Post-traumatic stress disorder (PTSD) is a type of anxiety disorder that is brought on witnessing or experiencing a traumatic life threatening event. The disorder is not limited to a specific age group and does include childhood. Stressors involved in producing the disorder include natural, accidental or deliberately caused disasters. (DSM-III-R, 1987) Symptoms of this disorder often occur immediately or very soon after the traumatic event. Symptoms of the disorder fall into three categories: reliving, avoidance, and arousal.
Reliving the event includes flashbacks of the event happening over and over again. This can also include repeated nightmares of the traumatic event. Situations which are similar to the event will bring on strong and uncomfortable reactions. Avoidance involves lack of interest in normal activities, avoiding places or people that are reminders of the event, feelings of detachment and having no future. A sense of emotional numbing, and the feeling that nothing matters anymore is also included with avoidance. Arousal involves irritability, hypervigilance, outbursts of anger, exaggerated startle response and insomnia.
There is no single test used to diagnose PTSD. Diagnosis is based upon signs, symptoms and psychological evaluations. To be diagnosed as having PTSD criteria of the Diagnostic and Statistical Manual (DSM) have to be met. The exact cause of PTSD is unknown. It is also unclear why traumatic events cause PTSD in some people and not others. However, it is known that psychological factors are involved in PTSD. Brain structure and function are both affected by PTSD; PTSD also changes the bodyâ€™s response to stress.
Certain areas of the brain are affected by PTSD, and are the areas that are involved in learning and memory. The hippocampus, which is located in the medial temporal lobe, is an area of the brain responsible for learning and memory. The hippocampus is the key component to memory. It is involved in many complex processes, and it forms, organizes and stores memories
Extreme stress can have long term lasting effects on areas of the brain involved in memory. One area in particular that is extremely sensitive to stress is the hippocampus. Damage to the hippocampus from stress can result in difficulties dealing with memories, and impair learning new material. (Bremner, 2000)
Gilbertson et al. (2002) conducted a study on monozygotic twins where one twin had been exposed to a traumatic event while the other twin had not. Magnetic resonance imaging (MRI) was used for measuring the hippocampal volume of each twin. It was shown that the trauma exposed twin had a smaller hippocampal volume than the non-exposed twin.
PTSD patients suffer from several cognitive impairments. Memory difficulties play a large part in their cognitive impairments. These individuals have difficulty remembering on a daily basis, whether it is an important date, a multiplication fact or an event which happened a day ago. Several studies have been done investigating the cognitive functions associated with PTSD.
Bremner et al. (1993) study found that the memory problems incurred by PTSD patients were comparable to patients suffering from substantial psychiatric impairments. The study compared the memory function of PTSD patients to matched controls. Patients and controls were matched by socioeconomic status, age, education, handedness, and alcohol abuse. (Bremner et al., 1993) The Addiction Severity Index interview was used to measure alcohol abuse amid the two groups to find equivalent matches. Researchers assessed the memory and intelligence of both groups with several neuropsychological tests.
The findings of the study were quite impressive. Intelligence levels between the two groups were quite similar, but the other test results did not share the same similarity. The verbal component of the Wechsler Memory Scale, used to measure logical memory for immediate and delayed memory, results showed a significantly lower score for the PTSD patients. PTSD patients immediate recall scores were 44% lower and there delayed recall scores were 55% lower than the other group.(Bremner et al., 1993) The results of the visual component of this scale showed lower scores for PTSD patients than the compared controls, but the scores were not significantly lower. Results of the Selective Reminding Test, used to measure memory performance, showed significantly lower scores for the PTSD group in both verbal and visual components. (Bremner et al., 1993)
Effects on memory deficits in PTSD patients are not limited to the adult PTSD population. Children and adolescents with PTSD exhibit cognitive impairments too. Using the Rivermead Behavioural Memory Test (RBMT), a standardized memory test, Moradi, Doost, Taghavi, Yule and Dalgleish (1999) investigated the memory function in children and adolescents with PTSD to determine if their memory impairments show a general cognitive deficit. Eighteen children and adolescents who met the DSM-III-R criteria for PTSD were compared to 22 children and adolescents with no history of psychiatric problems in the study. All participants were between the ages of 11 and 17 years of age, and each was tested individually with each testing session lasting 45 minutes.
