Mental wellness regarding first responders has been receiving heightened attention in the media and our society lately. This is good news in that it gives the general public a greater awareness of possible personal consequences we may experience in our career. However, awareness does not always equate to an accurate understanding of and action taken to address it.
We believe first responders and military personnel enter our line of work as resilient individuals. We also believe our career builds on that resiliency and, at times, tears at it. We drill regularly to maintain optimal physical response to many emergency scenarios with the best tools and techniques. The result is that we can pragmatically, methodically, and systematically approach any scenario. Those skills become ingrained and help us to maintain emotional distance. What we do not drill or train on are our emotional and mental responses. That is another way we present ourselves as resilient.
From our first call forward, we each build on our personal coping skills in ways that we believe at the time work for us to see us through the mild to horrific scenes we encounter. With that said, all of us have experienced one or more calls that have lingered in our minds, for whatever reason, longer than we care for and in varying intensities. What we choose to do in response to that is important to our overall well-being. We are resilient; however, the ways we choose to cope are not always healthy and useful.
When images and memories begin to intrude in our waking and sleeping hours, affecting our daily behaviors and ability to respond and cope, we should stop, take a moment, and assess how we are doing. It is normal to experience these reactions after direct or indirect exposure to a traumatic event. Normally, the reactions typically fade with time and we move on. However, if the reactions do not fade, begin to interfere with our daily functioning, and maybe intensify, we should consider the possibility that we may be experiencing Posttraumatic Stress Disorder (PTSD).
PTSD is the current term for a condition that is believed to date far back in writings and experiences and under other names. Most of us are now aware of the term; however, simple familiarity with the concept that PTSD is experienced as a result of trauma is not enough. We don’t believe it is a new, sudden experience or an epidemic. We consider the current attention to it an opportunity—an opportunity to offer you information. This article summarizes some influencing factors in PTSD history, identifies some conditions similar to it, provides an overview of the PTSD diagnosis, describes evidence-backed treatments, and offers considerations when choosing a therapist. A better understanding can lessen the stigma and apprehension that may come with the idea of PTSD. Our hope is that we can offer you some clarity and insight that will be useful to you and support our resiliency.
A Personal Account
I (Daniel) have had my share of runs, but one incident hit me the hardest. It was 1990; I had been on the job a couple of years when an afternoon call came in for a house fire. I was a truckie and part of the search and rescue team. We went in for our primary search. We entered the house with no information that anyone might be inside so, as always, we performed our assigned duty. After our primary search found nothing, a family member arrived and informed us that two children were inside. We performed our secondary search and, as we neared the end of it, frustration set in as we still could not locate the children.
I was standing in a hallway when one of my team members came to a locked linen closet in a bathroom. We found that unusual and forced the door. Two children’s lifeless, charred bodies fell out onto the bathroom floor. We all froze. Time seemed to move in slow motion as the moment unfolded. It consumed us. I was flooded with thoughts and emotions. The pragmatic me questioned the situation: How did we not know? How did they get in there? Why were they locked in there? Could we have saved them?
We learned later that the children were locked in the closet by their grandmother while she went to the store. Hearing this only added to the surge and mix of emotions we were all already experiencing. The emotional me felt disbelief, sadness, remorse, guilt, and anger all at once. Then, in my head, I began to question my reaction: Who was I to feel these feelings? What was happening? I had no children, so I could only imagine that what I was feeling was nothing compared to what my fellow firefighters who had children were feeling.
I struggled with the fire scene and my reaction, replaying my thoughts in my head over and over. As a young firefighter, I followed the lead of my senior coworkers and did not bring it up again at work, even to this day. Despite being in the counseling field in addition to my firefighting career, I did not talk with anyone or seek assistance in dealing with my thoughts. I convinced myself that I would be fine, that it came with the job, but inside, down in my gut, I knew it really affected me.
The following day, I went to my counseling job. Coworkers noticed a change—I went from being outgoing to quiet and reserved. Rather than checking in with me and asking how I was, they poked fun at me. My then friend, now wife, asked me what was up. I shared with her what happened. She listened and commented on my flushed face, teary eyes, and stuttering and empathized with how much I must have been affected. We talked about it briefly and then, as most of us do, I retreated from further discussion. I never dreamed about it or self-medicated, but it has entered my mind on many occasions. To this day, I still struggle to share the story without showing some reaction. As you’re reading this, what pops into your head?
At the time, PTSD and associated conditions were not mental disorders discussed much in the general psychiatric community. They were identified as a category within anxiety disorders and treated as such.
PTSD, as we know it now, first appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM), DSM-III, in 1980. Prior to that, written accounts of it are considered PTSD by historians because they describe symptomatology that would, today, fit with our understanding and diagnosis of it. We will refer to these accounts identified under other terms as “PTSD-like conditions.” PTSD and PTSD-like conditions have symptoms such as racing heart, rapid pulse, headaches, nightmares, disturbances in appetite and sleep, mood changes, change in level of socialization, avoidance, hyperarousal, panic attacks, depression, difficulty concentrating, and memory issues.
Information about the history of PTSD is abundant, and PTSD has been experienced for a very long time. In addition to that, labeling the condition, establishing its source, perceptions of how to approach it, ways to prevent it, and ways to treat it were all significant components to the historical progression that spanned many countries, doctors, psychiatrists, writers, and documented experiences and are still evolving.
