| Post-traumatic stress disorder (PTSD) is an anxiety
disorder that can develop after exposure to a terrifying event or
ordeal in which grave physical harm occurred or was threatened.
Traumatic events that can trigger PTSD include violent personal
assaults such as rape or mugging, natural or human-caused disasters,
accidents, or military combat. PTSD can be extremely disabling.
Military troops who served in the Vietnam and Gulf Wars; rescue
workers involved in the aftermath of disasters like the terrorist
attacks on New York City and Washington, D.C.; survivors of the
Oklahoma City bombing; survivors of accidents, rape, physical and
sexual abuse, and other crimes; immigrants fleeing violence in their
countries; survivors of the 1994 California earthquake, the 1997
North and South Dakota floods, and hurricanes Hugo and Andrew; and
people who witness traumatic events are among those at risk for
developing PTSD. Families of victims can also develop the disorder.
About 3.6 percent of U.S. adults ages 18 to 54 (5.2 million
people) have PTSD during the course of a given year. About 30
percent of the men and women who have spent time in war zones
experience PTSD. One million war veterans developed PTSD after
serving in Vietnam. PTSD has also been detected among veterans of
the Persian Gulf War, with some estimates running as high as 8
percent. Source:
http://www.nimh.nih.gov/anxiety/ptsdfacts.cfm
|
1. Criteria for a PTSD
diagnosis
Matthew J. Friedman, M.D., Ph.D.
states that the "A" stressor criterion specifies that a person has been
exposed to a catastrophic event involving actual or threatened death or
injury, or a threat to the physical integrity of him/herself or others.
During this traumatic exposure, the survivor's subjective response was
marked by intense fear, helplessness, or horror.
The "B", or
intrusive recollection, criterion includes symptoms that are perhaps the
most distinctive and readily identifiable symptoms of PTSD. For
individuals with PTSD, the traumatic event remains, sometimes for
decades or a lifetime, a dominating psychological experience that
retains its power to evoke panic, terror, dread, grief, or despair.
These emotions manifest in daytime fantasies, traumatic nightmares, and
psychotic reenactments known as PTSD flashbacks. Furthermore,
trauma-related stimuli that trigger recollections of the original event
have the power to evoke mental images, emotional responses, and
psychological reactions associated with the trauma. Researchers can use
this phenomenon to reproduce PTSD symptoms in the laboratory by exposing
affected individuals to auditory or visual trauma-related stimuli (Keane
et. al., 1987).
The "C", or
avoidant/numbing, criterion consists of symptoms that reflect
behavioral, cognitive, or emotional strategies PTSD patients use in an
attempt to reduce the likelihood that they will expose themselves to
trauma-related stimuli. PTSD patients also use these strategies in an
attempt to minimize the intensity of their psychological response if
they are exposed to such stimuli. Behavioral strategies include
avoiding any situation in which they perceive a risk of confronting
trauma-related stimuli. In its extreme manifestation, avoidant behavior
may superficially resemble agoraphobia because the PTSD individual is
afraid to leave the house for fear of confronting reminders of the
traumatic event(s). Dissociation and psychogenic amnesia are included
among the avoidant/numbing symptoms and involve the individuals cutting
off the conscious experience of trauma-based memories and feelings.
Finally, since individuals with PTSD cannot tolerate strong emotions,
especially those associated with the traumatic experience, they separate
the cognitive from the emotional aspects of psychological experience and
perceive only the former. Such "psychic numbing" is an emotional
anesthesia that makes it extremely difficult for people with PTSD to
participate in meaningful interpersonal relationships.
Symptoms
included in the "D", or hyper-arousal, criterion most closely resemble
those seen in panic and generalized anxiety disorders. While symptoms
such as insomnia and irritability are generic anxiety symptoms,
hyper-vigilance and startle are more characteristic of PTSD. The
hyper-vigilance in PTSD may sometimes become so intense as to appear
like frank paranoia. The startle response has a unique neurobiological
substrate and may actually be the most pathognomonic PTSD symptom.
