Excessive anger is often observed in people with PTSD and other anxiety-related disorders. In PTSD, a propensity towards excessive anger may be apparent before exposure to a trauma, for example as a personality trait. Or it could be a result of exposure to the trauma itself and a symptom of PTSD. Elevated anger in people with PTSD has clinical implications as it may be a barrier to effective treatment outcomes. Therefore, anger and aggression are key targets for improvement early in the treatment process.

What is the evidence for anger and aggression in people with PTSD?

Moderate to high quality evidence finds a large increase in difficulty with anger in people with PTSD than in people without PTSD. There were high levels of anger and hostility in veterans, police, and firefighters prior to exposure to trauma and development of PTSD.

In veterans post-deployment, the overall prevalence of any aggressive behaviour is around 36%, which is significantly higher than in veterans who have not had combat exposure. Veterans deployed to combat situations who subsequently develop PTSD show the highest levels of aggressive behaviour, particularly if they also misuse alcohol.

August 2021

Image: ©Haze – Fotolia – stock.adobe.com

The post Anger and aggression appeared first on NeuRA Library.

Many people with PTSD experience worrying, fear, and sleep problems. These may disrupt daily functioning, but may not meet the criteria for an anxiety disorder. They may be associated directly with the trauma itself, such as being diagnosed with a physical illness or being exposed to forced displacement or war. They may also be aggravated by other, core symptoms of PTSD, including emotional distress, physical reactivity after exposure to reminders, and upsetting memories, nightmares, and flashbacks. This topic concentrates on the presence and severity of subclinical anxiety symptoms in people with PTSD. Please also see the related disorder topic that is located under the co-occurring mental disorders category.

What is the evidence for anxiety in people with PTSD?

Moderate to high quality finds a medium association between more severe PTSD symptoms and increased levels of anxiety. This association was found in North Korean refugees and in cancer patients. There was also a medium association found between more severe PTSD symptoms and more anxiety sensitivity. This sensitivity relates to fear of the physical sensations associated with anxiety, fear of cognitive incapacitation, and fear of social or public observation of anxiety.

August 2021

Image: ©Rocketclips inc – stock.adobe.com

The post Anxiety appeared first on NeuRA Library.

Avoidance is a core symptom of PTSD, with at least one avoidance symptom required for a diagnosis. People often try to cope with the trauma by avoiding distressing memories, thoughts, or feelings associated with the event. This may be effective in the short-term, but in the long term it may be associated with poorer outcomes.

What is the evidence for avoidance symptoms in people with PTSD?

Moderate to low quality evidence finds three clusters of avoidance symptoms. These are avoidance of thoughts and feelings, avoidance of activity, and avoidance of memory.

Avoidance of thoughts/feelings;

I tried not to talk about the trauma. I tried not to think of things that remind me of something bad that happened to me. I tried not to think about the trauma. I avoided thinking about or talking about a stressful experience from the past. I avoided thinking about or talking about the trauma.

Avoidance of activity;

I felt less connected to people after the trauma. I avoided situations because they reminded me of a stressful experience. I tried to avoid situations or people that reminded me of the trauma. I avoided situations that might remind me of something terrible that happened to me. I tried to avoid activities, people or places that remind me of the traumatic event. I avoided activities that reminded me of the trauma.

Avoidance of memory;

I stayed away from reminders of the trauma. I tried to forget about the bad things that happened to me. I had trouble remembering important parts of the stressful experience. I could not remember much about bad things that have happened to me. I had difficulty remembering. I had difficulty remembering some things that happened during the event/trauma.

August 2021

Image: ©Yvonne Halvarsson – stock.adobe.com

The post Avoidance appeared first on NeuRA Library.

Depression symptoms are common in people with PTSD. It is characterised by a depressed mood and a loss of interest or pleasure in activities. Symptoms of depression can also include changes in appetite, weight, sleep, or psychomotor activity, decreased energy, feelings of worthlessness or guilt, difficulty concentrating or making decisions, and thoughts of death or suicide. Depression may also be associated with increased hopelessness, which is the absence of positive future orientation.

This topic concentrates on the occurrence of depressive symptoms rather than depressive disorders in PTSD. Please see the co-occurring mental disorders topic for information on comorbid depressive disorders in people with PTSD.

What is the evidence for depression symptoms in people with PTSD?

Moderate to high quality evidence finds a medium-sized correlation between increased PTSD symptoms and increased depressive symptoms. This was found in North Korean refugees and in cancer patients. In North Korean refugees, the relationship was stronger in adults than in youths, and stronger in refugees with more than five years outside of North Korea, although the effect sizes were all medium-sized.

August 2021

Image: ©Helder Sousa – stock.adobe.com

The post Depression appeared first on NeuRA Library.