Presumed initial accounts and depictions of PTSD relate to battle and war experiences; the earliest are believed to date back to 1300 to 609 B.C. during the Assyrian Dynasty. These writings detailed unexplained symptoms that soldiers experienced. As time went on, PTSD-like accounts were given names that mostly reflected the perception of their theorized cause such as battle fatigue, combat stress reaction, battle shock, shell shock, nostalgia, war neuroses, homesickness, to be broken, soldier’s heart, irritable heart, concussion of the spine, railway spine, nervous shock, exhaustion delirium, combat exhaustion, and gross stress reaction. From the names alone, you can speculate how they project the theorized source as being physical or psychological in nature.
During the Civil War, many soldiers were discharged as a result of PTSD-like symptoms. The soldiers experienced physiological and psychological symptoms that baffled doctors, like the ones identified above. Doctors did not comprehend at the time that trauma could impact the minds of individuals as it did and initially regarded it as “homesickness.” They later turned to “nostalgia,” a term originally coined in Europe in 1600s to describe the PTSD-like symptoms. Attitudes back then stressed courage, strength, and manhood; no consideration was given to the mental wounds the war created beyond the physical ones. At that time, for veterans, the symptoms, diagnosis, and lack of a tailored treatment came with the stigma of possessing a weak character or expressing a predisposed, deeper mental illness. Then, following the war, many more soldiers began to experience “nostalgia.” This, in turn, prompted Congress to increase the number of insane asylums and liberated access to them for soldiers. Psychiatrists and therapists during this time were primarily involved in inpatient treatment of mental disorders. As mental health professionals were unsure how to treat the condition otherwise, soldiers were deemed incurable and simply placed in these facilities and offered the best treatment to ease symptoms and keep them comfortable through simple actions like reading, singing, and talking.
In that same time period, another influence of the etiology of PTSD was materializing: the American Industrial Revolution. The introduction of the railway led to a realization that a traumatic event could cause both physical and psychological harm. With the railway came accidents. The symptoms people demonstrated following the accidents, physically injured or not, paralleled those identified as nostalgia and were called “railway spine.” Since doctors still did not make the connection that trauma could result in mental and physical effects, they turned to a physiological cause. The name stemmed from the primary belief that neurological damage occurred as a result of damage to the spine from the accident, in turn causing psychological symptoms. This helped begin a turn in thinking that PTSD-like conditions could occur outside of a war experience and opened the door to thoughts of how other life events might also lead to it.
The main impact of PTSD-like symptoms still came from the Civil War. Years following this war, the National Committee for Mental Hygiene focused on forward thoughts and practices for psychiatry promoting outpatient treatment over inpatient, research of causes of mental illness, and ways to prevent it. Dr. Thomas Salmon, a psychiatrist and the medical director of the committee, wanted to put these beliefs into practice and was able to do so entering World War I. He and other psychiatrists believed the PTSD-like condition developed in individuals who were predisposed to experiencing it as a result of underlying psychological conditions. Prior to the United States entering the war, he advised the military to screen potential recruits to weed out those susceptible to weak-mindedness and demonstrating signs of mental illnesses, as he believed they would not do well in service. The U.S. military liked the idea in hopes of having stronger, more capable soldiers. Salmon created a screening process; approximately 2% of recruits were prevented from joining based on the screenings. Unfortunately, following the war, the large number of soldiers experiencing PTSD-like symptoms labeled “war neuroses,” later called “shell shock,” led military officials and psychiatrists to conclude that the screenings weren’t selective enough.
Salmon also studied British interventions for shell shock and formulated one modeled after a French neurologist’s approach that became known as “forward therapy,” also called PIE, which is based on three principles: proximity, immediacy, and expectancy. Salmon added two more: simplicity and centrality. Salmon’s approach had three tiers based on proximity to the front lines. Those who could would be treated near the front lines and would return to duty. Others were sent to two other locations for longer, more intensive treatment. This approach was believed useful for the military in two ways. First, it communicated to the soldiers that demonstration of PTSD-like symptoms would not result in discharge as it had in the Civil War, so it was not viewed as a way out. Second, treatment was initiated as close to the onset of symptoms as possible, which helped increase success with treatment. Doctors had believed after the Civil War and studying Britain’s approaches that the longer the symptoms went untreated, the less likely the suffering individuals would recover.
The next large influence in both battle and civilian PTSD-like conditions came out of World War II. Entering the war, the focus was on a more detailed screening process. This time, approximately 12% of recruits did not make it to serve based on the screening. Military officials believed this was the answer to problems the war presented with “shell shock” and set aside ideas of any need for forward therapy.
Again, psychiatrists studied soldiers throughout the war. They noted that soldiers were experiencing shell shock symptoms even when they were not in proximity to bullets and shell blasts. They considered other factors contributing to the condition such as stress and ideas and began to call it “combat exhaustion” rather than shell shock. This led the U.S. Army to create an official slogan during the war: “Every man has his breaking point.” Training videos were made on methods to treat combat exhaustion and distributed to medical officers. One psychiatrist reintroduced the concept of forward therapy to military officials, and it was implemented in the latter part of the war. Statistics initially presented from this suggested many soldiers returned to duty. Despite these efforts, nearly double the number of soldiers left the war experiencing combat exhaustion as did in World War I. Following the war, general disappointment and lack of faith regarding the field of psychology began to set in.
Among the psychiatrists studying soldiers during World War II, two psychiatrists’ viewpoints stood out—those of Grinker and Spiegel. They wrote a manual on “war neuroses,” a new term but the same symptoms, and ways to treat it, citing more than 60 case studies they followed. They fostered the shift in concept that those who experienced PTSD-like symptoms were mentally weak to the idea that they were normal individuals who could no longer cope with what they were exposed to. They further solidified the idea that everyone has a breaking point. Similarly, other psychiatrists who studied the war supported shifts in our perception from considering abnormal minds in normal times to normal minds in abnormal times. In addition, another shift was a change in our focus of PTSD originating from individual predispositions toward external factors.
