GRSJ224/PTSD

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The Medicalization of Post-Traumatic Stress Disorder (PTSD)

Medicalization

Medicalization is a term that was constructed by sociologists to describe how common emotions and traits are turned into treatable conditions[1].  These behaviours may not be self-evidently biological or even medical[2]. Some examples include bad breath becoming halitosis, impotence becoming erectile dysfunction and overdoing plastic surgery becoming body dysmorphic disorder[1].  Other similar terms for medicalization include “pathologizing”, which is the practice of seeing a symptom as an indication of a disease or disorder, or “disease mongering” which is the practice of widening the diagnostic boundaries of illnesses and aggressively promoting their public awareness in order to expand the markets for treatment. Medicalization may be viewed as a benefit to human society. Upon identification of a condition as a disease, such as evidence of post-traumatic stress disorder in soldiers, certain symptoms and conditions can be treated which will improve their overall quality of life.

Post-Traumatic Stress Disorder

Trauma is often unexpected, and many people say that they felt powerless to stop or change the event.  Post-traumatic stress disorder (PTSD) is a mental illness that may develop after a person has experienced or witnessed a traumatic or terrifying event. Traumatic events may include crimes, natural disasters, accidents, war or conflict, or other threats to life[3]. It could be an event or situation that you experience yourself or something that happens to others, including loved ones.  For military personnel the trauma may relate to direct combat duties, being in a dangerous war zone, or taking part in peacekeeping missions under very difficult and stressful conditions[4]. PTSD causes intrusive symptoms such as re-experiencing the traumatic event such as through vivid nightmares, flashbacks, or thoughts of the event that seems to come from nowhere[3]. For example, Gale is an adult transsexual survivor of sexual assault. This assault occurred during his teenage years when he was brutally raped by several older men. Gale is plagued by these intrusive thoughts and images at random intervals throughout the day. No specific trigger is needed; they occur spontaneously. Gale can be in the middle of working, or studying, or trying to fall asleep, and suddenly he becomes flooded with horrible thoughts and images.[5]

PTSD will forever be connected with Vietnam vets, and in fact as many as 30 percent of them were diagnosed with symptoms at some point.[6]

Someone who suffers from PTSD will often avoid places and things that remind them of the trauma.  Someone who was injured in a car accident might avoid driving and someone who was sexually assaulted may avoid new or romantic relationships.  PTSD can make people feel very anxious or ‘on edge’ nearly, if not, all the time. Many startle very easily, have a hard time concentrating, become irritable, or have problems sleeping well. They may feel that a terrible outcome or event in inevitable and bound to occur, even when they are safe.  Some people who suffer from PTSD also report feeling numb, disconnected and detached from society. 

Intrusive Symptoms[4] Avoidance and Numbing Symptoms[4] Arousal Symptoms[4]
Distressing memories or images of the incident Difficulty imagining a future. Environmental reminders

(triggers) play a part in raising these intrusive memories by recalling an image, sound, smell or feeling that is associated with the original events (e.g. a loud noise may be experienced

as gunfire or a bomb blast)

Sleep disturbance
Nightmares of the event or other frightening themes Gaps in memory — forgetting parts of the experience Anger and irritability
Flashbacks (reliving the event) Losing interest in normal activities Concentration problems
Becoming upset when reminded of the incident Feeling cut-off or detached from loved ones Constantly on the look-out for signs of danger
Physical symptoms, such as sweating,

increased heart rate, or muscle tension when reminded of the event

Trying to avoid any reminders of the trauma, such as thoughts, feelings, conversations, activities, places and people Jumpy, easily startled
Feeling flat or numb

PTSD is characterized by three main groups of problems. They can be classified under the headings of intrusive (unwanted, unbidden, and therefore, involuntary[5]), avoidance (generally refer to those symptoms that reflect difficulties in experiencing positive emotions[7]) and arousal symptoms (exaggerated startle response, sleep disturbance, Irritability and/or aggressive behaviour[8], etc.). These symptoms cause intense distress and can result in other emotions such as guilt, fear or anger.

Who is at risk?

While most people experience trauma at some point in their life, not all traumatic experiences lead to PTSD. However, PTSD can affect people of any age, rank, culture or gender. Researchers are not sure why trauma causes PTSD in some people but not others, but it’s likely linked to many different factors[3]. This includes the length of time the trauma lasted, the number of other traumatic experiences in a person’s life, their reaction to the event, and the kind of support they received after the event. Some jobs or occupations that put people in highly dangerous or intense situations, such as military personnel, first responders (police, firefighters, and paramedics), doctors and nurses, experience higher rates of PTSD than other professions.

In addition to diverse careers experiencing different rates of PTSD, it was discovered that differences in PTSD by sexual orientation already exist by age 22. PTSD has been found in young adult gay men, lesbians, bisexuals, and “mostly heterosexuals” compared with completely heterosexuals at considerably younger ages than previously identified, according to a new study by Harvard School of Public Health (HSPH) and Boston Children’s Hospital researchers[9] According to the findings, sexual minorities had between 1.6 and 3.9 times greater risk of probable PTSD than heterosexuals. Child abuse victimization disparities accounted for one third to one half of PTSD disparities by sexual orientation. Also, higher prevalence of gender nonconformity before age 11 years partly accounted for higher prevalence of abuse exposure before age 11 years and PTSD by early adulthood in sexual minorities (range = 5.2%–33.2%[10])

Treatment

Counselling

Therapists use a variety of techniques to aid patients in reducing symptoms and improve functioning. Cognitive-behavioural therapy (or ‘CBT’) is a type of counselling that has been shown to be effective for treating and managing PTSD. Therapists employing CBT may encourage patients to re-evaluate their thinking patterns and assumptions in order to identify unhelpful patterns (often termed “distortions”) in thoughts, such as overgeneralizing bad outcomes and negative thinking that diminishes positive thinking. This is intended to help the patient re-conceptualize their understanding of their traumatic experience and their understanding of themselves. Exposure to the trauma narrative, as well as reminders of the trauma or emotions associated with the trauma, are often used to help the patient reduce avoidance and maladaptive associations with the trauma. The goal is to return a sense of control, self-confidence, and predictability to the patient, and reduce escape and avoidance behaviours[11].  Due to the sensitivity, the exposure to objects or situations related to the trauma are very controlled and delicately handled.

