An Extensive Literature Review on Post-Traumatic Stress Disorder (PTSD)
May 1, 2022
Most people, at some point in their lives, will experience a traumatic event. The way we react to, process, and store this event varies widely depending on the person, setting, intensity, and a number of other factors. Post-traumatic stress disorder (PTSD) is a psychiatric disorder which can occur after a person has experienced or witnessed a traumatic event. The DSM-5 references a traumatic event as exposure to actual or threated death, serious injury or sexual violence. Exposure is defined as directly experiencing the event, witnessing it occur to others, learning of a traumatic event happening to family or close friend (event must be violent or accidental), or experiencing repeated or extreme indirect exposure to traumatic events.
PTSD has often been referred to as “shell shock”, the term, coined by soldiers in war, used to describe someone presenting with symptoms of PTSD. As most early information on trauma and PTSD came from studies of male Veterans, post-traumatic stress disorder has continued to be heavily tied to and sometimes isolated to war, combat and male soldiers. Researchers have begun to study and learn the effects of sexual assault (occurring most often to women) and found the repercussions on women were similar to that of male combat Veterans (U.S. Department of Veteran Affairs, 2018). In a meta data analysis done of one billion adult survivors who experienced the war between the years of 1989 to 2015, 23.81% of those met the diagnostic criteria for PTSD (Hoppen & Morina, 2019). This, compared to survivors of sexual assault with 74.58% (one-month post-assault) and 41.49% (12 months post-assault) meeting the diagnostic criteria for PTSD. (Dworkin, 2020). This strongly suggests sexual assault is a top cause of PTSD and is associated with higher rates of PTSD than other traumas (Dworkin et al., 2021).
As mentioned, causes and rates of PTSD greatly depend on a wide number of interconnected variables such as age, gender, race, sexuality, country, socioeconomic status, occupation, house hold environment, etc. In a study done by the British Journal of Psychiatry (2016), Canada had the highest rate of PTSD of 24 countries studied. The life time prevalence of PTSD in Canadian adults is 9.2% versus 6.8% in American adults. Sexual assault is the most underreported violent crime in Canada with only 5% of incidents reported by victims to police in 2014. Considering gender; women are more than twice as likely than men to have PTSD (Government of Canada, 2020), predictably as they also have a greater risk of certain violence, are more likely to experience trauma and make up 91% of sexual assault victims (U.S. Department of Veteran Affairs, 2018; U.S Department of Justice, 2002). Other groups disproportionally affected by PTSD are Latinos, Black peoples and Indigenous peoples (American Psychiatric Association, 2022). The highest average annual rates of sexual assault in Canada were reported in Nunavut (567.4 per 100,000 people), the Northwest Territories (404.3) and Yukon (204.8). (Rotenberg, 2017), when the average annual rate of sexual assault report overall in Canada was 62.1 incidents per 100,000 population.
Symptoms and Diagnosis of PTSD
The symptoms of PTSD are subdivided into four categories and can vary in severity. Like many mental health disorders, the presence of these symptoms is the criteria for diagnosis. The four categories of symptoms are: intrusions, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity.