Aside from these psychiatrists, another psychiatrist studying troops in Africa came to the conclusion that the development of PTSD-like symptoms came not just from experiencing a traumatic event but that people’s perceived external support, their morale, played a role in whether they were susceptible to breaking down. Perceived cohesiveness and support with fellow soldiers, officers, equipment, and support from home both at familial and societal levels related conversely to the likelihood a soldier might experience combat exhaustion. Simply put, the better the support, the fewer incidents. A more nurturing approach also prevailed suggesting rest, nourishment, and positive support from therapists for successful recovery. In line with this, military psychiatrists believed limited tours of duty with periods to provide rest and relaxation while serving would lessen mental breakdowns.
Aside from soldiers, psychological effects resulting from World War II were expansive. PTSD-like conditions presented themselves not just in soldiers but in those who suffered in concentration and death camps, civilians experiencing military occupation, civilian responses to bombings and feelings of oppression from the political climate, as well as family members of those who served. At this point, it was imperative for mental health professionals to better examine and address what was happening, the effects PTSD-like conditions were creating, and how to handle them. We were advancing in our efforts to address this.
In America, at that time, four manuals existed to identify physical and mental disorders, primarily for statistical and coding purposes.
International Classification of Diseases (ICD). This was implemented worldwide as a basis for epidemiologic purposes regarding diseases. In 1948, the ICD included a section on mental disorders for the first time. The PTSD-like condition it identified was “Acute Situational Maladjustment,” and it listed three kinds.
Diagnostic and Statistical Manual of Mental Disorders (DSM-I, DSM-II, DSM III). The American Psychological Association wanted to create a manual that could be used by all in the field of psychiatry in classifying and diagnosing mental disorders. This manual would offer a means to have everyone on the same page, so to speak, and minimize ambiguity regarding diagnosing patients. The DSM was created in 1952 and identified 106 disorders referred to as “reactions.” “Gross stress reaction” replaced the term “combat exhaustion” and was identified as a “reversible reaction” whose causes were attributed to severe physical demands or extreme emotional stress. It was a crude representation of PTSD; however, it substantiated all the documented incidents and experiences of PTSD-like developments and gave professionals a name to work with. This development occurred when America was involved in the Korean War.
In the Korean War, American soldiers served overseas in areas that were scattered and changed frequently; therefore, it was viewed that forward therapy was not practical to implement. Initial accounts of the war detailed high rates of what were called “neuropsychiatric conditions” but were later lessened as reports suggested most returned to their duties. Statistics following the war suggested that most who served returned home and went back to work, so PTSD-like conditions were not a concern. Korean War statistics were not identified independently but rather lumped in with either World War II or Vietnam War statistics.
Studies continued moving forward, particularly in reviewing previous works, theories, and practices worldwide in addressing the mental wounds war appeared to be creating. The next war, the Vietnam War, entered new territory in psychological repercussions. It affected those who served, their families, and Americans in general.
The Vietnam War created struggles and debates that remain to this day with respect to PTSD. Going into the war, some suggestions of proactive measures to minimize PTSD-like conditions made after World War II were implemented. Tours of duty were limited to a year and incorporated periods of rest. Psychiatrists and psychologists were assigned throughout the troops so soldiers had immediate access to assistance, PIE. In the first half of the war, data suggested soldiers were doing well, with low rates of PTSD-like conditions that warranted treatment. The second half of the war saw the statistics turn in the other direction. Researchers suggested the shorter tours of duty for soldiers, and even shorter ones for officers, interfered with comradery and unit cohesiveness, in turn affecting soldiers’ morale. Back home, Americans were torn in their support for our participation in the war. This spilled into the war itself, with those serving worn and plagued with discontent about fighting. Heroin was introduced to our troops by Vietnamese soldiers, and reports suggested our soldiers were abusing the drug along with alcohol to cope. Psychiatrists reported that rates of soldiers in need of psychiatric assistance for mental conditions as well as drug and alcohol abuse skyrocketed.
How exactly this amounted statistically in psychological casualties from the war is difficult to pinpoint. Data following the war was sketchy and skeptical. The articles written all varied in perceptions of levels of PTSD-like conditions and no consistent, solid statistics were offered. What was agreed on was that as the war progressed and the attitudes toward it back in America became sour, so did the soldiers. This appeared to affect their well-being, and when they returned home they faced a torn nation, and countless Americans who opposed the war were openly hostile toward them.
Onset was not always immediate in many Vietnam vets identified as having PTSD-like conditions. This delayed onset will later appear in the DSM as “delayed-onset PTSD.” Some literature suggests the PTSD-like conditions the veterans were experiencing far exceeded the number documented from all of America’s previous wars. America was left with a staggering number of Vietnam vets suffering from PTSD and PTSD-like conditions, behavioral disorders, depression, readjustment issues, and drug and alcohol abuse.
Along with the soldiers, the mental health professionals who served were also negatively impacted. Approximately 135 psychiatrists served in the Vietnam War alongside the soldiers to offer immediate assistance and rapid recovery of soldiers to return to battle. Many of these therapists struggled with the concept of being there to treat soldiers simply to maintain their ability to fight. They, too, experienced little support from their colleagues at home. Mental health professionals in America were unsupportive of the therapists who served, believing they did not take care of the soldiers psychologically like they should. Along with the soldiers, the serving therapists reported experiencing PTSD-like symptoms after their return from the war.
