302 Post-Traumatic Stress Disorder (PTSD)

DSM-IV-TR Criteria

• A. The person has been exposed to a traumatic event in which both of the following have been 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 or others
  2. The person’s response involved intense fear, helplessness, or horror. NOTE: In children, this may be expressed instead by disorganized or agitated behavior.

• 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. 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 young 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. Physiological reactivity on 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 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. 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. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.
  1. Difficulty falling or staying asleep
  2. Irritability or outbursts of anger
  3. Difficulty concentrating
  4. Hypervigilance
  5. Exaggerated startle response
• F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

In addition, clinicians specify if the PTSD is acute (duration of symptoms is less than 3 months) or chronic (duration of symptoms is 3 months or more) and if it was a delayed onset (if onset of symptoms is at least 6 months after the stressor).

Associated Features

In addition to the diagnostic criteria, individuals with PTSD often describe feelings of guilt about surviving when others did not survive or about the things they had to do to survive a trauma. A number of other symptoms can occur, such as feelings of shame, despair, or hopelessness; feeling permanently damaged; a loss of previously sustained beliefs, social withdrawal; impaired relationships with others; or a marked shift from the individual’s previous personality. Especially problematic are the self-destructive behaviors that can develop with PTSD, such as alcohol and drug abuse, suicidal behaviors, and risky sexual behavior.

Avoidance of situations or activities that remind a person of the trauma can cause functional impairment, problems with interpersonal relationships, and lead to marital conflict, divorce, or loss of job. Some individuals become greatly limited in the places and activities that they are able to engage in due to avoidance. Compared to healthy controls, people with PTSD report having a greatly reduced quality of life, and are at an elevated risk of poor physical health.

Having PTSD also puts one at a greatly elevated risk of developing comorbid disorders, even when compared to people with other anxiety disorders. Data indicate that over 80% of people with PTSD meet criteria for at least one other diagnosis, with over 50% having two or more comorbids. In persons with PTSD, high rates of simple (31%) and social phobias (27%) are seen, but the most commonly co-occurring disorders are non-anxiety ones, particularly major depression (48%) and substance abuse. Over 50% of males and almost 30% of females meet criteria for alcohol abuse or dependence, while other drug abuse is present in over 34% of males and 27% of females. In studies examining males veterans, even higher comorbidity rates are found for major depression, with 86% meeting criteria, but similar rates of anxiety and substance abuse problems were found.

Child vs. Adult Presentation

Exposure to traumatic events can have major developmental influences on children. While the majority of children will not develop PTSD after a trauma, best estimates from the literature are that around a third of them will, higher than adult estimates. Some reasons for this could include more limited knowledge about the world, differential coping mechanisms employed, and the fact that children’s reactions to trauma are often highly influenced by how their parents and caregivers react. These impact the development and presentation of PTSD, leading to differences not only from adults, but within different age groups of children. In the weeks after a trauma, up to 90% of children may experience heightened physiological arousal, diffuse anxiety, survivor guilt, and emotional lability. These are all normal reactions and should be understood as such (similar things are seen in adults. Those children still having these symptoms three or four months after a disaster, however, may be in need of further assessment, particularly if they show the following symptoms as well. In children under the age of six, these may indicate problematic adjustment to the disaster: generalized anxiety about separation, strangers, or sleep problems; avoidance of certain situations; preoccupation with certain symbols / words; limited emotional expression or play activities; and loss of previously acquired skills. For older children, warning signs of problematic adjustment include: repetitious play reenacting a part of the disaster; preoccupation with danger or expressed concerns about safety; sleep disturbances and irritability; anger outbursts or aggressiveness; excessive worry about family or friends; school avoidance, particularly involving somatic complaints; behaviors characteristic of younger children; and changes in personality, withdrawal, and loss of interest in activities.

Gender and Cultural Differences in Presentation

Women are significantly more likely to develop PTSD after a traumatic experience than men, even when predominantly female victim traumas, such as sexual crimes, are taken into account, with lifetime prevalence rates well over double that for men (9.6% vs. 3.6%). The genders also show differential patterns of response to traumas. For example, only 1% of males threatened with a weapon will develop PTSD, but over 30% of females in similar situations will. Females also show higher rates after physical and sexual assaults.

