By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Post Traumatic Stress Disorder (PTSD) is one of the stress induced disorders. The name of the disease is self explanatory. This disease of the mind occurs in those people who have experienced or witnessed any traumatic event such as –
A life-threatening accident
An act of terrorism
Threat of death
Serious kinds of injuries etc
Other names (from the past, no longer used)
Shell Shock – during World War I
Combat Fatigue – after World War II
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Table of Contents
In whom does PTSD commonly occur?
All people of any ethnicity, nationality or culture, at any age. It affects nearly 3.5 % of the population of US, especially adults every year. It is estimated that 1 in 11 persons will be diagnosed with this condition in their lifetime. Women suffer from this condition twice in comparison to men.
People suffering from PTSD would experience the symptoms for a longer time even after the causative traumatic event has ended. These experiences may be in the form of disturbing thoughts and feelings related to the traumatic event. They may feel sadness, fear or anger. They may also feel detached from other people. These people either avoid situations or people that have caused or remind them of the traumatic event they had experienced in the past.
History of ‘exposure to an upsetting and disturbing traumatic event’ and the symptoms following thereafter are mandatory for the diagnosis of PTSD to be made. Example – This condition could occur in persons who have news of a close family member or friend had a violent death. It can also occur due to repeated exposure to details of trauma – Example, the police officials regularly exposed to the horrible details of cases of child abuse.
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The symptoms of PTSD can be put into 4 categories. The specific symptoms of each type may vary in case of severity.
|Sl No||Category of PTSD Symptoms||Symptoms||Additional observations|
|1||Intrusion||Experiencing intrusive thoughts like |
a. repeated or involuntary memories
b. distressing dreams
c. flashbacks of traumatic events
|Flashbacks – they are so vivid that the patients feel they are re-living those traumatic experiences or as if they are seeing it happen before their eyes|
|2||Avoidance||People will try to avoid reminders of traumatic events. |
Avoid people, places, activities, objects, situations
|These people will try to avoid thinking about or remembering the traumatic event. Also resist talking about what happened or how they feel about the event.|
|3||Alterations in cognition and mood||People will have|
a. inability to remember important aspects of the traumatic event
b. negative thoughts and feelings – leading to ongoing and distorted beliefs about self and others. Ex. I am not good, none of these people are trustworthy etc
c. distorted thoughts about cause or consequences of the event – this leads to blaming self or others, ongoing fear, horror, shame, guilt or angered. very less interest in the same activities which she or he enjoyed doing previously
e. feeling detached from others
f. inability to experience positive emotions / void of happiness / void of satisfaction
|4||Alterations in arousal and reactivity||Symptoms of arousal and reactivity include –|
a. being irritable
b. having angry outbursts
c. behaving in a self-destructive way
d. overly watchful about one’s own surroundings in a suspecting way
e. being easily startled
f. having problems with concentrating
g. having problems with sleeping
These symptoms in varied proportions are experienced by those facing traumatic events in the days following that event.
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For a given condition to be diagnosed as PTSD –
The symptoms related to the traumatic event should have been lasted for more than a month. Those symptoms must cause significant distress or problems in the daily functioning of the individuals who had faced that traumatic event
Many people develop symptoms within 3 months of suffering from the trauma. The symptoms may also appear later and often stay for many months or years. This condition often occurs with other conditions like depression, memory problems, substance use and other health issues (physical and mental).