1. Intrusions can be defined as repeated, involuntary images, memories; distressing dreams; or flashbacks of the traumatic event as if it were recurring. (1+)
2. Avoidance includes avoiding reminders of the traumatic event such as people, places, activities, objects and certain situations. Avoiding any thoughts, memories or conversations associated with the trauma. (1+)
3. Alterations in cognition and mood may be an inability to recall important aspects of the traumatic event, negative and distorted beliefs about oneself or cause and consequences of the trauma; fear, anger, or shame; less interest in activities; feeling detached or estranged from others; being unable to experience positive emotions; or feeling numbness. (2+)
4. Alterations in arousal and reactivity can appear as irritability, angry outbursts; reckless behaviour, self-destructing, hypervigilance; exaggerated startle response; problems with concentration or sleep. (2+)
To be diagnosed with PTSD, symptoms must last for more than a month and cause significant distress or impairment in function (social, occupational, or other important areas of functioning). Onset of full expression of symptoms many times is delayed, occurring months or even years after the traumatic event. Symptoms can persist for years following. When lasting for less than a month, this array of symptoms is defined as acute stress disorder. (American Psychiatric Association 2013)
Stress response in the body
Many of the symptoms of PTSD involve the well known “fight, flight or freeze response” - the activation of the sympathetic nervous system. The physical actions of ‘fight’ or ‘flight’ that takes place is only the first domino of a very long chain reaction called the stress response. The autonomic nervous system (ANS) is a branch of the nervous system with sensory & motor neurons in which the response is involuntary, meaning any nervous system response is not consciously controlled. Within the ANS, there are three subsections; the sympathetic nervous system (fight-or-flight), the parasympathetic nervous system (rest and digest) and the enteric nervous system – this regulates smooth muscle and glands of the gastrointestinal tract and is controlled by the other two branches of the ANS.
The stress response includes three distinct phases and begins with the alarm phase; the initial activation of the sympathetic nervous system. This starts in the brain when a stress is perceived – but it is important to note the perception of a stress is highly individualized. What one-person experiences as stress, another may experience very differently, and this can vary in the same person at different times. If the stress is extreme, unusual or long lasting it triggers the stress response. When person’s nervous system has faced severe or persistent stress however; the nervous system has become dysregulated. Common in those with PTSD, the stress response can then be triggered inappropriately, and to even seemingly harmless external stimuli, eliciting the stress response. This perception and distinction of ‘safe or unsafe’ is highly regulated by the amygdala, the emotional processing center of the brain that interprets images and sounds and is critical for the fear response. The sends a distress signal to the hypothalamus, which communicates with the body through the ANS, activating the sympathetic nervous system branch and the first of three steps in the stress response. Nerve impulses are sent to the adrenal medullae, causing the immediate release of epinephrine into the blood stream. The purpose of this is to get the body ready to either literally fight, or flee from the perceived stress. The pupils dilate, more oxygen is sent to the brain becoming highly alert, liver rapidly breaks down glycogen to glucose for energy, heart rate increases, airways dilate, blood vessels to muscle and essential organs dilate, blood vessels constrict to non-essential organs like the kidneys and GI tract.
The second stage of the stress response is the longer lasting resistance reaction, which kicks in after the initial surge of epinephrine subsides, to continue to help fighting the stress. This starts with the hypothalamic-pituitary-adrenal-axis (HPA) consisting of the hypothalamus, the anterior pituitary and the adrenal medullae. The hypothalamus secretes corticotropin-releasing hormone (CRH) instigating the production and release of adrenocorticotropic hormone (ACTH) from the pituitary, which triggers cortisol to be released from the adrenals. Cortisol, the primary stress hormone, continues to keep the body in fight-or-flight, effecting the function and hormones of almost all other systems in the body. Typically, the resistance stage lasts long enough to bring the body to safety after a stressor has passed, the cortisol levels fall and the body’s state slowly returns to normal. Occasionally it can fail to combat the stressor - when the third and most detrimental stage of the stress response occurs; exhaustion. This stage results from the depletion of stress hormones and body resources in the resistance stage. This is one of many physical repercussions of PTSD and a dysregulated nervous system.
