Dr. Carrie Steiner, Psy.D.;

Dr. Carrie Steiner, Psy.D., is a 13 year veteran of Chicago Police Department. She is a clinical psychologist focusing her practice on first responders, and is the founder of the First Responder Wellness Center in the Western Suburbs of Chicago. Carrie is also the Clinical Advisor for Serve & Protect.
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Due to the record rise in Veteran suicides, 22 a day, there has been a push to rename post-traumatic stress disorder to post traumatic stress injury.   Many feel that this may reduce stigma, encourage people to get treatment, is a more accurate description of the injury, and is more honorable to those who have been exposed to trauma.  Irrespective, post-traumatic stress disorder (PTSD), unlike other DSM-5 mental health diagnosis, must have a traumatic event, an external event.  Anxiety, depression, schizophrenia, etc. do not have to have anything external to occur to develop these disorders.  Although most disorders have a biological aspect none have one external cause, which differentiates PTSD from other mental health disorders.   The goal of understanding PTSD and clarifying the biological aspects of the injury encourages people to understand the injury so false assumptions about the injury do not continue or blame the person suffering.

PTSD is a biological injury that develops after a person has experienced a trauma.   It should be stated that most people will recover after a trauma incident but an average of 25-30% develop PTSD symptoms.   Of those who develop PTSD, most can manage their injury with treatment but fair much worse without treatment and increase the risk of suicide.  Therefore, helping persons who have PTSD symptoms seek treatment is critical.

To understand the biology of PTSD, the areas of the brain that are affected include the amygdala, hippocampus, and prefrontal cortex.  The activation of the amygdala starts the trauma response or “fight or flight” response.   Stress increases cortisol and norepinephrine production, (stress hormones).  Studies have shown people diagnosed with PTSD have an increased cortisol and norepinephrine production in response to stress.   The increased production of stress hormones contributes to a person with PTSD reacting out of proportion to reminders of the trauma they experienced.    Additionally, persons diagnosed with PTSD show increased amygdala function, smaller hippocampus, and decreased medial prefrontal cortex.   Therefore, due to the changes in the brain after a trauma, many believe that the changes are best described as an injury to the brain rather than a disorder.   Regardless of the terminology, the brain responds differently after developing PTSD.

When there is a trauma, the amygdala is activated, the amygdala is part of the limbic system, which is the “fight or flight” response network of the brain.  The amygdala’s primary function is having emotional reactions, processing memory (formation and storage of memories associated with emotional events), and emotional decision making.   When a trauma occurs and someone develops PTSD, the amygdala increases its function often producing intense negative emotions surrounding the trauma or situations that remind the person of the trauma.   When a person has PTSD and is exposed to a trigger or reminder of the trauma, the amygdala initiates the fight or flight response.  However, the amygdala cannot distinguish between a real threat or perceived theat.   Therefore, many persons with PTSD will have negative physiological reactions to situations that are similar to the trauma event, even though there is no threat.   This makes a person who has PTSD feel scared of many situations and often frustrated because they are not able to control their emotional response, particularly to non-threatening situations.   Simply put, once a person has been exposed to a trauma and develops PTSD, the amygdala is quicker to react due to the increased amygdala function.   It is very difficult for a person who is having these reactions to reduce them without treatment.

When a person has PTSD, the amygdala increases in production and there is a reduction in the size of the hippocampus.   The hippocampus is the part of the brain that is responsible for processing long term memory and emotional responses.    A smaller hippocampus will make it more difficult for a person with PTSD to process and recall the traumatic event and store it appropriately in their long-term memory.   For example, a person might recall the smell of the rain on the day of their car accident, but not recall how long it took for the police to arrive.    It is also common for persons with PTSD to not pay attention to minor, insignificant or perceived insignificant details as the body is on survival mode.  When the body is on survival mode, the brain will not find it important to count how many steps it takes to get out of a bar when there is a gunman shooting, but that the brain was able to get the body to move out of the bar safely.  Hence, a person with PTSD, is often ‘on guard’ so simple things like recalling the grocery list or playing Legos with their child may seem unimportant to their overall survival, hence, they may have difficulties concentrating or finding value with these types of activities.    Additionally, because their amygdala is overactive, they are constantly hypervigilant and scanning, therefore mundane activities will seem unimportant as they are not life or death.   An overall smaller hippocampus can affect day to day living and limit their cognitive skills. Antidepressants are often prescribed for PTSD as the medication can influence the amygdala and hippocampus that counteracts the effect of stress.    Medication can often be one of the treatment strategies for PTSD.

Lastly, a person with PTSD will have a decrease in the medial prefrontal cortex function.   The prefrontal cortex is responsible for executive function (planning, complex decision-making, analytical thinking, etc.), personality expression, and moderating social behavior.   Further, the prefrontal cortex function does not allow the person with PTSD to process what occurred to them.    Therefore, a person with PTSD will be more prone to make poor decisions and social choices, have difficulties regulating their emotions, have poor self-insight and self-monitoring, and increased rumination, etc.    Due to these changes in the brain a person with PTSD will have difficulties recovering without treatment.  Treatment for PTSD often includes evidenced based trauma therapy, specifically, cognitive behavioral therapies (cognitive processing therapy and exposure therapy), eye movement desensitization and reprocessing (EMDR) as well as psychotropic medication.    Understanding that PTSD changes the brain helps persons with PTSD and their loved ones understand that treatment will provide the best opportunity for them to recover.

References:

Acierno, R., Kilpatrick DG, Resnick H.S.  Post-traumatic Stress Disorder in adults relative to criminal victimization: prevalence, risk factors and comorbidity.  In Saighn, PA, Bremer HD Post-traumatic Stress Disorder:  A comprehsnive Text.  Allyn and Bacon; New York: 1999, 44-68.

Bremner, JD . Traumatic Stress:  Effects on the brain.  Dialogues in Clinical Neuroscience. 2006; Dec:  8 (4):  445-461.

Elzinga B.M. & Bremner, JD.  Are the neural substrates of memory the final common pathway in PTSD?  Journal of Affective Disordered 2002; 70:1-17.

Glover R.W., Birkel, R., Faenza, M., et al.  New Freedom Commission Report:  The Campaign for Mental Health Reform:  A new advocacy partnership.  Psychiatric Services. 2003; 54:  1475-1479.

Prigerson H.G., Maciejewsi, P.D., Rosenheck, R. A.  Combat trauma: Trauma with the highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. Journal of Nervous and Mental Disease 2001; 189: 99-108.

US department of Veteran Affairs.  (2016, August 2).  VA Releases Report on Nation’s Largest Analysis of Veteran Suicide.  Retrieved from https://www.va.gov/opa/pressrel/pressrelase.cfm?id=2807

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