The "E", or
duration, criterion specifies how long symptoms must persist in order to
qualify for the (chronic or delayed) PTSD diagnosis. In DSM-III, the
mandatory duration was six months. In DSM-III-R, the duration was
shortened to one month, which it has remained.
The "F", or
functional significance, criterion specifies that the survivor must
experience significant social, occupational, or other distress as a
result of these symptoms.
Since 1980,
there has been a great deal of attention devoted to the development of
instruments for assessing PTSD. Keane and associates (1987) working,
with Vietnam war-zone veterans, have developed both psychometric and
psychophysiologic assessment techniques that have proven to be both
valid and reliable. Other investigators have modified such assessment
instruments and used them with natural disaster victims, rape/incest
survivors, and other traumatized individuals. These assessment
techniques have been used in the epidemiological studies mentioned above
and in other research protocols.
Neurobiological research indicates that PTSD may be associated with
stable neurobiologicalalterations in both the central and autonomic
nervous systems. Psychophysiological alterations associated with PTSD
include hyper-arousal of the sympathetic nervous system, increased
sensitivity and augmentation of the acoustic-startle eye blink reflex, a
reducer pattern of auditory evoked cortical potentials, and sleep
abnormalities. Neuropharmacologic and neuroendocrine abnormalities have
been detected in most brain mechanisms that have evolved for coping,
adaptation, and preservation of the species. These include the
noradrenergic, hypothalamic-pituitary-adrenocortical, serotonergic,
glutamatergic, thyroid, endogenous opioid, and other systems. This
information is reviewed extensively elsewhere (Friedman, Charney &
Deutch, 1995; Friedman, in press).
Longitudinal
research has shown that PTSD can become a chronic psychiatric disorder
and can persist for decades and sometimes for a lifetime. Patients with
chronic PTSD often exhibit a longitudinal course marked by remissions
and relapses. There is also a delayed variant of PTSD in which
individuals exposed to a traumatic event do not exhibit the PTSD
syndrome until months or years afterward. Usually, the immediate
precipitant is a situation that resembles the original trauma in a
significant way (for example, a war veteran whose child is deployed to a
war zone or a rape survivor who is sexually harassed or assaulted years
later).
If an
individual meets diagnostic criteria for PTSD, it is likely that he or
she will meet DSM-IV-TR criteria for one or more additional diagnoses (Kulka
et. al., 1990; Davidson & Foa, 1993). Most often, these comorbid
diagnoses include major affective disorders, dysthymia, alcohol or
substance abuse disorders, anxiety disorders, or personality disorders.
There is a legitimate question whether the high rate of diagnostic
comorbidity seen with PTSD is an artifact of our current decision-making
rules for the PTSD diagnosis since there are not exclusionary criteria
in DSM-III-R. In any case, high rates of comorbidity complicate
treatment decisions concerning patients with PTSD since the clinician
must decide whether to treat the comorbid disorders concurrently or
sequentially.
Although
PTSD continues to be classified as an Anxiety Disorder, areas of
disagreement about its nosology and phenomenology remain. Questions
about the syndrome itself include: what is the clinical course of
untreated PTSD; are there different subtypes of PTSD; what is the
distinction between traumatic simple phobia and PTSD; and what is the
clinical phenomenology of prolonged and repeated trauma? With regard to
the latter, Herman (1992) has argued that the current PTSD formulation
fails to characterize the major symptoms of PTSD commonly seen in
victims of prolonged, repeated interpersonal violence such as domestic
or sexual abuse and political torture. She has proposed an alternative
diagnostic formulation that emphasizes multiple symptoms, excessive
somatization, dissociation, changes in affect, pathological changes in
relationships, and pathological changes in identity.
PTSD has
also been criticized from the perspective of cross-cultural psychology
and medical anthropology, especially with respect to refugees, asylum
seekers, and political torture victims from non-Western regions.