Risk factors and Correlations
PTSD often occurs with other mental disorders such as anxiety disorders, substance use disorders, depression, attention-deficit hyperactivity disorder (ADHD), Pre Menstrual Dysphoric Disorder (PMDD) as well as a number of physical health diseases. These include diabetes, traumatic brain injury, high blood pressure, memory problems, chronic pain, asthma, gastrointestinal disorders and chronic diseases (Government of Canada, 2020; Pietrzak et al., 2012). Many of the listed health disorders can be consequences of PTSD, or be risk factors. Risk factors include low cortisol, reduced hippocampus size and traumatic brain injury (TBI) at time of traumatic exposure, all of which could be causations from previous trauma, which in itself is a risk factor. Other predisposing factors include being female, childhood adversity, having other psychiatric disorders, a family psychiatric history, nature of the trauma; sexual assault specifically is especially traumatic (Staniloiu & Feinstein, 2017; Sherin & Nemeroff, 2011). Distinguishing causation versus correlation of many of these diseases in combination with PTSD is still controversial as brain imaging studies in PTSD began only 12 years ago thus there are still gaps in the knowledge of underlying neurobiological mechanisms (Bremner, 2007). The complex nature of PTSD is that situations which can lead to trauma, and the way in which situations are handled after the trauma are of equal importance. “Post-traumatic factors that predict PTSD include insufficient or inappropriate coping strategies and trauma-related losses (e.g., financial or material loss).” (Staniloiu & Feinstein, 2017). It is suggested also that the time period in which an individual receives treatment can be critical in handling PTSD, for reasons partially unknown. “Most symptom recovery occurred within the first 3 months following sexual assault, after which point the average rate of recovery slowed.” (Dworkin et al., 2021)
Lasting effects of stress in the body
Lasting effects of PTSD in the body are the result of constant states of stress, and a dysregulated nervous system. Commonly found are low levels of cortisol, serotonin, endorphins and GABA. Thyroid malaise, adrenal exhaustion and pituitary malfunction can be lasting effects from constant over use. Prolonged exposure to high cortisol, epinephrine and norepinephrine causes muscles deterioration suppression of immune system, ulceration of gastrointestinal tract, and failure of pancreatic beta cells. Almost all physical disorders that accompany PTSD can be attributed to the chemical results of prolonged and repeated stress. Stress diseases include: Autoimmune disease, Cancer, Cardiovascular disease, Diabetes, Gastritis, Headaches, Hypertension, Immune suppression, Irritable bowel syndrome, Menstrual irregularities, Rheumatoid arthritis, Ulcerative colitis. As stated previously most of the symptoms of PTSD occur from inappropriate brain and nervous system responses to stimuli, and hat stimuli may be internal or external. This naturally dictates the course of treatment; psychotherapy and medications which are both indicated to change / control brain chemistry and nervous system activation as well as resilience to stressful stimuli.
Mainstream Treatment
The treatment of PTSD to date has been controversial, with varying levels of effectiveness. Stigma surrounding PTSD and shame around the traumas that cause it have created a society in which seeking out treatment can be difficult, expensive and inaccessible. The main treatment options include different types of psychotherapy and medications. Some therapies include talk therapy; cognitive behaviour therapy (CBT), or exposure therapies; Prolonged exposure therapy, and Eye Movement Desensitization and Reprocessing (EMDR). These therapies are used to focus of modifying negative emotions, identify triggers and develop coping mechanisms, confront distressing memories and rewire thoughts around those memories (American Psychiatric Association 2020). In a control trial done on veterans with PTSD 30-50% in CBT or exposure therapy failed to show clinically significant improvements, with 30-44% dropping out in randomized trials and clinical studies (Shannahoff-Khalsa, 2015). Medications can be used in combination with therapy and in some cases have been found more effective than therapy alone, however medication alone has shown limited effectiveness (Staniloiu & Feinstein, 2017). Common pharmacological therapies use antidepressants like selective serotonin re-uptake inhibitors (SSRIs), or serotonin-norepinephrine re-uptake inhibitors (SNRIs), or antianxiety drugs like benzodiazepines. The harmful side effects of medications are by the thousands and effect nearly every organ of the body, can be addictive, and cause severe illness. The danger of solely relying on, and taking these medications for extended periods cannot be over stated. Therefore, when dealing with a previous trauma (to help prevent PTSD) or on a healing journey from PTSD it is very important to consider brain chemistry and current stress / predisposing factors in the body.
