Post Traumatic Stress Disorder in Inner City American Youth: A Review and Analysis of the Literature as it Pertains to Public Health

Background and Significance

What is PTSD?

Post Traumatic Stress disorder (PTSD) is a comprehensive diagnosis describing a condition in which individuals suffer long term effects from exposure to a traumatic event. PTSD was originally used to describe the maladies experienced by war veterans, but now is used to relate to any individual who has experienced trauma and has the sustained psychological and/or physiological abnormalities associated with the diagnosis, such as elevated heart rate, increased anxiety, or flashbacks. (US Department of Veterans Affairs, 2014) These symptoms are common after experiencing a traumatic event, but what differentiates PTSD as a deviation from the normal response is the impact that the event continues to have for more than one month after the individual experienced the event. ( National Institute of Mental Health, 2013)

Public Health Impact

Individuals diagnosed with PTSD suffer from a spectrum of ailments. In adults these symptoms can include depression, anxiety, lack of impulse control, anger, and violent outbursts; in children the symptoms can also include inability to talk, nightmares, acting out the event at playtime, and being unusually attached to their caretaker. Many of these symptoms have a larger effect on the community. (Kirsch, 2011) People who suffer from PTSD are more likely to be unemployed and homeless, less likely to finish school, and more likely to exhibit violent tendencies. In urban neighborhoods, the exposure to risk factors for PTSD is high and the methods for coping with the ailment is lacking in many ways, which will be discussed further in later sections. (Madan, 2011)

Health Systems Management Impact

PTSD was recognized in soldiers after the Civil War and called “nostalgia”, later “shell- shock”, and has had a myriad of other nicknames, but the impact on health systems has been relatively constant. (Bentley, 2005) There was an outcry after the Civil War because the number of homeless veterans was so high; this prompted the establishment of the first military hospital for the insane. At that time in history little was known about the disease, but for the “good” of the public these individuals were removed from civilian life. This cycle of war veterans returning, not receiving treatment, and becoming a burden on social services has repeated after every significant American war. It can also be argued that the gang wars in the inner cities of the United States are producing a similar scenario. Young people are exposed to crippling violence that impacts their day-to-day lives and for varying reasons are given little to no treatment or psychological care. (Madan, 2011) This can lead to an exaggerated display of PTSD symptoms, prolonging the cycle of violence.

Why does it matter?

PTSD has been studied extensively as it relates to war veterans, but the problem extends beyond the military and into civilian lives and needs to be addressed as it pertains to non- military persons as well. The aim of this report is to analyze the data relating to PTSD generally, youth experiences with PTSD, urban violence, and any correlations in between in an attempt to better understand the public health implications of PTSD suffered by youth in inner cities of the United States.

Rationale

Biological Basis of PTSD

The biological basis for PTSD is related to the hypothalamic-pituitary-adrenal axis (HPA axis), normally related to fear and the “fight-or-flight” response. Normal HPA axis function coordinates the levels of cortisol1 and norepinephrine2 released in response to stimuli; in non-PTSD patients there is a rise in both cortisol and catachoamine3 levels, but in patients with PTSD urine analysis shows low secretion of cortisol and higher secretion of catechoamines, which suggests an abnormal pathology. ( National Institute of Mental Health, 2013) It has been suggested that low levels of cortisol prior to exposure to a traumatic event may lead to more severe effects of PTSD or even increase the chances of developing PTSD in the first place. Studies also show that low levels of serotonin and dopamine are present in individuals suffering from PTSD, which can lead to behavioral disorders such as aggression, irritability, apathy, attention and motor deficits, and anxiety. (Palosaari, 2013) These hyper-responsive reactions may be due to a maladaption of the norepinepherine receptor in the prefrontal cortex of the brain. When a disruption occurs in these receptors, patients are unable to process the emotions associated with the traumatic event. and have been known to have flashbacks and nightmares with emotional and physiological responses as elevated as if they were experiencing the event first-hand. Neuroanaomy plays a key role in PTSD, with the main parts of the brain involved being the hippocampus, the prefrontal cortex and the amygdala. Studies performed across Vietnam-era veterans showed reductions in the size of the hippocampus among PTSD patients compared to veterans who did not exhibit symptoms of PTSD. (US Department of Veterans Affairs, 2014) The hippocampus is responsible for storing and cataloging memories, does not function properly under highly stressful conditions. For most individuals the memories eventually fall into place, but in individuals suffering from PTSD these traumatic experiences do not “grab-hold” and thus can be relived rather than remembered.

1 Cortisol is a hormone produced by the adrenal gland that’s main purpose is to increase blood glucose levels and suppress the immune response.

2 Norepinepherine is a neurotransmitter that can increase the heart rate when it is released in the sympathetic nervous system; it also affects the amygdala where fight or flight responses are controlled.
3 Catachoamines are a group of organic compounds; in the body they are most commonly found as norepinephrine, epinephrine, and dopamine.