America and the field of psychology were flooded with many veterans suffering from various mental and behavioral conditions. This, as well as civilians affected by World War II atrocities and the women’s movement raising attention to child abuse and battered women, helped contribute to the introduction of the term “Posttraumatic Stress Disorder” in the third edition of the DSM in 1980. This term replaced the gross stress reaction that was in the DSM-I. In this edition, PTSD was included as a subcategory under the diagnosis of anxiety disorders. In the DSM-III, within the diagnosis, the concept that the condition stemmed internally shifted to one identifying the traumatic event occurring outside of the person. The event identified was categorized as outside the range of normal human experience. The diagnosis also included the notion of delayed onset—symptoms warranting diagnosis do not appear for at least six months following traumatic events.
A standard had been established. The therapeutic community had a means to diagnose the PTSD-like conditions they were working with. Not only were soldiers able to be diagnosed and treated, but the door was opened to individuals outside of war experience who were suffering both psychologically and physically from traumatic experiences. The inclusion of delayed onset in the diagnosis supported the idea that effects from traumatic experiences could initially appear under control and later intensify.
What we have discussed to this point has related primarily to war and soldiers. As far as historical advancements pertaining to PTSD and PTSD-like conditions, this is where the majority of experiences warranting and necessitating change have stemmed from. As the world’s technology advanced, our attention to social issues such as abuse opened up, along with the extensive psychological traumas felt after World War II; psychology absolutely had to be much more inclusive toward events outside of war in everyday life that could produce PTSD and PTSD-like conditions. Alterations and modifications within the DSM reflect this, despite lingering controversy to this day as to what and how they are included. On a side note, interestingly, in 1968 the DSM-II was released and, as we in America were considered in a time of peace, gross stress reaction was dropped from the manual as it was not perceived relevant.
In another faction of history, still primarily relating to war and battle, some authors created narratives depicting vivid images and experiences of characters possessing PTSD-like symptoms. Writers such as Homer, Charles Dickens, William Shakespeare, and Stephen Crane made reference to PTSD-like symptoms and their effects in some of their works. Dickens was believed to have experienced it personally following a train derailment he was involved in. He described lingering and lasting psychological and physical symptoms he experienced, in a letter to a friend, months after the accident. His son also added that his father expressed reluctance about traveling on railways after the incident.
Moving forward into the 1980s and 1990s, with the broadened scope of populations considered susceptible to developing PTSD, countless research studies began focusing on many variables associated with PTSD. The studies have identified correlations between particular life experiences and levels of susceptibility to developing it, considered what types of treatment are best for specific populations, offered annual statistics on the epidemiology of it, and cited still more studies on veterans from World War II and Vietnam as they aged and their experiences with PTSD. Medical and psychological treatment possibilities have been pursued both in the preventive and treatment approaches.
Then came the 2000s. The year 2001 was a pivotal one that shook the fundamental securities we as Americans embraced since colonization: We experienced 9/11. Studies, specific to effects of the attacks, erupted. Within the studies, the sample sizes varied and were classified into different populations based on their connection to 9/11. Research populations concentrated on varied in professions, proximity to attacks, amount of media exposure experienced about the attacks, relation to those who perished, and more. Participant results were subjective as they were obtained through self-report questionnaires. Researchers published results of American citizens and PTSD symptomatology. Most results showed a significant amount of PTSD symptoms were experienced immediately following the attacks in all groups. The general population percentages dropped below half that amount at the six-month mark following the attacks. Researchers viewed this a positive reflection on our resiliency as a nation. Some of the populations were studied further as their results suggested persistence of symptoms leading into a PTSD diagnosis that followed them years later. First responders and those either directly involved in the attacks or those who were very close to those who lost their lives were two of those groups.
As the American military found itself involved in fighting wars in both Iraq and Afghanistan, more studies surfaced addressing PTSD, including active and retired military, and its connection with other mental disorders and suicide—a term in psychological diagnosis designated as “comorbidity.”
Specific to the military, statistics of those experiencing PTSD as a result of the Iraq and Afghanistan wars vary. Keep in mind statistics were still affected by resistance to self-reporting and continuing stigma. The Department of Veterans Affairs estimates that about 11% of veterans from the war in Afghanistan and approximately 20% of veterans serving in the war with Iraq have been affected by PTSD.
Some documented current statistics on PTSD follow. Some of the life circumstances most common in PTSD diagnoses include physical or sexual abuse as a child, physical or sexual assault at any point in life, exposure to natural disasters, exposure to combat, serious accidents, exposure to active shooting scenes, and terrorist attacks. Some populations who have been identified as experiencing PTSD more than 50% of the time include outpatient mental health professionals, victims of severe traumatic events, and sexually abused children. Many who experience PTSD also experience other mental disorders such as depression and anxiety. The DSM-III diagnosis of PTSD was a tremendous advance in PTSD history. It gave a name to a condition plaguing humankind for a very long time. It clarified etiology of PTSD and set criteria for individuals to be diagnosed. With each DSM published, modifications have continued to improve all aspects of the diagnosis. However, before the diagnosis clearly included indirect exposure to trauma as a potential criterion, psychiatrists began to develop their own language for that. At that time, the concept was relatable to many, especially those of us in first responder and military careers.
We would be remiss if we did not discuss terms that have arisen specific to individuals who experience trauma-related, PTSD-like symptoms indirectly. People experience events daily that could be considered traumatic. Others who are either involved with these individuals or the event in an indirect capacity may also experience symptoms similar to those directly involved. Psychiatrists took notice of this and developed language to fit such a situation. “Secondary traumatic stress” (STS), “compassion fatigue” (CF), and “vicarious trauma” (VT) are terms created and still used today.
