Posttraumatic Stress Disorder

This article briefly examines the history of the diagnosis of Posttraumatic Stress Disorder (PTSD), the current symptoms that characterize this syndrome, risk factors for PTSD, and evidence about the prevalence of this disorder in relation to specific traumas. It also summarizes the debate about the expression of PTSD in children and other special populations and discusses the ongoing controversies surrounding this diagnosis. A special effort is made to include mention of forensic issues relevant to the diagnosis of PTSD.

History of the PTSD Diagnosis

PTSD was officially introduced into the mental health nomenclature in 1980 with the publication of the American Psychiatric Association’s Diagnostic and Statistical Manual, third edition (DSM-III). The concept of a cluster of symptoms that occur in response to a particular stressor, however, has existed for centuries and has been referred to by terms such as nerve-trauma hypothesis, shell shock, and stress response syndrome. In DSM-I, veterans of World War II and the Korean War who continued to experience traumatic symptoms were diagnosed as having gross stress reactions. By DSM-II, in 1968, this term was replaced with transient adjustment disorder of adult life. The actual addition of the diagnosis of PTSD to the DSM-III has been attributed to the political and social pressure applied by advocates and psychiatrists after the Vietnam War; although these individuals more specifically lobbied for the inclusion of a DSM diagnosis of post-Vietnam syndrome. However, the DSM-III Task Force argued against including a diagnosis that was tied to a specific political event, while they were simultaneously persuaded by data showing that similar stress reactions occurred in victims exposed to other traumatic stressors, including natural disasters, rape, and/or confinement in a concentration camp. The DSM-III Task Force thus decided that an individual suffering from PTSD must have been exposed to a traumatic event, including but not necessarily restricted to combat, that was outside the realm of ordinary experience to meet the criteria for PTSD. Consequently, PTSD and the recently included diagnosis of acute stress disorder are distinctive in the DSM system because, unlike the majority of DSM diagnoses, the causal origin of these disorders is explicitly delineated in the diagnostic criteria.

Current PTSD Diagnostic Criteria

The research related to the disorder was greatly intensified after the inclusion of PTSD in the official nomenclature of DSM-III, was instrumental in the development of a variety of assessment tools geared toward measuring trauma symptoms, and led to the development of scholarly journals devoted to the topic of trauma. These events, in turn, provided much of the information to be considered by the task forces dedicated to creating the DSM-III-R, which was published in 1987; the DSM-IV, which was published in 1994; and the DSM-IV-TR, which was published in 2000. Considerable changes to the diagnostic criteria for PTSD were introduced in these revisions. One striking difference was in the nature of the trauma that had to be experienced to receive this diagnosis. The trauma criteria in DSM-IV-TR now specify that the affected person had to experience, witness, or be confronted with an event(s) that involved actual or threatened death, serious injury, or a threat to the physical integrity of self or others. The person also had to experience intense fear, helplessness, and/or horror in response to the traumatic event or events.

These changes have considerably broadened the types of events that can be considered as precipitants to PTSD since the traumatic event did not have to be directly experienced by the individual with PTSD symptoms or be highly unusual or statistically infrequent. Consequently, PTSD has now been claimed to result after a variety of events, including a difficult labor (even with a healthy baby), a miscarriage, watching a traumatic event on TV, the shock of receiving even inaccurate bad news from a doctor, learning that one’s child has a chronic disease such as diabetes, and completing work duties as a policeman or fireman. Of particular relevance to forensic psychologists is the determination that PTSD can also occur as a result of automobile accidents or workplace injuries and even in response to hearing sexual jokes or experiencing verbal harassment. Compensation for traumatic symptoms resulting from these types of events is now routinely being sought through legal channels.

The symptom criteria for PTSD in DSM-IV-TR were also changed. To receive the diagnosis, the traumatized person is now required to report at least one reexperiencing symptom, three or more avoidant/numbing symptoms, and two or more symptoms of hyperarousal as a response to the traumatizing event. Moreover, according to the DSM-IV-TR, the traumatized individual has to experience these symptoms for at least 1 month, which is considerably less than the 6 months required for the PTSD diagnosis as specified in the DSM-III.

