Posttraumatic Stress Disorder

Historical Overview of Traumatic Reactions: late 19th century

• Terms used in combat veterans populations– Cardiovascular:

• Soldier’s heart

• Da Costa’s Syndrome

• Neurocirculatory asthenia

– Psychiatric• Nostalgia

• Shell shock

• Combat fatigue

• War neurosis

• Terms used in civilian populations– Railway Spine

Later Descriptions of Traumatic Reactions (1940s-1980s)

• Later descriptions of post-traumatic responses were labeled according to the type of trauma– Rape trauma syndrome

– Survivor syndrome

– War neurosis

– Shell shock

PTSD: DSM-III (1980)

• PTSD becomes an established diagnosis

• Traumatic event defined as “a recognizable stressor that would evoke significant symptoms of distress in almost anyone.”

• Three symptom clusters (based on clinical experience): reexperiencing, numbing and detachment, and changes in personality

PTSD: DSM-III-R (1987)• Definition of trauma was narrowed:

– “An event outside the range of usual human experience and that would be markedly distressing to almost anyone”

• Avoidance symptoms were added to numbing cluster

• Symptoms expanded from 12 to 17• Duration and onset criteria added• Impairment in functioning and/or distress added.• Issues with definition:

– Definition proved too restrictive as traumas more common than originally believed

– Did not allow for individual differences

PTSD: DSM-IV (1994)

• Exposure to a traumatic event in which the person:– experienced, witnessed, or was confronted by death or serious

injury to self or others AND – responded with intense fear, helplessness,

or horror

• Symptoms – appear in 3 symptom clusters: reexperiencing,

avoidance/numbing, and hyperarousal– last for > 1 month– cause clinically significant distress or impairment in functioning

Acute Stress Disorder: DSM-IV (1994)

• Exposure to a traumatic event in which the person:– experienced, witnessed, or was confronted by death or serious injury to

self or others AND – responded with intense fear, helplessness,

or horror

• > 3 dissociative symptoms• >1 reexperiencing symptoms• >1 anxiety/arousal symptoms• Onset: 2 days to 4 weeks• Clinically significant distress or impairment in

functioning

Criterion A: Exposure Criteria

• Experienced or Witnessed an Event that involved actual or threatened death or serious injury or a threat to physical integrity

• Person’s response involved fear, helplessness, or horror or in children agitated behavior

Criterion B: Re-experiencing Criteria

• Recurrent and Intrusive distressing recollections of the event (images, thoughts, or repetitions)

• Recurrent distressing dreams of the event

• Acting or feeling as if the traumatic event were recurring

Criterion B continued…

• Intense Psychological Distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

• Physiological Reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Criterion C1: Persistent Avoidance Criteria

• Efforts to avoid thoughts, feelings, or conversations associated with the trauma

• Efforts to avoid activities, places, or people that arouse recollections of the trauma

• Inability to recall an important aspect of the trauma

Criterion C2: Numbing of Gen. Responsiveness Criteria

• Markedly diminished interest or participation in significant activities

• Feeling of detachment or estrangement from others

• Restricted range of affect

• Sense of foreshortened future

Criterion D: Increased Arousal Criteria

• Difficulty falling or staying asleep

• Irritability or outbursts of anger

• Difficulty concentrating

• Hypervigilance

• Exaggerated startle response

Criterion E

• Symptoms in criteria B, C, and D are more than 1 month

Criterion F

• The disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning

Specifications

• Acute: if duration of symptoms is less than 3 months

• Chronic: if duration of symptoms is 3 months or more

• With delayed onset: if onset of symptoms is at least 6 months after the stressor

Acute Stress Disorder

Criterion A: Exposure Criteria

• Experienced or Witnessed an Event that involved actual or threatened death or serious injury or a threat to physical integrity

• Person’s response involved fear, helplessness, or horror or in children agitated behavior

Criterion B: Dissociative Criteria

• Subjective sense of numbing, detachment, or absence of emotional responsiveness

• Reduction in awareness of one’s surroundings (e.g., “being in a daze”)

• Derealization

• Depersonalization

• Dissociative amnesia

Criterion C: Re-experiencing Criteria

• Recurrent images

• Thoughts, dreams, illusions

• Flashback episodes, or a sense of reliving the experience

• Distress on exposure to reminders of the traumatic event

Criterion D: Avoidance Criterion

• Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people)

Criterion E: Physiological Criteria

• Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness)

Criterion F: Psychosocial Criteria

• Clinically significant distress or impairment in social, occupational, or other important areas of functioning

• Impaired ability to pursue some necessary task, such as obtaining personal assistance or mobilizing personal resources

Criterion G: Time Criteria

• Minimum of 2 days

• Maximum of 4 weeks

• Occurs within 4 weeks of the traumatic event

Inter-relationship between ASD and PTSD

Event ASD PTSD

2 days – 4 weeks

4 weeks and on

How does someone develop PTSD?

Classical Conditioning

Unconditioned Stimulus

Unconditioned Response

Car Jacking

Thoughts

Feelings

Behaviors

CS CR

Validity is Well Established

• PTSD has proven to be a useful and valid diagnosis after 25 years of clinical use

• Although there have been minor revisions to the diagnostic criteria the core concept has withstood the test of time

PTSD Prevalence in US Adults

• National Comorbidity Survey (1995); NCS-Replication (2005)– Large national probability samples (Ns > 5000)– Benchmark for prevalence of mental disorders in US

• Lifetime PTSD prevalence = 6.8% (NCS-R)– 9.7% women– 3.6% men

• Current PTSD prevalence = 3.6% (NCS-R)– 5.2% women– 1.8% men

The Burden of PTSD

• Individuals with PTSD have:– Elevated risk of mood, other anxiety, and substance abuse

disorders

– Elevated risk of suicide attempts

– Greater functional impairment

– Reduced quality of life

• PTSD had the greatest impact of all anxiety disorders on economic burden to society (Greenberg et al., 1999)

PTSD and Functioning in the NCS

In NCS, PTSD associated with: – 40% elevated odds of academic failure

– 30% elevated odds of teenage parenthood

– 60% elevated odds of marital problems

– 150% elevated odds of current unemployment