred in the relatively distant past with multiple life events occurring in the intervening years. In such cases, no generalities can be made regarding causation. In some circumstances, substantial cause may appropriately be attributed to intervening events while in other circumstances, defying the seduction of temporal proximity; substantial cause may still legitimately rest with the trauma distant in time.
Recovery is variable. While 30 percent of patients recover completely, 40 percent continue to have mild symptoms, 10 percent continue to have moderate symptoms, and 10 percent remain unchanged or become worse. In those who retain symptoms of PTSD, available studies indicate that the ongoing clinical course typically is fluctuating, often with a gradual decline in symptomatology over time. Symptoms of intrusive imagery may decrease the most significantly with time, particularly during the first two years, while symptoms of avoidance and dysregulated arousal may be more enduring. Consequently, if findings of temporary total disability have been present and persistent, reassessment for permanent and stationary status with termination of temporary total disability may be reasonable after about one year. Assessment for permanent disability will need to take into account that residual symptoms are likely to show ongoing fluctuation with an overall gradual diminution with time. For example, in one study 54 percent of those who had PTSD immediately after a disaster had remaining symptoms at forty-two months. However, when followed to eight years, only 4 percent continued to attract the diagnosis of PTSD.
As symptoms of hyperarousal and withdrawal are more lasting, residual impairment, if present, may be somewhat context dependent with capacity to return to work at the pre-injury position affected by the degree of external stimulus in the setting. Environments with limited external input may facilitate greater functional ability.
Multiple factors seem to influence the onset and severity of PTSD symptoms. By definition, a severe external stress is the primary course of the development of the disorder. However, the external stress alone is not necessarily the sole or sufficient cause of developed symptoms. Traumatic response is not always proportionate to the objective stress and may be significantly influenced by the subjective meaning to the individual of the trauma. Even when faced with overwhelming trauma most people do not develop PTSD. For example about 30 percent of Vietnam Veterans experience this condition. Predisposing factors increasing vulnerability to the disorder include the presence of childhood trauma, an Axis II personality disorder diagnosis, isolation or a failing support system, recent stressful life events, constitutional vulnerability, tendencies to externalize, excessive ETOH use, the occurrence of actual physical injury, and dissociation at the time of the actual trauma.
Medical Treatment
Medical treatment approaches usefully may employ a variety of modalities. The ones selected should be chosen to utilize the preexisting characterologic strengths of the individual and avoid areas of functional weakness. Such modalities may include various psychotherapeutic techniques and psychopharmacotherapy. The ultimate goal of treatment is to restore neural stability through integration of the experience and meaning of the traumatic event into overall memory and self-view. Pharmacological treatment may usefully include agents from a variety of categories. Zoloft, a selective serotonin re-uptake inhibitor antidepressant, in a recent study demonstrated efficacy in treatment of women with PTSD. Other medications from this class may be useful as well. At times, antipsychotic and antianxiety agents may also be of benefit.
In summary, PTSD results from exposure to events that threaten life or limb. It does not result from situations that are only upsetting or disliked. Once developed, PTSD involves an actual disorder of brain functioning resulting in symptoms that are no more under voluntary control than those of a seizure. Outcome is variable and not connected solely to the severity of the precipitating trauma. Appropriate early diagnosis and treatment by a psychiatric specialist knowledgeable in PTSD is critical to reduce length of lost time from work, reduce permanent disability, if any, and, when possible, return the worker to full employment.
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