Dissociation is a disruption in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, or behaviour. Common dissociative experiences include mild forms of absorption, such as daydreaming. Less common and more severe dissociative experiences include amnesia, derealisation, depersonalisation, and fragmentation of identity. Dissociation is not required for a diagnosis of PTSD.

Trait dissociation is a stable characteristic that may be a vulnerability factor for PTSD. In contrast, state dissociation occurs in response to situations. Peritraumatic dissociation is a form of state dissociation and refers to dissociation that occurs during a trauma. It may be a causal factor for PTSD.

What is the evidence for dissociation symptoms in people with PTSD?

Moderate to low quality evidence found people with PTSD had higher scores on the Dissociative Experiences Scale than people with other psychiatric disorders. These included borderline personality disorder, conversion disorder, schizophrenia, somatic symptom disorder, substance-related and addictive disorders, eating disorders, and affective disorders. People with PTSD had lower dissociation scores than people with dissociative disorders. People with PTSD also report symptoms of depersonalisation. Depersonalisation items endorsed by people with PTSD include; “I felt split into two people and one of me is watching what the other is doing”, “things around me felt unreal or dreamlike”, “I felt like I was in a dream”, “I felt that I was in a daze”, and “I’m not feeling like my actual self”.

Moderate quality evidence found an association between increased state/peritraumatic dissociation and increased self-reported meta-memory fragmentation. Meta-memory involves thinking about or recalling an event and making self-report ratings on the quality of the memory. There was no relationship between state/peritraumatic dissociation and narrative fragmentation, which involves recalling an event that is analysed by a clinician. There were also no relationships between trait dissociation and either meta-memory or narrative fragmentation.

Moderate to low quality evidence finds around 50% of people with PTSD report hearing voices, and there were significant associations between hearing voices and having dissociation symptoms.

August 2021

Image: ©Nomad_Soul – stock.adobe.com

The post Dissociation appeared first on NeuRA Library.

Traumatic distress consists of negative emotions experienced during or shortly after a traumatic event. Responses of fear, helplessness, and horror represent a subset of distress reactions that currently define trauma exposure in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), along with life threat. It is unclear if traumatic distress affects the development or persistence of core symptoms across time. Core PTSD symptoms include intrusions, avoidance, hyperarousal, and negative thoughts and mood.

What is the evidence for distress in people with PTSD?

Moderate to high quality evidence found increased severity of PTSD symptoms was related to increased feelings of distress. There may be declines in distress over time, in particular before one-month compared to after one-month post-trauma.

August 2021

Image: ©panitan – stock.adobe.com

The post Distress appeared first on NeuRA Library.

Hyperarousal is a core symptom of PTSD, with at least two hyperarousal symptoms being required for a diagnosis. Hyperarousal symptoms include irritability or aggression, risky or destructive behaviour, hypervigilance, heightened startle reaction, difficulty concentrating, and difficulty sleeping.

What is the evidence regarding hyperarousal in people with PTSD?

Moderate to high quality evidence finds small effects of less sleep efficiency, less total sleep time, less slow wave sleep, and more wake time after sleep onset in people with PTSD. Moderate to low quality evidence finds a medium-sized effect that people with PTSD and sleep disturbances were more likely to report suicidal behaviours.

Moderate to low quality evidence finds five clusters of hyperarousal symptoms. These are irritability and anger, difficulty concentrating, hypervigilance, startle, and sleep difficulty.

Items relating to irritability/anger

I lost my cool and exploded over minor everyday things. I lost my temper. Little things made me angry. I felt irritable. I had angry outbursts. I felt that if someone pushed me too far, I would become angry.

Items relating to difficulty concentrating

I had difficulty paying attention. I was unusually forgetful. I had difficulty concentrating. I had trouble concentrating. I had trouble keeping my mind on what I was doing. I had more trouble than usual remembering things.

Items relating to hypervigilance

I watched out for danger since the trauma. I was overly alert (for example, checking to see who was around me). I was very aware of my surroundings and nervous about what’s going on around me. I felt on guard.

Items relating to startle

Unexpected noises made me jump. I was jumpy or easily startled by ordinary noises or movements. I was watchful or on guard. I got startled when there was a sudden noise or movement. Unexpected noises startled me more than usual. I was jumpy or startled at something unexpected. I felt jumpy or easily startled.

Items relating to sleep difficulty

My sleep was restless. I had trouble falling asleep. I had sleep problems. I had trouble staying asleep.

August 2021

Image: ©Yanyong Kanokshoti – stock.adobe.com

The post Hyperarousal appeared first on NeuRA Library.

Intrusions are core symptoms of PTSD, with at least one intrusion symptom being required for a diagnosis. Intrusion symptoms include unwanted and upsetting memories, nightmares, flashbacks, and emotional distress and/or physical reactivity after exposure to reminders.

What is the evidence for intrusions in people with PTSD?

Moderate to low quality evidence finds five clusters of intrusion symptoms; distressing memories, distressing dreams, flashbacks, emotional cue distress, and physiological cue reactivity.