Hidden stress in the body
To best prevent the development of PTSD after a traumatic experience is to keep the brain, body and nervous system in a healthy state supported by optimum nutrition - most able to fight stress. After a PTSD diagnosis, testing for signs of unwanted and excessive biochemical stress in the body correcting those through nutrition is the first step. Stress in the body can look like nutrient deficiencies, poor diet, lactic acid accumulation, heavy metal toxicity, metallothionein deficiency, adrenal imbalance, blood sugar irregularities, pituitary or thyroid disorders. All of the above cause stress inside the body, and impair its ability to respond to stress during a sympathetic nervous system response and to employ calming measures and recover after.
Foods to be avoided in PTSD include caffeine which cause nervousness, anxiety, irritability, heart palpitations, insomnia, all of which are already symptoms of PTSD. Alcohol causes chemical stress on the body and increases oxidative stress, this causes depletion of critical antioxidants, supresses GABA, increases adrenal hormone output and interferes with normal brain chemistry and sleep cycles – again, already affected by PTSD. Refined carbohydrates put further stress on blood sugar levels, which, again, is already impaired by PTSD and shown to play a major role in anxiety. Cortisol is factor contributing to rapidly fluctuating blood sugar levels, generally related to some degree of insulin resistance, made worse by overconsumption of refined carbohydrate foods. Excessive sodium intake can throw off the potassium-to-sodium ratio which is integral for proper adrenal function. Most Americans have a dietary potassium to sodium ratio of less than 1:2, yet most researchers recommend a ratio of over 5:1. A natural diet rich in fruits and vegetables can produce ratio over 50:1. Anxiety, fatigue and depression have been found to be associated with allergies, avoiding and/or determining any food allergies or sensitivities is important. Carl Pfeffer who founded the brain bio center in Princeton found a connection between high histamine and copper levels and extreme fear, phobias and paranoia. Niacin, vitamin B12, C, and zinc help to lower levels. Keeping lactic acid levels under control with sufficient B1 and keeping the blood sugar stable is important in preventing chemically induced panic and anxiety attacks.
Nutrition’s role in the treatment of PTSD
Treating PTSD through nutrition involves the same process as medication, but instead using nutrients to alter the brain chemistry balance and also supporting vital glands in the stress response. The adrenal, pituitary and thyroid glands are the three main players in the stress response and become most effected by chronic stress, especially in PTSD. Each of these glands work in conjunction with one another and need optimal nutritional support to continue to work in such stressful environments.
Adrenal glands have two major causes of exhaustion; loss of potassium ions and a depletion of DHEA and adrenal glucocorticoid hormones (cortisol). The elevated level of cortisol causes hyperglycemia, weakness, increased susceptibility to infection, decreased resistance to stress, and mood swings, aggravating anxiety, depression, and chronic fatigue. Nutrients especially important for supporting adrenal function are vitamin C, B6, B5, zinc, and magnesium. All these nutrients play critical roles in supporting the adrenal gland and manufacturing all of its hormones. These nutrients in whole foods would include: whole grains, legumes, fish, eggs, nuts, cauliflower, broccoli, sweet potatoes. Most notable botanical medicines to support to adrenal function are Chinese & Siberian ginseng, rhodiola rosea, ashwagandha and cordyceps. All of these plants exert beneficial effects on adrenal function, exert calming effects and enhance resistance to stress. Holy basil is an herb traditionally used in Ayurvedic medicine as an adaptogen to support the body during stress. It is a powerful antioxidant with antibacterial, antifungal, and anti-inflammatory properties making it helpful for not only emotional stressors but physical stressors as well.
The anterior pituitary produces adrenocorticotropic hormone ACTH, which is critical to stimulate the adrenals, and thyroid-stimulating hormone (TSH) critical to regulate the thyroid gland. The Pituitary also produces and secretes follicle-stimulating hormone (FSH) and luteinizing hormone (LH) which act on the ovaries and menstrual cycle, one possible explanation why menstrual irregularities are a side effect of chronic stress. The last important hormone secreted by this gland is prolactin, which plays a role in the menstrual cycle and in immune function. Usually disordered pituitary is caused by head trauma, that causes damage to the posterior pituitary or the hypothalamus, but consistent over use of the glands cause an extra need for support. A common symptom is excretion of large volumes of urine, with resulting dehydration and thirst. Magnesium is essential to regulate the pituitary through the hypothalamus as well as regulate neurotransmitters.