Acute Stress Disorder –
- Occurs following traumatic event (similar to PTSD)
- Have similar symptoms
- Symptoms occur between 3 days – 1 month following the event
- Patients relive trauma events, have nightmares and flashbacks
- Patients feel detached from selves and others, feel numb about things and people
- Symptoms cause severe distress and problems
- About half of acute stress disorder patients develop PTSD in future
- Approximately 13-21 survivors of car accidents and about 20-50% of survivors of rape, assault and mass shootings develop acute stress disorder
PTSD can be avoided and symptoms of acute stress disorder can be eased by psychotherapy including cognitive behavior therapy
SSRI antidepressants can also help in relieving the symptoms
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Adjustment Disorder –
- occurs in response to stressful life events
- symptoms are usually more severe than what is generally expected for the type of event causing the disorder
- Symptoms include – feeling tense, withdrawal, sadness, feel of hopelessness, impulsive behavior, acting defiantly, physical symptoms like tremors, headaches and palpitations
- symptoms cause severe distress and problems functioning in important areas of life like in work place, school, social interactions etc
- symptoms begin within 3 months of stressful event, do not last for more than 6 months after the stressor or the effects of stressor have ended
- stressors may be single or multiple, recurring or continuous, might affect an individual or an entire family or larger group of community as in natural disaster
- about 5-20% individuals coming for mental health check up or treatment are diagnosed to have adjustment disorder
- as per recent studies more than 15% adults with cancer had adjustment disorder
- this condition can be mainly treated with psychotherapy
Dis-inhibited social engagement disorder
- occurs in children who have had experienced severe social neglect / deprivation before the age of 2 years
- occur in children lacking basic emotional needs for comfort, affection and stimulation
- occurs in children wherein they are prevented from forming meaningful and strong attachments with others due to repeated changes in caregivers
- found in children engaging in familiar or culturally inappropriate behavior with unfamiliar adults’ example – child may be willing to go off with an unfamiliar adult without any inhibition or hesitation
- child finds difficult to relate with adults and peers
- symptoms may improve when the child is mobilized to a normal care-giving environment
- symptoms may progress into adolescence
- developmental delays, mainly cognitive and language delays are found
- treatment includes working on strengthening the relationship of the child with family
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Reactive Attachment Disorder
- occurs in children who have experienced severe social neglect / deprivation during their initial life years
- can occur in children lacking basic emotional needs for comfort and affection as in the above said condition
- children are emotionally withdrawn from the adults / caregivers
- they hardly turn to or never turn to caregivers for comfort, protection or support
- they do not respond to comforting when they are in a state of distress and someone is trying to comfort them.
- show little or no positive emotion and may show fear or sadness
- problems appear before 5 years of age
- cognitive and language delays
- it is an uncommon disorder
- treatment – mainly involves strengthening the relationship bonds between children and their caregivers
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Treatment of PTSD
Is treatment really required?
Yes, treatment is needed for PTSD but not in all cases. Everyone who experiences trauma does not develop PTSD. And not everyone who develops PTSD requires psychiatric treatment. Symptoms of PTSD subside or disappear over a period of time for some people. Many other people get better with the help of caring family, friends or counselors. Many people with PTSD need professional treatment. PTSD is surely treatable. There are better chances of recovery if this condition is treated at the earliest.
Effectively treating PTSD is the expertise of mental health professionals and psychiatrists. They use various methods proven by research to help people recover from this condition. Talk therapy / psychotherapy and medication are the best methods to provide effective treatments for PTSD. CBT – Cognitive Behavior Therapies is a category of psychotherapy and is an effective intervention in PTSD.
Types of CBT
Cognitive Processing Therapy – Some painful negative emotions like shame, guilt etc and beliefs like ‘I am a failure’, ‘the world is a dangerous place to live’ etc are manifested due to mental trauma. This therapy focuses on modifying these beliefs and emotions, of course guided by expert therapists.
Prolonged exposure therapy – This helps a person to face and gain control over his fears and distress and to cope up with the same. This is achieved by using repeated, detailed imagining of the trauma. Alternatively, it is achieved by making the person get progressively exposed to symptom triggers in a safe and controlled way. Example – a controlled therapeutic way of re-experiencing the battlefield is used in the form of virtual reality programs to help war veterans suffering with PTSD.
Stress inoculation therapy – this provides necessary coping skills to defend against stressful triggers. This is done by making the person get exposed to milder levels of stress. It acts just like a vaccine.
Group Therapy – There are groups which comprise many survivors of similar traumatic events. These groups encourage these survivors to share their experiences and reactions in a setting which is comfortable and non-judgmental. The group members help each other and make each other realize that they have felt the same trauma, emotions and have responded the same way as others.
These therapies are alternatives for those who do not prefer to get exposed to the reminders of their traumas.
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Medication – Medicines can control symptoms of PTSD. The relief obtained through medications prompts more people to participate effectively in psychotherapy. To treat the core symptoms of PTSD antidepressants are commonly used.
