Post-traumatic stress disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event. It is natural to feel afraid during and after a traumatic situation. Fear triggers many split-second changes in the body to help defend against danger or to avoid it.
Emotional disorders also occur after physical assault (particularly rape), car accidents, natural catastrophes, or the sudden death of a loved one. PTSD is the best known of these disorders.
DSM-5 describes the setting event for PTSD as exposure to a traumatic event during which an individual experiences or witnesses death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation. Learning that the traumatic event occurred to a close family member or friend, or enduring repeated exposure to details of a traumatic event.
Afterward, victims reexperience the event through memories and nightmares. When memories occur suddenly, accompanied by strong emotion, and the victims find themselves reliving the event, they are having a flashback. Whereas, victims most often avoid anything that reminds them of the trauma.
New to DSM-5 is the addition of “reckless or self-destructive behavior” under the PTSD E criteria as one sign of increased arousal and reactivity. Also new to DSM-5 is the addition of a “dissociative” subtype describing victims who do not necessarily react with the reexperiencing or hyperarousal, characteristic of PTSD. Rather, individuals with PTSD who experience dissociation have less arousal than normal along with (dissociative) feelings of unreality.
Moreover, victims with PTSD seem to respond somewhat differently to treatment if they meet criteria for a dissociative subtype.
In DSM-IV a disorder called acute stress disorder was introduced. This is really PTSD, or something very much like it, occurring within the first month after the trauma, but the different name emphasizes the severe reaction that some people have immediately.
According to a recent survey, approximately 50% of individuals with acute stress disorder went on to develop PTSD. But these surveys also indicated that as many as 52% of a sample of trauma survivors who went on to develop PTSD did not meet criteria for acute stress disorder in the month following the trauma (Bryant et al., 2011). Acute stress disorder was included in DSM-IV because many people with severe early reactions to trauma could not otherwise be diagnosed and, therefore, could not receive insurance coverage for immediate treatment.
Symptoms of Posttraumatic Stress Disorder (PTSD).
- Repetitive play- trauma themes
- Distress at exposure to similar stimuli
- Avoidance of talk of trauma
- Avoidance of trauma recollections
- Regressive behavior
- Restricted affect
- Sleep disturbance
- Anger outbursts
- Startle response
Diagnostic Criteria for Posttraumatic Stress Disorder.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
- 1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as they occurred to others.
3. Learning that the event(s) occurred to a close relative or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
- 1. Recurrent, involuntary and intrusive distressing memories of the traumatic event(s). Note: In young children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or also affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In young children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
- 1. Avoidance of or efforts to avoid distressing memories, thoughts, feelings, or conversations about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, as well as situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (e.g., unable to have loving feelings)
7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “no one can be trusted,” “the world is completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent distorted cognitions about the cause or consequences of the traumatic event(s) that lead thE individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
E. Duration of the disturbance (Criteria B, C, D and E) is more than one month.
F. However, the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
With delayed expression: If the diagnostic threshold is not exceeded until at least 6 months after the event (although it is understood that onset and expression of some symptoms may be immediate).
With Dissociative Symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of depersonalization or derealization.
PTSD is the one disorder for which we know the cause at least in terms of the precipitating event: someone personally experiences a trauma and develops a disorder. Whether or not a person develops PTSD, however, is a surprisingly complex issue involving biological, psychological, and social factors.
Children experiencing severe burns are likely to develop PTSD in proportion to the severity of the burns as well as the pain associated with them.
As with other disorders, we bring our own generalized biological and psychological vulnerabilities with us. The greater the vulnerability, the more likely we are to develop PTSD. If certain characteristics run in your family, you have a much greater chance of developing the disorder. Moreover, a family history of anxiety suggests a generalized biological vulnerability for PTSD.
individuals that characteristics such as a tendency to be anxious, as well as factors such as minimal education, predict exposure to traumatic events in the first place and therefore an increased risk for PTSD.
6-year-old children with externalizing (acting out) problems were more likely to encounter trauma (such as assaults), probably because of their acting out, and later develop PTSD.
However, individuals from unstable families are at increased risk for developing PTSD if they experience trauma. Family instability was found to be a pre-war risk factor for the development of PTSD.
Treatment for PTSD.
From the psychological point of view, most clinicians agree that victims of PTSD should face the original trauma, process the intense emotions, and develop effective coping procedures in order to overcome the debilitating effects of the disorder.
In psychoanalytic therapy, reliving emotional trauma to relieve emotional suffering is called catharsis. The trick is in arranging the re-exposure so that it will be therapeutic rather than traumatic.
Imaginal exposure, in which the content of the trauma and the emotions associated with it are worked through systematically. And also has been used for decades under a variety of names. At present, the most common strategy to achieve this purpose with adolescents or adults is to work with the victim to develop a narrative of the traumatic experience that is then reviewed extensively in therapy. Cognitive therapy to correct negative assumptions about the trauma. Such as blaming oneself in some way, feeling guilty, or both is often part of treatment.
David H. Barlow, V. Mark Durand. Abnormal Psychology, An Integrative Approach. (7th ed).