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Trauma and Post-Traumatic Stress Disorder

I. Overview

A. The puzzling, and disturbing effects of psychological trauma on human functioning has been described for generations, as far back as Homer's Iliad. In more recent times, large numbers of American Civil War veterans complained of generalized weakness, heart palpitations and chest pain-thought to be a result of the physical stress of war, and referred to as 'soldier's heart'. In the First World War, psychologically disabled veterans were thought to have suffered from brain damage, or 'shell shock.' Kardiner treated World War Two veterans, describing a syndrome that foreshadowed the current diagnosis of post-traumatic stress disorder, he labeled it a 'traumatic neurosis of war', and made the point that the syndrome was physiological in nature. Post-traumatic stress was virtually ignored until after the Vietnam War when both veterans groups and the feminist movement spoke out about psychological trauma. Horowitz helped to formulate the diagnosis that found its way into the DSM-III. Earlier in the century Freud and Janet became interested in how psychological trauma lead to post-traumatic stress disorder. Freud proposed that childhood sexual abuse was linked to symptoms of hysteria, an idea he later abandoned.

B. Since its inception in the DSM-III, the diagnosis of post-traumatic stress disorder (PTSD) has helped researchers study the connection between psychological trauma and psychiatric morbidity. Initially it was thought that PTSD described a normal, expectable response to trauma. It was felt that the severity and chronicity of the syndrome might be directly related to the nature of the trauma. Subsequent research has shown that the diagnostic criteria for PTSD describe several phenomena; an initial, expectable response to trauma, an initial pathological response, and a more prolonged, pathological state.

C. Acute and long-term responses to traumatic events are varied and multi-determined. Nearly every person can be expected to have some disruption in their mental functioning following a significantly traumatic event, a 'normal' stress response. On average, most people are able to adapt following a traumatic event and return to their previous level of functioning, with or without some chronic symptoms. When the symptoms following a trauma impair functioning, they often appear as syndromes, labeled in the DSM-IV as Acute Stress have a significant impact on the individual.

II. Posttraumatic Stress disorder

The DSM-IV criteria for PTSD are listed below and define 'trauma' and the three central groups of post-traumatic symptoms; intrusive/reexperiencing, avoidance/numbing and hyperarousal. If these symptoms are pervasive, prolonged and debilitating enough, they reach threshold for a diagnosis. A typical post-traumatic response may involve alternating symptoms of avoidance and reexperiencing as the person struggles to come to terms.

A. The DSM-IV defines "trauma" in a specific way

1.' Trauma' involves a physical threat to life or bodily integrity, examples include:

a. Exposure to military combat, violent assault, including rape and robbery, domestic violence, automobile accidents, childhood physical and sexual abuse or neglect, natural disasters and sudden catastrophic medical illness.

b. Witnessing a traumatic event

c. Being told about a trauma experienced by a loved one.

2. A defining characteristic of a traumatic event, according to the DSM-IV, is that the person's response involves "intense fear, helplessness or horror." Because of the intensity of the feelings associated with a trauma, perception of the event may be distorted; it may be experienced as fragments of sensations, time may be slowed or accelerated.

B. Intrusive, reexperiencing symptoms are a hallmark of PTSD.

Traumatic memories are often quite disruptive; they are vivid, sensory experiences, that can intrude unbidden. Nightmares are common, often repetitive, lifelike and disruptive to sleep; patients begin to dread sleep and will 'fight it', to avoid the frightening nightmares. Flashbacks, hallucinations and other experiences of reliving the trauma can occur. Intense emotional distress and physiological reactivity.

C. Avoidance of reminders of the trauma and psychological numbing can be the most disabling symptoms.

Following a trauma, persons may avoid anything that may remind them of the trauma, including thoughts or feelings, activities, places or people that are associated with the event. There can be amnesia for the trauma itself.

D. Hyperarousal symptoms can create interpersonal problems. These symptoms include, marked sleep difficulty, irritability and anger outbursts, difficulty with concentration, hypervigilance.

DSM-IV Diagnostic criteria for Post-traumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self.

(2) The person's response involved intense fear helplessness.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

(1)Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions.

(2) Recurrent distressing dreams of the event.

(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 on awakening or when intoxicated).

(4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

(5) Physiological reactivity on exposure to internal or external cues that symbolize.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) 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) Marked diminished interest or participation in significant activities.

(5) Feeling of detachment or estrangement from others.

(6) Restricted range of affect (eg, unable to have loving feelings).

(7) Sense of a foreshortened future (eg, does not expect to have a career. Marriage, children, or a normal life span).

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

(1) Difficulty falling or staying asleep

(2) Irritability or outbursts of anger

(3) Difficulty concentrating

(4) Hypervigilance

(5) Exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational or other important area of functioning.

Specify if:

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

III. Stress Disorder

This disorder describes an acute response to trauma. It includes the criteria for PTSD but adds and emphasizes dissociative symptoms. An acute stress disorder may follow any trauma, but a typical example includes a soldier responding to battle, becoming acutely disoriented, and being in a "daze." Acute Stress Disorder appears to be a good predictor of subsequent PTSD; the presence or absence of the diagnosis predicted PTSD at 6 months in 83% of cases in one study. The diagnostic criteria are listed below.

DSM-IV Diagnostic criteria for Acute Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others

(2) the person's response involved intense fear, helplessness or horror

B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

(1) subjective sense of numbing, detachment or absence of emotional responsiveness

(2) a reduction of awareness of his or her surroundings (eg, "being in a daze")

(3) derealization

(4) depersonalization

(5)dissociative amnesia (inability to recall an important aspect of the trauma)

C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

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

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

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.

H. The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition, is not better accounted for by a Brief Psychotic Disorder, and is not merely an exacerbation of a preexisiting Axis I or Axis II disorder.

IV. Epidemiology

A. Prevalence of PTSD in General Population

1. Results range from 1% to 14%. The Epidemiological Catchment Area Study showed lifetime PTSD rates of around 1.3% at two sites. More subjects reported sub-clinical symptoms following a trauma, around 15%.

2. A survey of 1,007 young adults in an HMO in Detroit showed that 39% were exposed to a traumatic event, 23.6% of those subjects developed PTSD, leading to a lifetime prevalence of 9.2%, 6.0% for males and 11.3% for females.

B. Prevalence of PTSD Following Specific Traumas

1. The rates of PTSD following natural disasters vary. Following the  volcano eruption of Mt. St. Helen, a population sample of those exposed showed lifetime prevalence of PTSD of 3.6% compared to 2.6% in controls. Following a dam break and subsequent flood at Buffalo Creek, researchers found a 59% lifetime prevalence of PTSD, 25% still met criteria at 14-year follow-up.

2. For war veterans, rates can vary according to traumatic exposure. Overall, lifetime PTSD rates for Vietnam veterans is 15%. Those exposed to median levels of combat showed rates of 28% compared to 65% among those exposed to the highest levels of combat. For political prisoners and prisoners of war, rates can range from 30% to more than 70%. For torture victims, rates can be as high as 90/3.

3. Among individuals who suffer a violent assault, there is a 20% rate of PTSD.

Victims of rape have been found to have rates of PTSD near 50% in some studies.

Witnessing a person being killed or seriously injured confers a risk of 7%.

4. Following a traffic accident, 10 to 30% still have PTSD 6 to 18 months following the accident.

5. In a group of individuals who experienced a sudden, unexpected death of a close friend or relative, 14% developed PTSD.