Clinicians and researchers working with such survivors argue that since
PTSD has usually been diagnosed by clinicians from Western
industrialized nations working with patients from a similar background,
the diagnosis does not accurately reflect the clinical picture of
traumatized individuals from non-Western traditional societies and
cultures. Major gaps remain in our understanding of the effects of
ethnicity and culture on the clinical phenomenology of posttraumatic
syndromes. We have only just begun to apply vigorous ethnocultural
research strategies to delineate possible differences between Western
and non-Western societies regarding the psychological impact of
traumatic exposure and the clinical manifestations of such exposure (Marsella
et. al., 1996).
The many
therapeutic approaches offered to PTSD patients are presented in Foa,
Keane, and Friedman’s (2000) comprehensive book on treatment. The most
successful interventions are cognitive-behavioral therapy (CBT) and
medication. Excellent results have been obtained with some CBT
combinations of exposure therapy and cognitive restructuring, especially
with female victims of childhood or adult sexual trauma. Sertraline
(Zoloft) and paroxetine (Paxil) are selective serotonin reuptake
inhibitors (SSRI) that are the first medications to have received FDA
approval as indicated treatments for PTSD. Success has also been
reported with Eye Movement Desensitization and Reprocessing (EMDR),
although rigorous scientific data are lacking and it is unclear whether
this approach is as effective as CBT.
Perhaps the
best therapeutic option for mildly to moderately affected PTSD patients
is group therapy. In such a setting, the PTSD patient can discuss
traumatic memories, PTSD symptoms, and functional deficits with others
who have had similar experiences. This approach has been most
successful with war veterans, rape/incest victims, and natural disaster
survivors. It is important that therapeutic goals be realistic because,
in some cases, PTSD is a chronic and severely debilitating psychiatric
disorder that is refractory to current available treatments. The hope
remains, however, that our growing knowledge about PTSD will enable us
to design interventions that are more effective for all patients
afflicted with this disorder.
There is
great interest in rapid interventions for acutely traumatized
individuals, especially with respect to civilian disasters, military
deployments, and emergency personnel (medical personnel, police, and
firefighters). This has become a major policy and public health issue
since the massive traumatization caused by the September 11 terrorist
attacks on the World Trade Center. Currently, there is controversy
about which interventions work best during the immediate aftermath of a
trauma. Research on critical incident stress debriefing (CISD), an
intervention used widely, has brought disappointing results with respect
to its efficacy to attenuate posttraumatic distress or to forestall the
later development of PTSD. Promising results have been shown with brief
cognitive-behavioral therapy.
4.
DSM-IV-TR criteria for PTSD
A. The
person has been exposed to a traumatic event in which both of the
following have been present:
1.
the person has experienced, witnessed, or been confronted with an event
or events that involve actual or threatened death or serious injury, or
a threat to the physical integrity of oneself or others.
2.
the person's response involved intense fear, helplessness, or horror.
Note: in children, it may be expressed instead by disorganized or
agitated behavior.
B. The
traumatic event is persistently re-experienced in at least one of the
following ways:
1.
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.
2.
recurrent distressing dreams of the event. Note: in children, there may
be frightening dreams without recognizable content
3.
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 upon
awakening or when intoxicated). Note: in children, trauma-specific
reenactment may occur.
4. intense psychological distress at exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic event.
5.
physiologic reactivity upon exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event
C.
Persistent avoidance of stimuli associated with the trauma and numbing
of general responsiveness (not present before the trauma), as indicated
by at least three of the following:
1.
efforts to avoid thoughts, feelings, or conversations associated with
the trauma
2.
efforts to avoid activities, places, or people that arouse recollections
of the trauma
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 foreshortened future (e.g., does not expect to have a career,
marriage, children, or a normal life span)
D.
Persistent symptoms of increasing arousal (not present before the
trauma), indicated by at least two of the following:
1.
difficulty falling or staying asleep
2.
irritability or outbursts of anger
3.
difficulty concentrating
4.
hyper-vigilance
5.
exaggerated startle response
E.
Duration of the disturbance (symptoms in B, C, and D) is more than one
month.
F. 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 three months
Chronic: if duration of symptoms is
three months or more
Specify if:
Without
delay onset:
onset of
symptoms at least six months after the stressor