Medication

People who suffer PTSD tend to also suffer from other adjacent mental illnesses such as anxiety disorders and major depression.  Medication, such as anti-anxiety meds or antidepressant medication, may help with anxiety itself, as well as related problems like depression or sleep difficulties. Medications can regulate the chemical imbalances that occur in the brain and thus reduce emotional and physical over-reactivity. According to the International Psychopharmacology Algorithm for PTSD, the first-line medication is usually a serotonin-selective reuptake inhibitor (SSRI) or a serotonin-and-norepinephrine reuptake inhibitor (SNRI)[12]. The reuptake inhibitors block the reabsorption of serotonin or norepinephrine by nerve cells, making the chemicals more available for transmitting signals in the brain. Meaningful symptom reduction usually takes place four to 12 weeks after beginning the medication. Common adverse (bad) reactions to these medications include dry mouth, nausea, drowsiness, headache, diarrhea, constipation and disordered sexual function. Most of these adverse reactions tend to disappear over time, although this may not be the case for sexual side effects. Adverse reactions can usually be successfully managed with selection of the “right” medication, gradual dose escalation, or use of another medication to minimize the adverse reactions. Many other medications are available for PTSD patients who do not respond to initial treatment.[12]

Support Groups

Support groups have also proven to be very beneficial in coping with PTSD. They are a place to share your own experiences and learn from others without judgement and help you connect with people who understand what you’re going through. Since PTSD is a disorder that can affect others surrounding the patient, there is also support groups for loved ones affected by PTSD.

Long-term Effects

If left untreated, PTSD symptoms can worsen and become very destructive to the person suffering and those around them. Some documented cases include addiction to drugs or alcohol, chronic pain, hypertension or physical maladies, self-injury, suicide, overwhelming fear of death, as well as compulsiveness and personality changes[13].

Glutamate and PTSD

PET images indicating higher mGluR5 receptor availability in an individual with PTSD vs. a healthy comparison participant. Credit: Yale University[14]

In terms of the biological aspects of PTSD, a study was conducted by the VA National Center for PTSD (NCPTSD), National PTSD Brain Bank, and Yale University. It has identified a new potential mechanism contributing to the biology of the disorder that may be targeted by future treatments.  The study, led by NCPTSD and Yale psychiatrist Irina Esterlis, is the first to implicate a specific alteration in brain glutamate signalling in PTSD.[14] The new study reports that emission tomography (PET) scans show increased levels of a subtype of glutamate receptor in the brain, metabotropic glutamate receptor-5 (mGluR5), in patients with PTSD.

In animals, overstimulation of mGluR5 is associated with fear and stress-related behaviours[14] and drugs that reduce mGluR5 function may be able to reduce these symptoms. With this is mind, according to the researchers the current study may have implications for the treatment of PTSD.  This study also provided potential insights into how the increases in mGluR5 might arise. An important feature of this study is that it is the first to link brain chemistry findings in patients with PTSD, as measured through PET scans, to detailed molecular analyses of brain changes in PTSD that can only be conducted in brain tissue that has been donated by veterans or their families for research purposes. [14]

More information: Sophie E. Holmes et al. Altered metabotropic glutamate receptor 5 markers in PTSD: In vivo and postmortem evidence, Proceedings of the National Academy of Sciences (2017)

References

  1. 1.0 1.1 Lane, Christopher. "On the Medicalization of Our Culture". Harvard Magazine.
  2. White, Kevin (2002). An Introduction to the Sociology of Health and Illness. Sage Publications. p. 42.
  3. 3.0 3.1 3.2 "Post-Traumatic Stress Disorder (PTSD)". Canadian Mental Health Association.
  4. 4.0 4.1 4.2 4.3 Post-Traumatic StressDisorder (PTSD)and the Family for Parents with Young Children (PDF). ISBN 0-662-42627-4.
  5. 5.0 5.1 Marich, Jamie. "Post-Traumatic Stress Disorder - Distressing Images, Thoughts, Memories".
  6. "Is PTSD More Common Among Soldiers Now Than in the Past?".
  7. Tull, Matthew. "Emotional Numbing and Other Avoidance Symptoms of PTSD".
  8. Marich, Jamie. "Arousal and Reactivity Symptoms".
  9. Datz, Todd. "Higher risk of PTSD for gay, lesbian, bisexual, 'mostly heterosexual' youth".
  10. Roberts, Andrea; Rosario, Margaret; Corliss, Heather; Koenen, Karestan; S. Bryn, Austin. "Elevated Risk of Posttraumatic Stress in Sexual Minority Youths: Mediation by Childhood Abuse and Gender Nonconformity". American Journal Of Public Health.
  11. "Cognitive Behavioral Therapy (CBT)". American Psychological Association.
  12. 12.0 12.1 Schoenfeld, F.B.; Marmar, C.R.; Neylan, T.C. (2004). "Current concepts in pharmacotherapy for posttraumatic stress disorder". Psychiatric Services: 519–531.
  13. "Longterm Effects". PTSD Association of Canada.
  14. 14.0 14.1 14.2 14.3 Hathaway, Bill. "New PTSD study identifies potential path to treatment".