Thyroids gland disorders affects all major body systems and is among the most common endocrine disorders. If the thyroid isn’t receiving enough TSH, (from the pituitary) it’s likely not able to produce enough free T3 and T4. T3 allows the brain to produce enough serotonin, melatonin and norepinephrine. With a fatigued thyroid, menstrual irregularities are often a first symptom in women, along with dampened digestion, shakiness, fatigue, anxiety – all of which, are also symptoms of PTSD which can be aggravated by a sluggish thyroid. Tyrosine and iodine are the most important nutrient for you thyroid. Foods important to avoid are wheat, rye, barley, soy, and cruciferous vegetables. Foods important to consume lots of include iron, selenium, zinc, and the B vitamins through lots of fruits and vegetables, especially leafy greens, potatoes, beans, fish and eggs. Ashwaganda, ginseng and chamomile are herbs which can be taken as teas, helpful for thyroid support.
Neurotransmitters play a vital role in telling the brain, nervous system and body what to do. Nutrients are vital to make and encourage the activity of neurotransmitters. To keep the brain making neurotransmitters it’s important to consume enough methylation nutrients; B6, B12, folic acid and TMG. Food sources are beans, nuts, seeds and leafy greens. All of the neurotransmitters are affected by medication in the treatment of PTSD and can also be manipulated and balanced with natural nutrients. Gamma-aminobutyric acid (GABA) is the main inhibitory neurotransmitter – facilitates communications of brain cells. This amino acid helps regulate and calm the nervous system, positively reduces the activity of brain neurons which relaxes the body and mind. GABA supplemented directly as GABA, foods eaten to raise levels include; soy proteins (beans), fermented yogurt, cruciferous vegetables, mushrooms, sweet potatoes, sprouted grains, certain citrus fruits. Taurine, valerian, hops, passion flower and magnesium are all helpful supplements for promoting GABA. Norepinephrine is an excitatory neurotransmitter in the brain and is involved in the stress response. Supplements to balance norepinephrine are L-theanine, L-tyrosine, while foods include high protein foods, eggs, salmon, cottage cheese, chicken and vitamins B, C, D, calcium and magnesium. Rhodiola rosea is an herb which exerts adaptogenic effects by working on neurotransmitters and endorphins. Ginko biloba and turmeric are also helpful in regulating neurotransmitters. Acetylcholine is another very important neurotransmitters which supports the ANS. Acetylcholine supplements include phosphatidyl choline, phosphatidyl choline and DMAE. Foods to enhance this neurotransmitters function includes fish, especially sardines, and egg yolks. Serotonin also play a key role in the brain of those with PTSD. This happy neurotransmitter turns into the vital sleep neurotransmitter – melatonin. Lots of people with PTSD have troubles with sleep and trouble with positive emotions. Direct supplements for increases serotonin in the brain include 5-HTP and tryptophan. Foods the supply the nutrients vital for serotonin production include chicken, cheese, tuna, tofu, eggs, nuts, seeds and milk.
Life style practices for PTSD
Managing stress through nutrition on its own isn’t enough, avoiding stressful environments and stressful life style practices is integral when managing PTSD. Mindset may be one of the most crucial roles in this circumstance. Choosing to see the glass half full is not always easy but is the line of defense in the face of any life stressor. How an individual handles stress plays a major role in determining their level of health. Laughter and positive emotional states alone can enhance immune function. Guided imagery, hypnosis, and other meditative states have also been shown to enhance the immune system and most organ systems. Sleep, one of the most over looked but most important aspects to avoiding bodily stress. At lease 8 hours of restful sleep is essential for the body, mind and nervous system to recharge and rest. Adequate sleep is absolutely critical to healthy immune function and stress response. Sleep deprivation consistently demonstrated to impair different components of immune function and mood. Exercise technically is a stress on the body, but it only elicits a small stress response in which the body adapts to and becomes healthier and stronger because of it. Exercise becomes a very effective stress reduction technique, enhancing body function, mood and often outlook on the world. In people with PTSD certain types of combat or defensive exercises can be a big form of exposure therapy as well as a mental aid in feeling safer in the world with new skills to feel safe.