Other medications target to lessen anxiety, to treat physical agitation, nightmares and sleep problems.
Other treatments include complementary therapies and alternative therapies. Examples – acupuncture and animal-assisted therapies.
Brain tissue yields clues to causes of PTSD – Post mortem analysis of brain tissue from people who had been diagnosed with PTSD may help in reflecting some mysteries related to this disorder like ‘why women are more susceptible to the disease’ or ‘if a dampened immune system response plays a role in dealing with stress’.
Brain biomarkers can help in identifying those at severe risk of PTSD – A study has linked brain activity related to associative learning with severity of PTSD symptoms. A study has shown neuro-computational contributions to develop PTSD in combat veterans. The findings have revealed patterns for how the brain and body respond to learning danger and safety depending on severity of PTSD symptoms. This explains why PTSD symptoms can be severe in some people and not in others.
Study – Effects of music relaxation and muscle relaxation techniques have been studied on sleep quality and emotional measures among individuals with PTSD.
Effectiveness of Trauma-focused Psychodrama in treatment of PTSD in inpatient Substance Abuse Treatment – Psychodrama is an experimental approach. It is often used in psychotherapy. It integrates role-playing techniques, dramatic enactment and spontaneous improvisation. One study highlights trauma focused psychodrama as a potentially effective treatment approach for treating PTSD. It offers a good alternative to traditional talk therapies for individuals who have experienced trauma. According to many client’s other types of trauma therapy are painful or sometimes intolerable. But in this study the participants found the therapy to be tolerable and even fun.
Timing of mental health treatment and PTSD symptom improvement among Iraq and Afghanistan veterans – PTSD should be treated promptly without delay. Interventions to reduce delays in initiating mental health treatment may improve treatment response in veterans.
Targeting Hyperarousal – Effect of Mantram repetition program for PTSD in US veterans – According to a study MRP i.e. Mantra Repetition Program appears efficacious in reducing hyperarousal and thereby impacting other PTSD symptom clusters, as one pathway to facilitating recovery.
Ayurveda Concept of PTSD
We cannot correlate PTSD to any one condition explained in Ayurveda but needs to be conceptually understood. This is a small attempt and hypothetical correlation in that perspective.
Manasika Roga and imbalance of mind doshas – The mind disorders according to Ayurveda are caused due to the imbalance of mind doshas i.e. rajas and tamas qualities. In PTSD we can see the symptoms pertaining to imbalance of both rajas and tamas qualities. This will be accompanied by reduced sattva quality.
Read – Manasika Doshas – Satva, Rajas, Tamas As Per Ayurveda
Sometimes the person shows high end emotions like anger, horror, fear, negative thoughts, alterations in arousal and reactivity, etc which reflects predominant imbalance of rajas quality. This type of display reflects predominant vitiation of vata which is also associated with rajas quality. There is also an associated pitta imbalance. These doshas will further contaminate the mind and mind carrying channels and worsen the condition. Imbalance of vata and pitta may also cause symptoms at the physical level making this condition a complete psychosomatic disorder.
Some other people will show low end emotions like being depressed, detached from everything and everyone, guilt, worry, shame, loss of interest, void of happiness and satisfaction. In these people the tamas quality would be predominantly imbalanced. People also may get fluctuated in between and swing in between the emotions contributed by imbalanced rajas and tamas at various points of time.
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Imbalance of dhee, dhruti and smriti – The 3 important faculties of the mind i.e. intellect, courage and memory are all disturbed in this condition. Negative thoughts and feelings, avoidance, alterations in arousal and reactivity reflect the disturbance of dhee i.e. intellectual component of the mind. Reliving the bad experiences and recollecting them, repeated and involuntary memories, distressing dreams, flashbacks of traumatic events, explain the imbalance of smriti i.e. memory component. Fear, self blame, anger outbursts, horror, shame, guilt, loss of interest in activities, feeling detached, void of happiness and satisfaction reflects imbalance of dhrti i.e. courage component.