The DSM IV gives a lengthy description of the characteristics necessary for a diagnosis of PTSD. (See Appendix 1) A summary of the diagnosis criteria is displayed in Table 1.

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 Impact on Community Health

Epidemiological studies have found that the majority of residents in inner cities have been exposed to events that could trigger PTSD, yet only a small portion of those involved actually develop the disorder. (Breslau, 2004) At first look this seems promising, but unlike viral or other communicable diseases, PTSD and related psychological diseases have a larger impact on the community as a whole. As discussed earlier, individuals with PTSD are more likely to be homeless, jobless, and violent than their non-affected counterparts. When examining the overall health of the community, factors such as levels of educational attainment, unemployment levels, and violent crime are indicators to the community’s well-being, and these are all largely effected by individuals suffering from PTSD. Furthermore, the maladies caused by having a large population suffering from Post Traumatic Stress Disorder are in turn the same risk factors associated with the development of the disease in young people, such as exposure to violence and lack of parental involvement. (Breslau, 2004)

Urban youth are particularly susceptible to PTSD due to their exposure to interpersonal violence4 (IPV) as well as community violence. Estimates suggest that up to 20% of youth in inner cities have witnessed a shooting first hand, and even greater percentages experience instances of IPV. (Urban Violence, Youth, 2008)

Impact of Sociodemographics and Built Environment

The environment where urban youth develop can play a large role in their susceptibility to PTSD. Youth in inner cities are often at a sociodemographic disadvantage to their suburban counterparts. The combination of being in a low socioeconomic class, often discriminated against as a minority, having limited access to sufficient educational systems, absentee parenting, and blighted neighborhoods, all play a role in worsening the symptoms associated with PTSD. (Breslau, 2004) Studies have shown that individuals who are among the ethnic minorities in every socioeconomic class have worse health outcomes than their white counterparts, especially in terms of daily exposure to stressors. Additionally, socioeconomic statuses are directly related to an individual’s health outcome at every level of income. Since chronic stress can exasperate the physiological response to a sudden traumatic event the aforementioned poor, minority individuals are at heighted risk for developing PTSD (Urban Violence, Youth, 2008)

4 Interpersonal violence is when once person uses their power to control another person through a violent act.

Impact on Social and Behavioral Health

The social and behavior health of an individual is largely tied to his/her interactions within their different social groups. Figure 1, derived from the theory of Social Ecological model of behavior shows the relationship of an individual within his/her specific ecology. According to this model, a young person, who by default has underdeveloped coping mechanisms, whose family and friends are poor and/or uneducated, who does not have access to sufficient mental treatment facilities, and lives in a community that is prone to violence, is highly susceptible to exposure to traumatic events and subsequently developing PTSD.

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Materials and Methods

Data Collection

This literature review was conducted by searching Academic Search Complete for published peer-reviewed literature from several databases including Medline, SpringerLink Books, American Medical Association, Oxford University Press, Cambridge University Press, OneFile, and the Wiley Online Library. A combination of search terms was used for this analysis are exemplified in Table 2.

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These combined search terms returned numerous results, 17 of which were deemed appropriate for use in this review. (See Bibliography) The resulting articles were analyzed for content and divided into 5 separate categories:

  1. Biological aspects of PTSD.

  2. Societal effects of mental illness.

  3. Individual effects of PTSD.

  4. Interventions for violence reduction.

  5. Treatment of PTSD.

These categories were then subdivided and relevant material pulled from each to form a meta-analysis, which is summarized and reported in the following sections.

Results

Cause and effect of PTSD in youth

The effects of PTSD on children in inner cities is significant and affects their overall mental, physical, and social wellbeing, as well as their ability to thrive. PTSD can be caused by a myriad of factors such as witnessing a shooting or stabbing, being a victim of a violent crime, and abuse of or by caregivers. Many of these triggers for PTSD are common to urban environments, and as such urban youth have higher levels of PTSD than their suburban and/or affluent counterparts. (Urban Violence, Youth, 2008) Young people with PTSD are less likely to finish school, more likely to be socially stunted, and more prone to violent outbursts. Individuals with PTSD often have trouble holding steady jobs and are more likely to be homeless than their non-PTSD counterparts.

Studies found that youth who are exposed to violence at a young age, and are not supplied with a strong support system are more likely to join gangs. (Urban Violence, Youth, 2008) Gang involvement leads to higher rates of exposure to and acts of violent offenses, nonviolent delinquency as well as higher rates of depression, anxiety, and suicidal behavior. In addition, young gang members are at an increased risk for victimization from both themselves and other gang members. Gangs can consist of a group of unrelated individuals, but also may be comprised of family members, neighborhood, or “cliques”. Gang involvement is considered a precursor to as well as a result of PTSD. (McGarrell, 2010)

Treatment of PTSD in youth

Treatment for Post Traumatic Stress Disorder can take any number of forms. Most involve a combination of therapeutic interventions as well as medication. Therapy can be used without medication, but medication based treatment without therapy is not recommended. The United States Department of Veterans Affairs (VA) is on the forefront for treatment of PTSD, and its practices are often adapted for use in private civilian hospitals.