References
American Psychiatric Association. (2020). What is posttraumatic stress disorder (PTSD). Psychiatry.org - What is Posttraumatic Stress Disorder (PTSD)? Retrieved May 1, 2022, from https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.) https://www.ncbi.nlm.nih.gov/books/NBK207191/box/part1_ch3.box16/
Bremner, J. D. (2007). Neuroimaging in posttraumatic stress disorder and other stress-related disorders. Neuroimaging clinics of North America. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729089/
Canada, P. H. A. of. (2020). Government of Canada. Canada.ca. Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/federal-framework-post-traumatic-stress-disorder.html
Dückers, M. L. A., Alisic, E., & Brewin, C. R. (2018). A vulnerability paradox in the cross-national prevalence of post-traumatic stress disorder: The British Journal of Psychiatry. Cambridge Core. Retrieved from
https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/vulnerability-paradox-in-the-crossnational-prevalence-of-posttraumatic-stress-disorder/44FD260C9AC21868E34F6FC3968421E2
Dworkin, E. R. (2020). Risk for Mental Disorders Associated With Sexual Assault: A Meta-Analysis. Trauma, Violence, & Abuse. Retrieved from https://journals.sagepub.com/doi/10.1177/1524838018813198?icid=int.sj-abstract.citing-articles.1
Dworkin, E. R., Jaffe, A. E., Bedard-Gilligan, M., & Fitzpatrick, S. (2021). PTSD in the Year Following Sexual Assault: A Meta-Analysis of Prospective Studies. Trauma, Violence, & Abuse. Retrieved from https://journals.sagepub.com/doi/10.1177/15248380211032213
Harvard Health Publishing. (2020). Understanding the stress response. Harvard Medical School. Retrieved from https://www.health.harvard.edu/staying-healthy/understanding-the-stress-response
Hoppen, T. H., & Morina, N. (2019, February 22). The prevalence of PTSD and major depression in the global population of Adult War Survivors: A meta-analytically informed estimate in absolute numbers. European journal of psychotraumatology. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394282/
Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2012). Physical health conditions associated with posttraumatic stress disorder in U.S. older adults: Results from Wave 2 of the National Epidemiologic Survey on alcohol and related conditions. Journal of the American Geriatrics Society. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3288257/
Rennison, C. M. (2002). Rape and Sexual Assault: Reporting to Police and Medical Attention. Bureau of Justice Statistics. Retrieved April 28, 2022, from https://bjs.ojp.gov/content/pub/pdf/rsarp00.pdf
Rotenberg, C. (2017). Police-reported sexual assaults in Canada, 2009 to 2014: A statistical profile. Statistics Canada: Canada's national statistical agency. Retrieved from https://www150.statcan.gc.ca/n1/pub/85-002-x/2017001/article/54866-eng.htm#r8
Shannahoff-Khalsa, D. (2015). How to heal post-traumatic stress disorder naturally. GreenMedInfo. Retrieved from https://greenmedinfo.com/blog/how-heal-post-traumatic-stress-disorder-naturally
Staniloiu, A., & Feinstein, A. (2017). Post-traumatic stress disorder (PTSD) in Canada. The Canadian Encyclopedia. Retrieved from https://www.thecanadianencyclopedia.ca/en/article/post-traumatic-stress-disorder-ptsd-in-canada
Sherin, J. E., & Nemeroff, C. B. (2011). Post-traumatic stress disorder: The neurobiological impact of psychological trauma. Dialogues in clinical neuroscience. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182008/
U.S. Department of Veterans Affairs . (2018). PTSD: National Center for PTSD. How Common is PTSD in Women. Retrieved from https://www.ptsd.va.gov/understand/common/common_women.asp