Another noteworthy addition is that PTSD is one of the few DSM-IV-TR diagnoses in which malingering is specifically identified as a necessary component of the differential diagnosis. Malingering has been defined as the intentional production of false or grossly exaggerated symptoms, as a result of external incentives. Therefore, clinicians assessing PTSD need to be able to rule out malingering as a diagnosis when financial remuneration and/or benefit eligibility are a part of their patient’s clinical picture. For example, more than 90% of veterans experiencing PTSD symptoms seek financial compensation for their emotional distress. Determining which, if any, of these patients are malingering is difficult because most PTSD symptoms are obtained by self-report measures and easily feigned clinical interviews. Therefore, one of the major problems with the diagnosis is that many PTSD symptoms are nonspecific and subjective.

It is now recommended that symptom validity tests be routinely included in PTSD assessment procedures. Clinicians also need to be able to detect when a patient has been coached to report particular symptoms (i.e., by his or her attorney or by a family member), as malingering has been considered a threat to the therapeutic alliance and has been shown to have a significant negative economic impact. Detecting malingering may require clinicians to collect accurate historical records related to the trauma and to interview other family members about the patient and his or her symptoms. Clinicians may also need to ask for specific examples of reported symptoms, look for inconsistencies in the self-report, and obtain physiological measures of responses to trauma-related versus neutral stimuli, if possible. Efforts should also be made to determine how to best manage and/or treat patients who have, or are thought to have, exaggerated or feigned their PTSD symptoms, as this may be a relatively common event in some settings.

Prevalence of PTSD

The DSM-IV-TR indicates that the lifetime prevalence for PTSD is approximately 8% in the population of U.S. adults. Women are at significantly greater risk of developing PTSD than are men. However, estimates of the rates of the disorder in at-risk or high-risk populations have varied substantially. For example, among the survivors of the Oklahoma City bombing, only about 35% developed PTSD. There is also evidence that the prevalence of PTSD has been increasing across cultures, perhaps as a consequence of the broadened criteria for what constitutes a significant trauma. Since only a small number of individuals who experience trauma go on to develop PTSD, researchers have concentrated on delineating risk factors for developing the disorder. These include lower intelligence, experiences of childhood trauma and interpersonal violence, having a psychiatric diagnosis prior to experiencing the trauma, dissociation in the weeks following the event, use of avoidance rather than problem-focused coping strategies, a poor social support network, and perhaps having a genetic vulnerability to strong physiological reactions to stress. The national comorbidity study also identified a number of consequences associated with a diagnosis of PTSD. These included increased risk of developing other psychiatric disorders, committing suicide, failing school, experiencing a teenage pregnancy or marital difficulties, and having an unstable work history.

Issues Related to Diagnosing PTSD in Children and Other Special Populations

Diagnosing PTSD is especially difficult in children because they may not have experienced significant distress at the time of the event (i.e., in some cases of childhood sexual abuse). They may also have limited verbal abilities, especially when they are very young, and may have little insight about their thoughts and feelings to offer the clinician. Children may also have a different symptom pattern that is not well represented by the adult criteria for PTSD. For example, it has been suggested that children may have longer durations of avoidance and fewer symptoms of reexperiencing (e.g., visual flashbacks) than adults have. Children may also be more likely than adults to mask their feelings of fear, helplessness, or horror with rage, hostility, refusal to go to school, and behavioral outbursts that may be more suggestive of conduct disorder than PTSD. Children may also report more concentration difficulties and cognitive changes post-trauma than adults do. Finally, some studies have shown that there are large numbers of children who have been exposed to a severe discrete trauma who fail to meet the full criteria for PTSD as specified for adults; yet these reactions were of sufficient severity to create a functional impairment for the child. Taken as a whole, these findings have led researchers, such as Michael Scheeringa and colleagues, to delineate an alternative set of criteria for PTSD that can be used with infants and very young children. The efficacy of these criteria is currently being considered.

Diagnosing PTSD in individuals who have suffered a traumatic brain injury is also controversial. Specifically, it has been questioned whether a person who has posttrauma amnesia for the traumatic event can receive a diagnosis of PTSD since these individuals also have no recollection of feeling helpless, fearful, or horrified in response to the trauma.