Contamination of mind carrying channels – This is one of the most important pathways of pathogenesis as far as the mind disorders are concerned. Traumatic events would imbalance rajas and tamas qualities and deplete the protective sattva quality. In due course of time (with events explained in tissue depletion and impact below) the physical doshas too will get imbalanced due to the effect of mind disturbance on the body functions and non-coordination of the physical-mental axis. These physical doshas will once again contaminate the mind carrying channels which have their root in hrdaya (heart / brain) and bring about the symptoms of PTSD.
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Vata factor – Trauma of any kind will aggravate vata, be it at physical level or mental level. Vata is the chief controller of mind. If vata is in balance, the mind is in balance. Balanced mind will also help keeping vata in control. When vata gets aggravated as an effect of ongoing effects of trauma it will cause serious impact and impair all activities of the body. When vata will be imbalanced the rajo guna too will be imbalanced. The double impact on the mind will lead to bad consequences. Controlling Vata is an important strategy in treating mind disorders. Mental disorders drastically respond by vata alleviating measures. At the same time mind relaxation therapies and measures will keep vata at bay.
Read – Vata Dosha – Introduction, 40 Things To Know
Tissue depletion and impact – Physical trauma including accidents, being a war victim, combat, being victim of terrorism, rape, sexual violence or of serious injuries will lead to depletion of tissues. This may be due to injury, the disturbance of mind to serious levels impending with the food and nutrition intake or the physical trauma leading to imbalance of mind leading to rejection of basic needs of life. Mental trauma too can cause similar problems. Due to depletion of tissues the body will lose its endurance, strength and immunity. This will lead to vitiation of vata. The mind trauma has anyways caused an imbalance of rajas quality. Increased vata and imbalanced rajo quality will mutually influence each other and cause serious symptoms at physical and mental levels. Deficit nutrition to mind carrying channels, sense organs and brain too will further damage the mind and its functioning.
Read – Decrease Of Tissues – Dhatu Kshaya – Reasoning, Symptoms
Agantuja Unmada – Unmada is a word which has been equated to madness, insanity or lunacy. But it is a wide spectrum mental disorder and encompasses many psychiatric conditions and mental disorders beneath its umbrella. Agantuja means ‘that caused by external causes’. Though trauma has not been directly mentioned in the pathogenesis of this subtype of the disease, PTSD can be considered as the affliction of mind or mental disorder caused by external causes – which in this case is trauma and the memories of trauma.
Mano-Abhighata – Trauma to the mind is one of the factors mentioned amongst the etiological factors of Unmada. All those who undergo mental trauma need not suffer from mental disorders. Those who have weak minds and cannot recover from the memories of trauma will suffer from diseases like PTSD. Herein fear or excessive ecstasy, anger etc are said to cause mental trauma in unmada. There are also other causes which do not fit into the discussion here. In weak minded people the aggravated doshas invade and occupy the seat of intellect i.e. hrdaya (brain?), and later enter the mind carrying channels and occupy them. Consequently they cause imbalance of mind and cause mental disorders. Loss of basic intelligence, deviation of mind, absence of mind, loss of courage, loss of memory, delirium, feeling of emptiness and detachment are explained among the symptoms of unmada. These symptoms are also found in PTSD.
Signs / diseases caused by imbalance of raja and tama qualities of mind – Master Charaka has enlisted many diseases which could be caused by imbalanced raja and tama qualities. Anger, ignorance, bewilderment, being in an intoxicated state, grief, stress, anxiety, fear, panic are the qualities which fit into the explanation of PTSD.
Best medicine for the mind – According to Ayurveda the best treatment for the mind is 3 fold. This will be the primary approach towards all mental disorders.
Dhee – Manipulation, correction and balancing intelligence and thought process. Cognitive Behavior therapy done in modern medicine fits into this category.
Dhairya – Seeding the courage in the mind of the person suffering from PTSD is mandatory. Talk therapy or psychotherapy and counseling are the parts of this strategy and counterparts of modern medicine.
Atmadi Vijnanam – The patient should be made to realize the worth of self and importance of self-care.