Although these terms may share symptoms with PTSD, it is important to note that they are not PTSD. At the time of their introductions, they addressed a population of people affected that the DSM-III did not recognize. Symptoms for the three terms parallel those of PTSD. The literature offers overlapping and sometimes conflicting definitions of each term.
STS emerged in a book written in 1983 by Dr. Charles Figley, whose doctorate is in human development. He publicly spoke the year prior, referencing what he called “secondary victimization,” which he changed to “secondary traumatic stress” in his book. The background for the term started in his service as a marine in the Vietnam War. He became concerned and interested in the mental health of the active military. After the war, he continued his work with veterans and expanded his studies to include their family members and the indirect trauma they experienced. He believed family members could be traumatized as a result of their concern for the veteran. He identified STS as an extreme form of burnout psychologically, physically, and socially arising out of concern for and wanting to help a family member. He later expanded the definition to include professionals whose careers were caretaking of others. As Figley worked on developing clarity in his proposed term, others were writing about it and developing their own versions that fit with their field of focus.
CF appeared in Coping with Compassion Fatigue (1992), published by Carla Joinson, a registered nurse, directed toward the nursing community. She postulated that caregivers’ personalities, with compassion and empathy, are what lead them to potentially experiencing compassion fatigue. She believed what the caregivers offer are themselves and their abilities, and the conditions they attend to in their profession are unavoidable, so they may develop this draining condition. In the same year, Figley referred to this condition as “compassion stress” and another colleague referred to it as “traumatic countertransference.” Further, with the term secondary traumatic stress receiving poor reception as professionals and the public linked a negative connotation to the term, the two professionals discussed moving forward using the term “compassion fatigue” to standardize the term.
VT was coined in 1990 by Drs. Laurie Anne Pearlman and Lisa McCann. They theorized that the world of psychotherapy was inundated with clientele in need and therapists were not necessarily equipped to handle what they were dealing with following the Vietnam War, the Women’s Movement, and increased attention to issues of abuse. The differentiating factor of VT to STS and CF was that Pearlman and McCann believed experiencing VT changed the cognitive perception of self and the world to the therapist. An example literature offered was working with victims of rape. The therapist might develop a worldview that all men are untrustworthy and begin to experience, similar to their clients, guilt, anger, sadness, and others associated with the condition. The affected therapists might also begin to question their own judgment and ability to protect themselves.
The individuals who created the terms STS, CF, and VT stipulate they all have distinguishing characteristics, but the terms are often used interchangeably.
Research continues regarding the effect caregiving has on individuals in professions involving working with those who have experienced traumatic events and on those personally involved with the same. To date, none of these terms have become actual diagnoses within the DSM.
We as first responders are becoming more self-aware of how our exposures to trauma scenes can affect us personally and possibly skew our worldview. Again, these conditions are not PTSD. The symptomatology is less severe—for example, when a person comments he feels depressed on a given day, that does not mean he has clinical depression. This is not to say it cannot develop into PTSD; it might if not recognized and managed.
The PTSD Diagnosis
We can’t stress enough: If you or someone you care about might be experiencing PTSD, it is of utmost importance to meet with and be evaluated by a licensed professional. A diagnosis of PTSD is established from clearly identified symptoms within eight distinct categories of criteria. Also, it is important to understand a person may experience one or more of the symptomatology identified without meeting all the criteria for a PTSD diagnosis; in this case, other diagnoses would be considered.
Since the DSM-III was published, a DSM-IIIR, DSM-IV, DSM-IV-TR, and DSM-V have been released. It is important to note that in each of the revisions, the PTSD diagnosis has been revised in some manner. The most significant adjustments were made in the DSM-V, 33 years after the term was established. PTSD is placed in a new category of trauma and stressor-related disorders. This helped clear up any misunderstanding from past versions that identified PTSD within anxiety disorders, which gave the impression that many of the symptoms were anxiety based, to a degree, missing the mark on the unique characteristics of the experiences felt by the individual being diagnosed. For PTSD, a person must have been exposed to a traumatic event or events, which is not necessary for a diagnosis of anxiety; this, in turn, could affect the course of treatment and its level of success. The presenting stressor spectrum was expanded to include more types of exposure to the events and more types of traumatic events applicable. So, indirect exposure to the trauma is considered as well as situations where involvement is indirect while direct in exposure to aversive aspects of the traumatic events. An example is being on the scene of an accident as a first responder and working directly with the injured or deceased bodies resulting from the accident. These were included in the DSM-IV but are clarified in the DSM-V.
Presently, the parameters for a PTSD diagnosis are broad enough to cover many aspects and circumstances surrounding experience of a traumatic event and specific enough to offer a very clear manner to diagnose PTSD that is less likely to be confused with other disorders. In the DSM-III, the five categories of criteria for diagnosis of PTSD that compared to the eight presented in the DSM-V were relatively narrow in scope. Also, now more additional diagnoses are presented that may be added to the primary diagnosis of PTSD, referred to as “comorbidity.” This is a helpful addition for clinicians to consider other disorders that may accompany PTSD. More symptom criteria are available, which, in turn, affects the diagnosis, prognosis, and course of treatment.
Another diagnosis relevant to PTSD is acute stress disorder (ASD). ASD symptoms fit with PTSD and are experienced immediately after exposure and last less than a month, which is in the DSM-IV. If the symptoms persist more than a month, the diagnosis automatically goes to PTSD. The DSM-V also offers a separate set of criteria for children under the age of 6.