The symptom pattern of PTSD may also be different and more complex in individuals who have experienced a chronic stressor (such as childhood physical or sexual abuse or kidnapping and torture) as opposed to those who have experienced a discrete stressor. Some have argued that complex PTSD is better described by the International Classification of Diseases, 10th revision (ICD-10) diagnosis of enduring personality change after catastrophic experience than by the symptom pattern detailed for PTSD.

PTSD: Current Controversies

Many controversies currently surround the diagnosis of PTSD. As stated previously, there are differences of opinion about which types of trauma should be considered as significant enough to generate symptoms of PTSD. There is also debate about the number of symptoms needed for the diagnosis, with some experts arguing that significant impairment can still occur in individuals who fail to qualify fully for the diagnosis. Moreover, PTSD has been shown to have high rates of comorbidity with other diagnoses such as major depressive disorder, alcohol dependence, and other anxiety disorders. These may be due to the high degree of symptom overlap between PTSD and other disorders. For example, PTSD and depression share symptoms of insomnia, impaired concentration, social withdrawal, and diminished interest in or satisfaction from previously pleasurable activities. Similarly, PTSD and generalized anxiety disorder share symptoms of irritability, hypervigilance, exaggerated startle response, impaired concentration, insomnia, and autonomic hyperarousal. Thus, the degree to which there is an identifiable stress reaction has been questioned, and debate continues about how to differentiate a normal reaction to a horrific event from an abnormal reaction to a horrific event, such that it would constitute a psychological disorder. Additionally, PTSD is theorized to have a dose-response relationship with experienced trauma, such that more severe stressors are thought to be associated with worse symptoms and a greater likelihood of receiving the diagnosis of PTSD. While some researchers have found evidence in support of this relationship, data from other studies have failed to establish a linear relationship between the severity of the trauma experienced and the likelihood of experiencing PTSD symptoms.

The development of a theoretical model for what causes PTSD to occur in some but not all individuals has also engendered debate, as the prevalence of PTSD is rather rare (between 1% and 8% of the general population) relative to the number of Americans known to have been exposed to a sufficiently severe and potentially traumatizing stressor (estimates suggest 66% or more of the general population). These findings have led researchers to conclude that trauma is necessary but not sufficient to cause PTSD and that the person’s subjective experience of and attributions about the trauma may be as important as the event itself.

Another controversy that surrounds the diagnosis of PTSD has focused on the validity of recovered memories of trauma. For example, if recovered memories of childhood sexual abuse are not accurate, then can they cause PTSD? Additionally, studies have shown that trauma memories change across time, are dynamic rather than static, and are related to a person’s current clinical state.

Last, further concern has been generated with regard to the efficacy of using early psychological interventions to promote recovery from posttraumatic stress. Data have accumulated that suggest that routine, one-shot psychological debriefing after trauma may not augment the recovery process and, in some cases, may actually impede it. Therefore, controversy about what constitutes a best-practice prevention effort for PTSD is ongoing.

References:

1. McNally, R. J. (2003). Progress and controversy in the study of posttraumatic stress disorder. Annual Review of Psychology, 54, 229-252.
2. Mizey, G., & Robbins, I. (2001). Usefulness and validity of post-traumatic stress disorder as a psychiatric category. British Medical Journal, 323, 561-563.
3. Perrin, S., Smith, P., & Yule, W. (2000). Practitioner review: The assessment and treatment of post-traumatic stress disorder in children and adolescents. Journal of Child Psychology and Psychiatry, 41(3), 277-289.
4. Rosen, G. M. (2004). Posttraumatic stress disorder: Issues and controversies. Chichester, UK: Wiley.
5. Rosenbaum, L. (2004). Post-traumatic stress disorder: The chameleon of psychiatry. Nordic Journal of Psychiatry, 58, 343-348.
6. Tierney, J. A. (2000). Post-traumatic stress disorder in children: Controversies and unresolved issues. Journal of Child and Adolescent Psychiatric Nursing, 13(4), 147-158.

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