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Understanding PTSD (Post-Traumatic Stress Disorder)

Posted Aug 27 2009 11:38pm

The term "PTSD" (Post-Traumatic Stress Disorder) has entered the popular vernacular, such that it is a term that is bandied about fairly commonly, and often incorrectly. Many times what people mean when they say "PTSD" is actually what psychiatrists classify as an Acute Stress Disorder (308.3), or an Adjustment Disorder with Anxiety (309.24), according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), the publication that mental health scientists use to operationally define psychiatric syndromes for the purposes of carrying out research.

In psychiatry there are no diagnostic blood tests or definitive biopsy samples; instead, diagnoses are arrived at by considering the presentation, history, and serial mental status examinations and by ruling out other medical conditions for which more objective laboratory tests and diagnostic procedures are available. Because mental health diagnosis is therefore inherently more subjective, in order to ensure that researchers were talking about the same clinical phenomenon it became necessary to devise a convenient method of classifying the various psychiatric disorders according to certain diagnostic criteria. This article briefly outlines the DSM-IV-TR diagnostic criteria for PTSD, so you can understand what doctors mean when they use the term and to improve communication between you and your healthcare provider, if you feel that you may be suffering from this disorder.

Before enumerating the established diagnostic criteria, it's worth emphasizing again that all DSM criteria were developed, by consensus, among panel members of the American Psychiatric Association for the purpose of improving communication among researchers and ensuring the cross-validity of their studies. The DSM is chiefly followed to make sure that one group of researchers studying "PTSD" is actually studying the same disorder as another group studying "PTSD," so that meaningful conclusions can be drawn and comparisons can be made.

Clinicians--practitioners seeing patients in a treatment, as opposed to a research, setting--are generally encouraged to follow the same guidelines, but the difference is that in the clinic we are less concerned with statistics and more concerned with patient outcome. Accordingly, if the DSM indicates that "4 out of 5 of the following criteria must be met for a diagnosis" of this or that disorder to be made, an experienced clinician is more than justified in substituting his or her own experience and judgment in making a diagnosis and proceeding with treatment if, for example, in any given case, only 3 criteria are clearly met, etc. In a clinical setting, it is more important to consider the entire presentation, including a patient's prior medical history and family history, than it is to be a stickler about the number of criteria that must be satisfied; the latter only becomes important in the context of conducting meaningful and valid comparative research.

That said, for any given psychiatric syndrome there are certain core criteria which, if absent, more or less preclude the diagnosis. With PTSD, the principal criterion is that the condition follows a traumatic event (hence "post-traumatic"). Without the presence of an obvious precipitating trauma, a diagnosis of PTSD cannot be justified. Likewise, the essential features of PTSD include the fact that the 1) trauma is followed by 2) re-experiencing, 3) avoidance, and 4) agitation.

Trauma. The person was exposed to ("experienced, witnessed, or was confronted with") a traumatic event that involved actual or threatened death or serious injury to the self or to others. Earlier versions of the DSM specified that the trauma had to have been of a universal character; i.e., an event or experience that anyone in similar circumstances would have found traumatic, and of a severity so as to be life-threatening. Updated criteria are less stringent, allowing for the mere fear of loss of life or limb in order for a person to have been sufficiently psychologically scarred so as to develop the symptoms of PTSD.

This more subjective interpretation of "traumatic" includes witnessing threatening or deadly events happening to others, in the absence of any perceived danger to the self, as well as merely hearing about violence or death done to others ("confronted with," although in this writer's opinion, this last form of trauma seems a bit broad, and at least to me suggests the presence of another, pre-existing anxiety disorder, and/or a personality disorder, or some other form of impairment in coping skills in such a vulnerable individual). PTSD can also develop in children who have experienced sexual molestation, even if it was not violent or life-threatening.

The second component to having experienced or witnessed a qualifying trauma is likewise largely subjective: "the person’s response involved intense fear, helplessness, or horror." Thus, even if the trauma was not life-threatening per se, so long as it was perceived as such and the person reacted with intense fear or horror, this criterion is considered met. The point is that the trauma is beyond ordinary. Classic examples are kidnappings, rape, and events of war. Working for a mean boss does not usually qualify, unless s/he literally torments you.

Once trauma has been endured, the PTSD syndrome itself consists of three major problems: mentally re-experiencing the trauma over and over again, engaging in avoidant behaviors to minimize traumatic recollections of the event(s), and persistent symptoms of increased physiological arousal.

Re-living the trauma. The traumatic event is persistently re-experienced in one or more of the following ways: recurrent and intrusive distressing recollections; nightmares of the event(s); flashbacks; and "intense psychological distress" and/or "physiological reactivity" at exposure to internal or external cues that symbolize or resemble the traumatic event. Physiological reactions might include an elevated heart rate, sweating, chest pain, difficulty breathing, other symptoms of a panic attack, light-headedness, fainting, etc.

Flashbacks consist of sudden, discrete episodes during which a person acts or feels as if the traumatic event were actually recurring. This can involve actual perceptual disturbances such as experiencing illusions and/or hallucinations, including those that occur upon falling into or awakening from sleep (hypnagogic or hypnapompic hallucinations, respectively) or while under the influence of an intoxicating substance. In other words, if a person only flashes back when drunk or half-asleep, it still counts.

Persistent avoidance. According to the DSM-IV-TR, three or more of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; the inability to recall an important aspect of the trauma (psychogenic amnesia); markedly diminished interest or participation in formerly significant activities; feelings of detachment or estrangement from others; restricted range of affect ("a numbing of general responsiveness"); and/or the sense of a foreshortened future (not expecting to live out a normal life span, failing to make distant future plans).

Persistent symptoms of increased arousal. Two or more of the following: difficulty falling or staying asleep; irritability or angry outbursts; difficulty concentrating; hypervigilance (paranoia); and/or an exaggerated startle response. Hypervigilance is treading with trepidation, metaphorically speaking, constantly looking over one's shoulder, half-expecting to re-encounter the trauma. It is especially common in attack victims and is often closely associated with being easily startled.

Duration requirement. The DSM also requires that, for any given psychiatric syndrome, symptoms endure for a minimum period of time in order to justify making a diagnosis. If symptoms last only a few hours or days and then disappear forever, we do not diagnose mental illness. For PTSD in particular, symptoms are expected to persist for more than one month before a person is considered affected.

Finally, the DSM requires that any mental health disturbance cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning," a criterion that attaches to all disorders by definition, although here the requirement seems a bit redundant: it is unlikely that such would not be the case if all other criteria of PTSD are met.

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