For the criteria for a diagnosis of PTSD, here are two links that spell out the diagnosis: https://www.brainline.org/article/dsm-5-criteria-ptsd and https://www.verywellmind.com/ptsd-in-the-dsm-5-2797324.
Considerations in Treatment
PTSD is treatable, and some research suggests certain approaches can eliminate its symptoms. So, what is the best treatment? It’s the one that works for you! Historically, many approaches to prevent and treat PTSD have been designed and implemented. Some have varied in success and have been modified throughout the years. Others have not been so successful and have faded.
PTSD treatments fall into two groups: trauma-focused and nontrauma-focused. Both fall under the umbrella of cognitive behavioral therapies (CBT). Those experiencing emotional pain as the result of a trauma might wonder why choose a treatment that is trauma-focused. The techniques will explain themselves. Both paths of treatment share one component: They begin with education. The client is educated on PTSD to better understand the condition and the symptoms he is experiencing. The client learns coping skills and techniques to help throughout the therapeutic process and beyond to better deal with future stressful situations and events.
Trauma-focused therapies directly address the traumatic event and thoughts, emotions, and memories of it. The focus is on exposing the client to the traumatic experience and processing the events and the corresponding mental perceptions that resulted from it. The client is exposed both indirectly and directly and works with the therapist to practice learned calming techniques and coping skills to lessen the effects of exposure to stressful experiences past and future. Two types of this approach are prolonged exposure (PE) and cognitive processing therapy (CPT).
PE therapy typically lasts for nine to 12 sessions, typically meeting once a week for 90 minutes. It begins with education on PTSD, discusses common symptoms, and reviews the symptoms the client is experiencing. The client learns breathing techniques to use when experiencing symptoms. In session, imaginal exposure is used—the client discusses in detail the experienced trauma and the thoughts and emotions associated with it, and the therapist and client process these. The session is recorded so the client can listen to it frequently while not in session and practice breathing techniques to lessen the experienced impact of the stressor.
In vivo exposure is also used and happens in stages. It involves a client facing people, places, and situations that trigger symptoms. The therapist and client make a list of these triggers, and the client exposes himself to these situations while using the calming techniques he has learned. The exposures are gradual, based on the level of symptomatology induced in the client, beginning with those least provoking.
CPT also begins with education regarding PTSD, including common symptoms, symptoms the client specifically is experiencing, and breathing techniques. The focus is more on how the client has mentally processed the traumatic event than the event itself. The belief is the client processes the event to make sense of it and rationalize what happened. While doing so, the client may develop thoughts and ideas about himself, others, and possibly the world that are skewed and carry over into his beliefs and behaviors. CPT typically lasts for 12 sessions of 50 minutes each. It can be done on an individual or a group basis. In session, the client first writes and reads a detailed description of his traumatic experience to begin addressing avoidance of it. Therapy moves forward discussing and processing the thoughts, beliefs, and behaviors the client has developed that have been maladaptive to a healthy lifestyle. The goal is to assist the client in recognizing the maladaptive processes that keep him stuck in feeling adverse symptoms resulting from the trauma and to replace those with useful, healthy ones that he can apply to the experienced traumatic event. These skills will help him move forward in generalizing the healthy skills and applying them in his life. As with PE, the client has “homework” between sessions to enhance the in-session work.
As these therapeutic avenues require constant exposure to experiences and memories of traumatic events, the client should be sure he is comfortable with what is entailed. If not, nontrauma-focused therapy might be more acceptable to him.
Nontrauma-focused therapy includes approaches that incorporate relaxation, present-centered therapy, and stress inoculation therapy (SIT) among others. SIT is mentioned with evidence-backed studies. It can be used alone or in conjunction with a trauma-focused approach. Information regarding duration and frequency varied among literature. Some suggested that although it can be done in a group setting, one-on-one therapy yields the best results. Some articles recommend eight to 15 sessions one to two times per week ranging from 20 to 40 minutes, with follow-up sessions lasting three to 12 months. Others recommend nine to 12 sessions once a week lasting 90 minutes.
Descriptions of SIT frequently compare the concept of inoculation to vaccination. People receive a vaccination to help prevent development of a specific disease. This therapy approach works to “inoculate” the client to help defend against developing PTSD or other anxiety conditions experienced when we encounter stress and stressful situations. SIT has three phases: conceptualization, skill acquisition and rehearsal, and application and follow-through.
Conceptualization is a time of learning. The therapist educates the client on stress. The client learns about stressors; what he can and cannot control; general stress reactions; and how he can, through thoughts and beliefs, develop a distorted perception of how to handle stressors. The therapist discusses with the client current stressors he is experiencing so the coping skills the therapist introduces to the client are individualized to his needs.
Skill acquisition and rehearsal are the part of the process when the therapist works with the client on conceptualizing his maladaptive coping skills and healthier, useful ones to use instead. The client’s strengths are amplified and vulnerabilities identified. The client learns relaxation, breathing techniques, problem-solving skills, and communication and socialization skills among others to use when recognizing triggers to stressors in his life.
Application and follow-through are when clients have the opportunity to practice what they have learned through visualization, modeling by the therapist, role-playing, and simply repetitive practice of the new coping skills to establish them as go-to skills to replace the former, maladaptive ones.
Regarding relaxation therapy and present-centered therapy (PCT), literature did not offer strong support for success with these treatments as opposed to the trauma-focused methods. They are still worth considering depending on a person’s comfort level; any techniques we can learn to help us handle stress are useful.