There are three main types of therapy used to treat PTSD, which can be used in both youth and adults. (See Table 3)

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Programs aimed to decrease PTSD or exposure to trauma

Though there are many factors that can contribute to the severity and likelihood of developing the disease, Post Traumatic Stress Disorder fundamentally derives from exposure to a traumatic event. The key way to “cure” the disease is to eliminate or prevent exposure to traumatic events. For the population of interest (inner-city youth) this primarily means making the inner city a safer place by eliminating violence.

There have been several programs developed to decrease violent crime in big cities in the United States, the national program Project Safe Neighborhoods is one of the largest to- date; it combines aspects of “focused deterrence and problem-solving processes”. (McGarrell, 2010) An analysis of the program found that improved and targeted policing, in addition to focused criminal justice initiatives, was the most effective method for reducing violence within inner cities. Some of the most effective programs, “Project Exile” and the “Boston Gun Project”, focused on increasing the penalty for firearm Kumler 14 of 24

related crimes, especially among youth. As a result, youth homicide and youth gun violence decreased as much as 60%. (McGarrell, 2010) One of the key parts of these interventions was the careful research of gun related crime patterns. Using this information, municipalities were best prepared to target their resources and effectively decrease crime.

Researchers analyzed all cities in the United States with populations greater than 100,000 people and grouped them into four categories: Non-treatment cities, Low Dosage Cites, Medium Dosage Cities, and High Dosage Cities.5 The findings showed that cities with low or no treatment experienced similar levels of violent crime, while cities with medium or high dosage experienced a decrease in violent crime. Estimates state that the reduction equated for approximately 45 less violent crimes per 100,000 people, or a 4.1% reduction. (McGarrell, 2010)

5 Dosages were a “composite variable designed to capture the specific policy adoption of the outlined [Project Safe Neighborhood] strategy” as defined by E. McGarrell et al.

Discussion

Problems Encountered

Extensive research exists on the effect and treatment of PTSD in veterans, however information on the civilian consequences of PTSD is limited. The information that does exist is often related to the experiences of children who have experienced war in developing countries, youth who have been exposed to interpersonal violence, or women who have been the victims of sexual assault. The long terms biological effects on children with PTSD, left treated or untreated, are not fully understood or sufficiently researched. Information on inner city violence is also outdated, recent census data has not yet been fully analyzed and thus most data available on inner city demographics and levels of crime are from 2005 or earlier and not necessarily representative of current levels.

Limitations

There is the potential for bias when analyzing PTSD data, the most significant of which is reporting bias due to self-reporting of exposure to trauma and the diagnosis of PTSD.

Policy Implications

As discussed earlier, the policy implications for treatment of PTSD are mostly centered on crime prevention. Studies show that the most effective methods of prevention are focused and specific, and because gun violence is the second leading cause of death among young Americans, the suggestion is that those interventions focus on gun related crime. (McGarrell, 2010) It should also be noted that PTSD can be treated once is has been diagnosed, so resources should be made available to individuals who are at risk for development of the disease. Programs such as “RESET” in New Orleans, which sends outreach teams into neighborhoods after a homicide show promise, but need to be further developed so that they do not simply make their presence known to the community, but also act as a liaison between caregivers and community members.

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Appendices

Appendix 1: DSM-IV-TR Criteria for Posttraumatic Stress Disorder

Reprinted from the DSM-IV

A. The person has been exposed to a traumatic event in which both of the following were present:

o (1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

o (2) The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

o (3) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

o (4) Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

o (5) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience; illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

o (6) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

o (7) Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistentavoidanceofstimuliassociatedwiththetraumaandnumbingofgeneral responsiveness (not present before the trauma), as indicated by three (or more) of the following:

o (8) Efforts to avoid thoughts, feelings, or conversations associated with the trauma

o (9) Efforts to avoid activities, places, or people that arouse recollections of the trauma

o (10) Inability to recall an important aspect of the trauma
o (11) Markedly diminished interest or participation in significant activities o (12) Feeling of detachment or estrangement from others
o (13) Restricted range of affect (e.g., unable to have loving feelings)
o (14) Sense of a foreshortened future (e.g., does not expect to have a career,

marriage, children, or a normal lifespan)
D. D. Persistent symptoms of increased arousal (not present before the trauma), as

indicated by two (or more) of the following: o (1) Difficulty falling or staying asleep o (2) Irritability or outbursts of anger
o (3) Difficulty concentrating

o (4) Hypervigilance

o (5) Exaggerated startle response

  1. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1

    month.

  2. The disturbance causes clinically significant distress or impairment in social,

    occupational, or other important areas of functioning.

Specify if:

Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor. (Center for Substance Abuse Treatment, 2009)