The majority of studies have been done by Western researchers using Western populations. As such, we have only a small body of literature to draw cross-cultural comparisons. There has been some research showing that African Americans returning from the Vietnam War more at risk of developing PTSD than Caucasians or other minorities. Subsequent findings found that, for the overall population, African Americans and Native Americans are at a higher risk than other minorities for developing PTSD. Much of the cross-cultural research around the globe has focused on differential rates of PTSD, with major findings indicating that (as in the U.S.) the more traumas one is exposed to, the greater likelihood of developing PTSD.

There have also been considerable critiques of the application of PTSD, with its inherent Western biases, to non-Western cultures. Twelve-month prevalence rates vary greatly between the U.S. (3.6%) and most other countries, such as urban China (0.2%), Japan (0.4%), Mexico (0.6%), and even Europe (0.9%) and Australia (1.3%). These large differences have led many to advocate for the use of more localized, culture-specific stress reactions (such as ataque de nervios in certain Latin and Hispanic cultures). Using biomarkers (such as exaggeration of startle response or physiological reactivity) has also been proposed, but there is only preliminary data so support their use at this time.

Epidemiology

The majority of people experience some sort of traumatic event at least once during their lifetime, with 25% of people experiencing multiple traumas. Rates are slightly higher for men (61%) than for women (51%), although types of trauma vary dramatically between genders. Women, for example, are much more likely to experience sexual assault or rape (9%) than males (1%), but men are much more likely to be involved in a serious accident (25% vs. 14%). Thankfully, though, the prevalence rate for PTSD is much lower than these numbers, as the vast majority of those involved in traumatic experiences do not develop it. Lifetime prevalence rate for the general U.S. population is 6.8%, with 12-month rates of only 3.6%.

Not all groups are equally at risk of developing PTSD, however. In high- or at-risk individuals (e.g., combat veterans, disaster victims, or criminal violence), prevalence rates ranging from 3% to 58% have been found. In countries with high rates of civil war and internal strife, shockingly high rates of PTSD have been found. In one study, over 37% of Algerians in the late 1990s met criteria for a PTSD diagnosis, compared to 6.8% of Americans. Interestingly, the type of disaster a person experiences greatly impacts the chance of developing PTSD. For example, while only 4-5% of those who live through a natural disaster develop PTSD, studies have found that 30% or more of people involved in man-made disasters (shootings, bombings, and so on) develop PTSD.

In recent U.S. combat veterans, studies have found that lifetime prevalence is about 39% in males, above the rate of 30% seen in veterans of the Vietnam War. When compared to other types of traumas that males experience, being in combat results in higher lifetime PTSD prevalence, a greater likelihood of delayed onset, and a greater likelihood of unresolved symptoms. Several studies examining PTSD in military females have found similar rates, even without the front-line combat experience. These studies have been criticized, though, due to some methodological difficulties.

Etiology

Alone among all the disorders listed in the DSM, PTSD has a specific etiological event – experiencing a trauma. While it is highly adaptive to have a strong fight-or-flight response during a trauma and when your life is threatened, these reactions should decrease once the trauma has passed. In persons with PTSD, however, they do not. As such, PTSD can be seen essentially as a failure to adapt to differing situations. Why people’s reactions fail to return back to normal after can be influenced by a number of factors. Prior to the event, a number of factors will greatly increase risk. These include being female, of a minority race, having a lower level of education, and having a lower income level. Also, a history of previous psychiatric problems and childhood trauma make it more likely that one will develop problematic symptoms. In addition to the type of trauma experienced, certain factors about the trauma can increase risk, such as greater perceived threat or danger and helplessness, as well as the unpredictability and uncontrollability of traumatic event. Post-trauma, lack of social support, overall amount of life stress, coping mechanisms used, and type of attributions made for the disaster can all increase risk.