An honorable mention is Eye Movement Desensitization and Reprocessing (EMDR). Literature varies a great deal on levels of success when using this method to treat PTSD. This is one you may have heard of and it is considered a trauma-focused therapy. In general, the client identifies the most disturbing image of an experienced trauma and thoughts, feelings, and physical responses associated with it. He also identifies responses he would prefer to the hindering ones he is experiencing. The therapist guides the client through sessions and directs eye movements in a specific manner as the client talks in a detailed manner through the traumatic event. The therapist helps the client to recognize when he is demonstrating unwanted reactions, then pauses and replaces those thoughts, feelings, and physical reactions with the identified desired ones. The process continues until the distress level brought about by the traumatic experience is lessened and the more positive reactions take hold. There is no set time frame for this. The client decides when he is satisfied in his response to the stressor. At this point, the client can choose to end sessions or address other traumatic events in the same manner.
Literature suggests trauma-focused approaches have higher success with PTSD than the nontrauma ones and prolonged exposure the highest of those. Any of these therapies can stand alone or be used in conjunction with medication.
Medications are another avenue used to treat PTSD. The medications used for treatment of PTSD are typically not identified as PTSD medications. They are pharmaceuticals that fall under categories used for treating conditions associated with PTSD such as depression, anxiety, sleep issues, and others. Lessening these symptoms may be helpful in alleviating a person’s PTSD experience. The medications may be used alone; however, often they are used in combination with psychotherapy to enhance the benefits of both.
Two medications classified as antidepressants are FDA approved for the treatment of PTSD—paroxetine (Paxil) and sertraline (Zoloft). These two medications as well as others in their class of drugs, selective serotonin reuptake inhibitors (SSRI), show effectiveness in treating overall PTSD symptomatology. Other medications may be used and some such as anti-anxiety and anti-psychotic are being studied for effectiveness.
Very recently, drugs that have typically been known to be abused are now being researched for treatment of PTSD such as Ketamine (a relative of PCP), psilocybin (magic mushroom), lysergic acid diethylamide (LSD), and MDMA (ecstasy). Results are promising enough so studies are continuing.
If medication is a consideration in treatment, it is important to thoroughly discuss it with the treating doctor—someone with the authority to prescribe medication whether a general practitioner, a psychiatrist, or a psychologist. We recommend to ask the following questions before beginning medication: What medication is being recommended and how will it help me? What are potential side effects I might experience and how long can they last? How long will I be on the medication? Will my sleep, appetite, and alertness be affected? If so, how? Will medication alone work for me?
You should be comfortable with what you choose and be open in communication with your prescribing doctor about how you respond to any medication you take. Whether it is psychotherapy, psychotropic medication, or both, the most important component to your treatment is you. You will achieve success if the treatment recommended to you is one you are comfortable with—comfortable with being uncomfortable if you choose a trauma-focused therapy and comfortable in challenging your beliefs, perceptions, and thoughts if you choose a nontrauma-focused therapy. These treatments have studies to back their success rates for lessening and sometimes eliminating PTSD symptoms. The therapist you choose is just as important. Therapists typically have an area of concentration in their approach and a population of clients they work with. It is important for you to understand a therapist’s beliefs about how to treat you, the therapist’s training and experience, and how you feel it will fit for you.
Who Can Help
Seeking therapy while coping with PTSD can be a daunting endeavor. We are in a time when the amount of formal education a therapist has does not directly define his therapeutic skills. Although PTSD focus within the therapeutic community is increasing, the number of therapists with specific training in techniques pertaining to trauma clientele is still limited. A study from 2014 suggested only a third of all psychotherapists in America had trauma-focused therapy training; other literature believes this number is even less.
So, what should you consider? First, be sure whoever you choose is licensed to practice counseling in the state they are in. Licensing requirements vary from state to state; however, most require at least a master’s degree with a specified amount of supervised clinical hours. Do not be timid when choosing a therapist; ask questions: How many years have you practiced? Do you have a specific school of thought or style you support? What is your level of experience in working with clients dealing with trauma and PTSD specifically? Do you have any specific certifications related to trauma-focused therapy? Do you consider medication a viable treatment with psychotherapy? If so, how long would I be on medication? How long should this treatment process take? How does the process work? How much will therapy and medication cost? Do you have a good understanding of my personal, cultural, and career background?
Although it is important to seek out treatment from licensed professionals with clinical experience, the therapeutic techniques described earlier do not require any certification to perform them; however, there are organizations that offer detailed training with a certification on completion.
- An internationally known organization, the International Association of Trauma Professionals (IATP), offers several certifications. The Certified Clinical Trauma Professional (CCTP) requires 12 hours of training, 80% minimum score on an assessment, and six trauma-related continuing education units (CEUs) per year. The Certified Expert Trauma Professional (CETP) requires a 12-week interactive course and six CEUs per year.
- The Association of Traumatic Stress Specialists (ATSS) offers several certification trainings, among them a Certified Trauma Services Specialist (CTSS) and a Certified Trauma Treatment Specialist (CTTS). The CTSS certification requires ATSS membership, 72 hours of trauma-specific training, and one-year-minimum experience in the field with recommended supervision. The CTTS certification requires ATSS membership, a graduate degree or clinical license, 500 hours of counseling experience specific to trauma, 190 hours of trauma-specific training, and letters of recommendation.
- Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) through the National Therapist Certification Program has extensive requirements for obtaining this certification.
- In nontrauma-focused therapy, training is offered for Cognitive Processing Therapy (CPT) through various organizations and one site, www.cptforptsd.com, offers CPT provider qualification as both a CPT provider and a quality-related CPT provider status.