Treatment for contaminated mind carrying channels – Heart and the great vessels taking from the heart are the roots of mind carrying channels. Therefore, therapies and medicines given for heart diseases will help in treating the mind related disorders like PTSD. Heart and brain are vital organs and are interconnected functionally. Mind is seated in the heart and brain and functions through the balanced prana and udana vata axis. Therefore, brain tonics are also mind tonics and vice versa.
Vata balancing therapies and medicines – External therapies like herbal oil massage, showering of medicated oils and milk over the body, oil therapies done on the head, nasal medication and herbal enemas are therapeutic and healing for mind and mental disorders. Vata balancing diet and lifestyle changes too should be included.
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Rasayanas and Vajikarana medicines – Rasayanas not only replenish and bring about increase and balance of all tissues, increase strength and vitality, but are also very effective mind medicines. Rasayanas balance the tissues and with this the vata and imbalance of doshas too will be corrected. Similarly, the herbal aphrodisiacs explained in Ayurveda and the formulations prepared of them also heal the mind which has been afflicted by stress and trauma.
Shodhana – Therapeutic purgation and emesis as and when required will help detoxifying the body, also bring about balance of mind and establish its health. They are also conducive to the channels in the body including mind carrying channels. Similarly therapeutic enema and errhines will help in the healing process and shall be electively used.
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Medhya Rasayanas – Brain tonics explained in Ayurveda be it single herbs like Mandukaparni (Centella asiatica), Shankapushpi (Convolvulus prostrates), Yashtimadhu (Glycyrrhiza glabra) and Guduchi (Tinospora cordifolia) or formulations prepared out of many mind healing medicines will help in PTSD.
Udvegajanaka – In stubborn cases of unmada Master Charaka mentions to administer special kinds of treatments which are stimulatory in nature. The measures include tying up the person in dark rooms, scaring him, give him things which he asks for and those which he has lost and is longing for, bring about interest and enthusiasm in him, create moments of pleasure, give assurance, cause fear by suddenly bringing in front of him a snake or tiger, cause shock suddenly, touch his body with hot iron, oil or water, hit him with sticks, etc. These will produce temporary shock or fear in him and he will realize the value of life. His mind gets stimulated in a positive direction and he will try to defend and protect himself knowing his self worth. These syncs with the explanation of prolonged exposure therapy and stress inoculation therapy explained in modern medicine as part of treating PTSD. They are also types of CBT. Giving assurance by friends and family blends with the modern explanation of ‘group therapy’.
Sanjna Prabodhana – The measures of stimulating the mind, intellect, memory and consciousness by administering anointments, powder massages, and oil massage, medicated smoking and oral consumption of medicated ghee. These principles are mentioned in the treatment of unmada.
Daiva vyaparhraya Chikitsa – Non-medicinal therapies should be administered along with other conventional therapies. They are healing and soothing for the mind. They include chanting sacred hymns, offering prayers, wearing sacred gems, sacrifices, oblations, etc. Meditation will also help.
Unmada Chikitsa – Treatment mentioned in Unmada.
Apasmara Chikitsa – Apasmara is often correlated to epilepsy. In fact apasmara encompasses all memory related disorders. Treatment of unmada and apasmara are often used interchangeably. In the pathogenesis of apasmara the affliction of mind by worries, stress, fear, anger, grief and stress has been mentioned.
Mustadi Marma Kashayam
Yoga and PTSD
Meditation and Yoga for PTSD – A meta-Analytic Review of Randomized Controlled Trials – Yoga has been shown to reduce physiological arousal in PTSD patients and is believed to affect the pathology of PTSD by improving somatic regulation and body awareness which are imperative to emotion regulation. (van der Kolk et al., 2014).
Read– How Yoga can help PTSD?
A Yoga Intervention for PTSD – A preliminary Randomized Control Trial – This study demonstrated significant changes in PTSD scores and other areas of wellbeing between the Yoga and waitlist control groups. The findings of this Kundalini Yoga PTSD study suggest that it may be an adjunctive or alternative intervention for PTSD.
Important Asanas for PTSD
Kapal Bhati Pranayama – Skull Shining Breathing Technique
Tadasana – Mountain Pose
Shavasana – Corpse Pose
Sethu Bandhasana – Bridge Pose
Konasana – Standing sideways bending one-arm pose
Marjariasana – cat pose