Empirically Supported Treatment

As with most anxiety disorders, both medications and therapy can be effective in treating PTSD, although certain psychotherapies are much more effective. Meta-analyses show that CBT, particularly Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), have much greater overall effect sizes than medications for both self-reported symptoms (1.2 vs. 0.65) and clinician ratings (1.5 vs. 1.05). Nonetheless, medication can certainly be a very useful adjunctive treatment, especially to assist in controlling comorbid problems such as depression, and is more widely available than therapists trained in PE or CPT. The SSRIs (such as citalopram, fluoxetine, paroxetine, and sertraline) are the most well-studied group of agents, and have been shown to significantly outperform placebos in both civilian and military populations. The drug with the highest effect sizes, though, is venlafaxine, a SNRI. It slightly outperforms the SSRIs in both populations.

The two most well-supported psychotherapies are both types of CBT: prolonged exposure and cognitive processing therapy. They both share general components of psycho-education, anxiety management, exposure with response prevention, and cognitive restructuring. Little is known about their relative efficacy, but there is some research showing that clients with strong guilt about the trauma may fare better in CPT. Dropout rates are similar and relatively low across treatments.

The first part of PE is psycho-educational and allows the client to learn about trauma and its effects on individuals, as well as understand the symptoms of PTSD. This also lays out the groundwork and rationale behind why exposing oneself to the memories and to particular stimuli (both of which they are actively avoiding) is going to eventually lead to symptom reduction. Next, the client learns breathing skills to help control their anxiety and distress they will experience during the exposures. The third component is in vivo EX/RP, where a hierarchy of feared and avoided stimuli that are actually safe is developed, then increasingly anxiety-provoking stimuli are encountered and endured until they do not trigger anxiety in the individual. Finally, the fourth component of PE is mental exposure to trauma. This is accomplished by repeatedly having the person imagine the event as it occurred and experience all of the sights, the sounds, the smells, and perceptions of that event. This is often accomplished by writing trauma narratives, detailed descriptions of the trauma that would be read aloud repeatedly.

There are significant overlaps between PE and CPT, but also differences. The first CPT phase provides education about PTSD, but with an emphasis on the role of thoughts and how one’s perceptions or beliefs influence the way that they feel. The second phase focuses on processing the trauma and can be done with or without a trauma account. There is a more historical focus in CPT, where the client is focusing on reflections of how they made sense of what happened to them and then being led to a different and more adaptive interpretation of the trauma. In the third component, cognitive restructuring is taught, allowing the client is to challenge their own negative and maladaptive thoughts and interpretations. The fourth and final component is focused on employing cognitive restructuring for both historical and current interpretations.

Proposed DSM-5 Revisions

In the DSM-5, it has been proposed that, given the differential presentation of PTSD across the lifespan, completely separate criteria be adopted for different age groups. In particular, distinctions between the presentation of PTSD in adults, adolescents, school-age, and preschool children have been discussed. This is primarily driven by the fact that the DSM-IV criteria were developed for and tested on older adolescents and adults. As such, the proposed criteria include large numbers of notes that describe developmentally appropriate symptoms (such as repetitive play reflecting the trauma or frightening dreams with no specific content), as well as lower number of symptoms required to meet diagnosis. The other major change proposed is the removal of DSM-IV Criterion A2 (“The person’s response involved intense fear, helplessness, or horror.”) as it has not been found to have either clinical or research utility.

Key References

Hembree, E.A., Rauch, S., & Foa, E.B. (2003). Beyond the manual: The insider’s guide to prolonged exposure therapy for PTSD. Cognitive and Behavioral Practice, 10, 22-30.

Friedman, M. J., Resick, P. A., Bryant, R. A. and Brewin, C. R. (2011), Considering PTSD for DSM-5. Depression and Anxiety. doi: 10.1002/da.20767

Hinton, D.E., & Lewis-Fernandez, R. (2010). The cross-cultural validity of posttraumatic stress disorder: Implications for DSM-V. Depression and Anxiety, 27, 1-19.

Lack, C.W., Doan, R., & Young, P. (2010). Working with children in schools after traumatic events. In J.E. Warnick, K. Warnick, & A. Laffoon, (Eds.). Educational policy and practice: The good, the bad and the pseudoscience. Volume II: Applied practices. Hauppauge, NY: Nova Science Publishers.

Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30, 635-641.

Scheeringa, M. S., Zeanah, C. H. and Cohen, J. A. (2011), PTSD in children and adolescents: toward an empirically based algorithm. Depression and Anxiety. doi: 10.1002/da.20736