Testing results revealed that the PTSD group when compared to the healthy controls group did have a deficit in memory. In accordance with the RBMT norms the PTSD patients showed that 55.6% suffered from poor memory and 22.2% had impaired memory. Results revealed that 77.85% of the PTSD group showed memory deficits. (Moradi et al., 1999) Only 13.6% of the healthy controls showed poor memory and none of the healthy controls showed impaired memory. When compared to the healthy controls the PTSD group scored lower on the total score proving a poor general memory. These results are in correlation of previous adult studies that also determined a general deficit in memory of adult PTSD patients.
As the study results have shown everyday memory is impacted by PTSD, but the study lacks clarity as to the presence of the memory effects. The study notes that the presence of reliving, avoidance and arousal symptoms of PTSD may interfere with everyday memory performance as well as the possibility of the development of poor reading skills impacting the memory deficits. It also makes mention of the possibility of a small hippocampal volume resulting in the everyday memory deficits.
Hayes, VanElzakker and Shin (2012) state that the key symptoms of PTSD involve modifications to cognitive processes. Things like memory, attention, planning, and problem solving, all of which show the unfavorable impact that negative stress has on cognitive functioning. Their review examined a study researching the encoding and recall of emotional words versus neutral words. The study consisted of word lists with either incidental or intentional encoding directives. Study participants were instructed to recall as many words as they could from the lists. Results of the study revealed that PTSD patients remembered more emotional words than controls.
Clinical studies have shown alterations in learning and memory in PTSD patients, which are consistent with deficits in encoding on explicit memory tasks and deficits in retrieval for specific trauma related material. (Vermetten, Vythilingam,Southwick, Charney and Bremner, 2003) A number of studies have shown abnormal cognitive patterns in PTSD patients when examining memory and nontrauma related functioning. Tapia, Clarys and Hage (2007) studied the effects of PTSD on different states of awareness and their involvement in how information is stored in memory. PTSD patients and controls with no traumatic experiences were compared in remembering and knowing recognition using non-trauma related material. The Remember and Know paradigm, which is a recognition memory test, was given to the participants. The paradigm instructed participants to assign their recognition decisions to either Remember, recognition accompanied through recollection of mental representation found by encoding, or Know, recognition achieved without access from information through the learning content. (Tapia et al., 2007)
Results showed that there was no overall recognition between the groups. The PTSD group did have a significantly dissimilar form of remembering and knowing answers representing a change from remembering to knowing. The findings suggest that the shift in the PTSD group is related with anxiety level, and a possibility of the formation of source memory being a characteristic in dissimilar types of PTSD. (Tapia et al., 2007) It can be seen from the study results that retrieval from episodic memory is impaired.