Items relating to distressing memories

Disturbing memories kept coming into my mind. I found myself remembering bad things that happened to me. Upsetting thoughts kept coming back to me over and over again. Memories of the trauma kept entering my mind. Upsetting thoughts or memories came into my mind against my will.

Items relating to distressing dreams

I had bad dreams about terrible things that have happened to me. My dreams were so real that I woke up and forced myself to stay awake. I had dreams about the trauma. I had bad dreams or nightmares about the trauma. I had disturbing dreams of a traumatic experience from the past.

Items relating to flashbacks

Being in certain situations made me feel as if I am back when the trauma occurred. I acted as if the trauma were happening again. I acted as though the event were happening again. I had flashbacks (sudden, vivid, distracting memories) of the trauma. I felt as though the trauma was happening again. I felt I was reliving the traumatic event.

Items relating to emotional cue distress

I felt upset when I was reminded of the trauma. Reminders of the trauma made me feel nervous. I became distressed and upset when something reminded me of the event. Any reminder brought back feelings about the trauma. I felt scared when something reminded me of the trauma. I felt upset by reminders of the event. I felt nervous when something reminded me of the trauma.

Items relating to physiological cue reactivity

I had sweating or dizziness when something reminded me of my experiences. I got an upset stomach when reminded of bad things that happened to me. When something reminded me of something bad that happened to me, I felt shaky. I had trouble breathing when something reminded me of a stressful experience from the past. Reminders of the trauma made me shake. Reminders of the trauma made my heart beat really fast.

August 2021

Image: ©Copyright 2017 – Shutterstock.com

The post Intrusions appeared first on NeuRA Library.

For a diagnosis of PTSD, there needs to be at least two “negative alterations in cognitions and mood”. These include negative thoughts or feelings that began or worsened after the trauma, an inability to recall key features of the trauma, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative affect (e.g., fear, horror, anger, guilt, or shame), decreased interest in activities, feeling isolated, and difficulty experiencing positive affect.

What is the evidence for negative thoughts and mood in PTSD?

Moderate to high quality evidence found a strong relationship between increased dysfunctional appraisals of the trauma and increased PTSD symptoms in children and adolescents. Increased shame was related to increased PTSD symptoms in adults. There was also a relationship between increased symptoms and increased guilt, particularly feelings of wrongdoing and self-blame. In veterans, poor mental health in general, poor social functioning, more substance use and more aggression were related to more emotional numbing. However, more treatment initiation and better treatment retention were also related to more emotional numbing in veterans.

Moderate to low quality evidence found decreased reward functioning in people with PTSD, being a reflection of an inability to feel pleasure. There was less anticipation and approach reward functioning, and also decreased hedonic responses.

Moderate to low quality evidence finds five clusters of items relating to negative alterations in cognition and mood. These are;

Decreased interest items

I lost interest in activities which used to mean a lot to me. I lost interest in my usual activities. I lost interest in free time activities that used to be important to me. I lost interest in social activities. I lost interest in activities that I used to enjoy.

Detachment items

I felt distant or cut off from people. No one, not even my family, understood how I felt.

Restricted affect items

I was not able to feel normal emotions. It seemed as if I have no feelings. I felt emotionally numb. I felt unemotional about everything. I was unable to have loving feelings for people who are close to me.

Foreshortened future items

I felt as if my plans for the future would not come true. I felt that I had no future. Making long term plans seemed meaningless to me. I felt as if I don’t have a future. I felt as if my future would somehow be cut short.

Guilt items

I felt guilty. I felt ashamed of the traumatic events that happened to me. I blamed myself. I felt guilt over things I did around the time of the event. I felt guilty for having survived.

August 2021

Image: ©2014 Igor Stevanovic – stock.adobe.com

The post Negative thoughts and mood appeared first on NeuRA Library.

Perceived defeat involves a perception of powerlessness from the loss or significant disruption of social status, identity, or hierarchical goals. A failure to attain, or loss of, valued social and material resources may induce perceptions of defeat. Social put-downs or attacks from others, and internal perceptions of self-criticism, worthlessness, and incompetence can also induce perceptions of defeat.

Perceived entrapment occurs when the usual motivation to escape threat or stress is blocked. This could be due to no or low likelihood of individual agency or rescue by others. Having a difficult job or relationship, being in an unwanted role as a caregiver, personal health problems, and unwanted negative thoughts or emotions are all examples of events that may induce perceptions of entrapment.

What is the evidence for perceptions of defeat and entrapment in people with PTSD?

Moderate to high quality evidence finds increased severity of PTSD symptoms, such as intrusions, avoidance, hyperarousal, and negative thoughts and mood, are related to increased feelings of defeat and entrapment.

August 2021

Image: ©terovesalainen – stock.adobe.com

The post Perceptions of defeat and entrapment appeared first on NeuRA Library.