To help you with your search, here are two links, one to the U.S. Department of Veterans Affairs and one to the American Psychological Association: https://www.apa.org/topics/ptsd/index.html and https://www.ptsd.va.gov/gethelp/find_therapist.asp. Both links take you to resources directly related to PTSD therapy providers. Remember, the level of experience a therapist has is key when treating trauma-related conditions. It is up to you to be diligent in your effort toward treatment of PTSD.
In our world, we experience many types of traumatic experiences both directly and indirectly, in varying degrees of intensity, and varying number of incidents. We are more aware than ever before as to how everyone can be affected. Evidence suggests some professions increase our susceptibility to developing PTSD. We recognize PTSD as a diagnosable mental disorder. We need to be more accepting of its presence and prevalence among us. With our greater awareness comes greater attention to PTSD. Therapeutic treatment approaches, psychological and neurobiological causes, genetic factors, and pharmacological treatments relating to PTSD are all being researched. The result is implementation of new approaches to better diagnose, treat, control, and possibly prevent incidents of PTSD.
In the realm of physiology, many avenues are being explored and studied. Specific genes are being studied and identified as possibly contributing to a predisposition to vulnerability in developing PTSD. Ways to block or increase neurochemicals that affect our formation, intensity of, and storage of fear memories are being explored. Neurologically, transcranial magnetic stimulation (TMS), a medical treatment, is showing improvements in PTSD condition for patients. Positron emission tomography (PET) scans, which use a radioactive drug to show levels of activity in tissues and organs, are being used. These scans, along with brain matter donated by veterans and their families, are offering a connection between two different levels of physical processing.
As for medications, studies of MDMA (ecstasy) show it lessens the effects of PTSD. Also, low doses of hydrocortisone administered within the first few hours to individuals who recently experienced a trauma show promising results in preventing PTSD “taking hold” later.
In preventive approaches, the military implemented “Operation Battlemind,” which is now referred to as “Resistance Training.” The military is investigating training with soldiers that stresses social interdependency, openness among soldiers, and attempts to eliminate factors such as avoidance. The program also offers aid in transitioning soldiers from deployment status to civilian life. SIT, aside from being a therapeutic technique, is being tested as a training tool to help prepare individuals in careers that may put them at a greater risk of developing PTSD from exposure to trauma.
More specific concentrated studies on CBT and its subtypes, alone and in combination with one another, are being studied in hopes of identifying ways to achieve greater effectiveness in treatment. There are more avenues being explored and more research being done. What will come from the research will most likely trickle into proactive, preventive, and posttrauma treatments. As mentioned earlier, psychological treatments are still being studied for their levels of effectiveness.
Despite support for success with these evidenced-based treatments, professionals who are properly trained to conduct these techniques are still limited in America. Research studies on therapies suggesting high levels of success in minimizing, even eliminating, symptoms of PTSD in patients are already supporting a need to train more professionals in these techniques and approaches to further spread successful outcomes in therapy.
Fortunately, PTSD and related conditions are experiencing a wave of forward progress. The future for advancement in our beliefs and approaches toward it looks promising. Unfortunately, as with other disorders, the stigma still lingers, more so with individuals in careers premised on being tough, strong, and resilient. Whether it is from fear, ego, ignorance, or misunderstanding, move away from the “I’m fine” attitude toward “… something’s up” and either “I could use some help” or “Do you need help?”
Throughout history, the medical and psychiatric communities have leaders who stood out to push forward in our description, perception, and treatment of PTSD. Our society today is predictably unpredictable. War, active shooter scenes, mob assaults, bombings, and terrorist attacks are now mixed in with everyday traumas we directly and indirectly experience like accidents, abuses, and natural disasters. Our career exposes us to a level of trauma most people do not experience. We wonder if our efforts toward treating and lessening the occurrences of PTSD in turn could contribute to less suicide, less depression, less drug/alcohol abuse, and less anxiety rooted in the psychological impacts of trauma we experience in our lives.
We hope that as present and future considerations continue to develop and broaden, we can get in front of PTSD. We can learn and apply techniques to better equip ourselves for what we encounter, raise our ability to recognize when we are being affected negatively, and reach out after experiences for assistance if needed.
A newer term that projects positivity and growth is “posttraumatic growth.” It is a great avenue to consider how we can take traumatic experience and use it toward personal growth with good experiences and good outcomes.
Keep the discussion moving forward; take care of yourselves mentally as well as physically. If you or someone you care about might be struggling with PTSD. please reach out! PTSD is treatable, and a person suffering from it can move through it and past it with help and support. Be that person!
DANIEL DEGRYSE, CFO, BA, BS, CADC, retired as a battalion chief following a 30-year career with the Chicago (IL) Fire Department. Throughout his career, he has been an advocate of awareness, education, and proper treatment for substance use and mental health issues. He has led training for fire and police departments locally and nationally and is a master instructor for the IAFF Peer Support Program. He has a bachelor’s degree in psychology and more than three decades of clinical experience working in the mental health field providing individual, group, and family therapy. He is the director of the Rosecrance Florian program, a tailored approach to treat first responders and military personnel facing substance use and mental health issues.
VICTORIA DEGRYSE has worked with abused women and children, volunteered with her church activities, participated in and been an officer for organizations with her childrens’ elementary school, volunteered for organizations assisting first responders, and volunteered and coordinated for a local childrens’ sports organization. She spends much of her time supporting her husband’s drive and devotion to bringing mental health awareness, education, and resources to first responders and the military. She has a B.A. from Purdue University and an M.S. degree from Northern Illinois University.