Research has shown evidence of memory impairment in PTSD patients. Unfortunately, it remains unclear if memory impairment is confined to verbal material or if memory impairment for nonverbal material is affected too. Jelinek et al. (2006) examined verbal and nonverbal memory for free recall and recognition. The goal of the study was to examine verbal and nonverbal memory for free recall and recognition. The goal of the study was to study the impairments of verbal and nonverbal memory in PTSD patients by using a task designed to minimize the impact of some confounds. The study included 40 PTSD patients and 40 healthy controls whose memory was assessed using the Picture Word Memory Test. This test measures short term and long term verbal and nonverbal memory. A computerized Stroop test was also used to measure attentional performance. Study results revealed that PTSD patients performed significantly worse than the healthy controls on all verbal memory tasks except for recognition where the decrease in performance was not significant. There was a significant difference in estimated verbal intelligence with PTSD patients recalling fewer items. PTSD patients also recalled fewer nonverbal items then healthy controls. There was a more noticeable memory deficit for verbal material, and nonverbal material was compromised though not as significant as the verbal memory. Study results are consistent with previous research showing impaired visual and verbal memory function in PTSD patients. (Jelinek et al., 2006)
Information from the exampled studies in this research paper can be summed up into one sentence which is PTSD patients experience impaired memory everyday due to the disorder. While there is no magic cure for the disorder there are a few things which can help patients effectively deal with the disorder. Cognitive Behavioral Therapy (CBT) and psychotropic medications have been shown to be effective and safe options in the treatment of PTSD. CBT is a type of psychotherapeutic treatment approach that aims at helping individuals understand the relationship between their thoughts, feelings and behaviors. Psychotropic medication is any type of medication that has the capability of affecting the mind, emotions, moods, and behaviors.
It has been shown that CBT has been used in the care and management of PTSD for many years. CBT is safe and effective in adults, children and adolescents, and is multicultural. It is a good preventative for PTSD immediately following a traumatic event. Studies have shown physiological, functional neuroimaging, changes in maladaptive cognitive distortions, and electroencephalographic changes in response to CBT. (Kar, 2011) CBT is a favorable treatment option for PTSD induced by terrorism and war trauma. While trauma focused CBT and group CBT has shown to be effective for PTSD induced by motor vehicle accidents. Evidence has been shown CBT following adult and childhood sexual abuse is an effect form of treatment.
Studies have shown that CBT has aided in the reduction of PTSD severity in patients. At follow up visits patients no longer met the criteria for a PTSD diagnosis. (Kar, 2011) Following traumatic events it is very common for children and adolescents to develop PTSD. CBT is considered to be the best option when treating PTSD in children and adolescents. It was shown in a controlled trial that children with PTSD who received trauma focused CBT showed a significantly greater improvement in symptoms with 92% of patientsâ€™ no longer meeting PTSD criteria. (Kar, 2011) It appears that early trauma focused CBT is a good preventative intervention for those at risk of developing PTSD.
Individuals suffering from PTSD have shown improvement with PTSD symptoms with the use of psychotropic medication. Vermetten, Vgthilingam, Southwick, Charney and Bremner (2003) in a 48 week study assessed the effects of long term treatment with paroxetine, an SSRI psychotropic medication, on hippocampal volume and declarative memory performance in PTSD patients. Declarative memory was assessed with the Wechsler Memory Scale-Revised and the Selective Reminding Test before and after 9-12 months of treatment in PTSD patients. MRIs measured hippocampal volume before and after 9-12 months of treatment. The goal of the study was to determine if an improvement in declarative memory performance and an increase of hippocampal volume would occur with the use of paroxetine.
Wechsler Adult Intelligence Scale-Revised, two subtests of Wechsler Memory Scale-Revised including logical memory and figural memory, and the verbal and visual components of the Selective Reminding Test, all standardized neuropsychological tests were given prior to the medication phase. Medication was prescribed during the first visit after the pretreatment assessment. First dosage of paroxetine was 10mg. daily and was titrated up to 20 mg. in four days. Patients who did not respond to the medication had their dosage increased in 10mg. increments up to a maximum of 50 mg. The average dosage was 20 mg. Weeks one through 12 patients had follow up visits every other week, and weeks twelve through thirty-six patients had follow up visits every four weeks. Medication was dispensed at every visit to ensure compliance and reduction of misuse.
At the study completion the neuropsychological tests and MRIs were readministered along with the Clinical Administered PTSD Scale. Results showed that the paroxetine treatment resulted in a 54% reduction of PTSD symptoms. (Vermetten et al.,2003) Paroxetine treatment resulted in significant improvements in verbal declarative memory and visiospatial memory, and a 4.6% increase in hippocampal volume. These findings suggest successful clinical treatment with paroxetine in the PTSD patients.
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