posttraumatic stress disorder historical overview of traumatic reactions: late 19th century terms...
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Posttraumatic Stress Disorder
Historical Overview of Traumatic Reactions: late 19th century
• Terms used in combat veterans populations– Cardiovascular:
• Soldier’s heart
• Da Costa’s Syndrome
• Neurocirculatory asthenia
– Psychiatric• Nostalgia
• Shell shock
• Combat fatigue
• War neurosis
• Terms used in civilian populations– Railway Spine
Later Descriptions of Traumatic Reactions (1940s-1980s)
• Later descriptions of post-traumatic responses were labeled according to the type of trauma– Rape trauma syndrome
– Survivor syndrome
– War neurosis
– Shell shock
PTSD: DSM-III (1980)
• PTSD becomes an established diagnosis
• Traumatic event defined as “a recognizable stressor that would evoke significant symptoms of distress in almost anyone.”
• Three symptom clusters (based on clinical experience): reexperiencing, numbing and detachment, and changes in personality
PTSD: DSM-III-R (1987)• Definition of trauma was narrowed:
– “An event outside the range of usual human experience and that would be markedly distressing to almost anyone”
• Avoidance symptoms were added to numbing cluster
• Symptoms expanded from 12 to 17• Duration and onset criteria added• Impairment in functioning and/or distress added.• Issues with definition:
– Definition proved too restrictive as traumas more common than originally believed
– Did not allow for individual differences
PTSD: DSM-IV (1994)
• Exposure to a traumatic event in which the person:– experienced, witnessed, or was confronted by death or serious
injury to self or others AND – responded with intense fear, helplessness,
or horror
• Symptoms – appear in 3 symptom clusters: reexperiencing,
avoidance/numbing, and hyperarousal– last for > 1 month– cause clinically significant distress or impairment in functioning
Acute Stress Disorder: DSM-IV (1994)
• Exposure to a traumatic event in which the person:– experienced, witnessed, or was confronted by death or serious injury to
self or others AND – responded with intense fear, helplessness,
or horror
• > 3 dissociative symptoms• >1 reexperiencing symptoms• >1 anxiety/arousal symptoms• Onset: 2 days to 4 weeks• Clinically significant distress or impairment in
functioning
Criterion A: Exposure Criteria
• Experienced or Witnessed an Event that involved actual or threatened death or serious injury or a threat to physical integrity
• Person’s response involved fear, helplessness, or horror or in children agitated behavior
Criterion B: Re-experiencing Criteria
• Recurrent and Intrusive distressing recollections of the event (images, thoughts, or repetitions)
• Recurrent distressing dreams of the event
• Acting or feeling as if the traumatic event were recurring
Criterion B continued…
• Intense Psychological Distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
• Physiological Reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Criterion C1: Persistent Avoidance Criteria
• Efforts to avoid thoughts, feelings, or conversations associated with the trauma
• Efforts to avoid activities, places, or people that arouse recollections of the trauma
• Inability to recall an important aspect of the trauma
Criterion C2: Numbing of Gen. Responsiveness Criteria
• Markedly diminished interest or participation in significant activities
• Feeling of detachment or estrangement from others
• Restricted range of affect
• Sense of foreshortened future
Criterion D: Increased Arousal Criteria
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response
Criterion E
• Symptoms in criteria B, C, and D are more than 1 month
Criterion F
• The disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning
Specifications
• 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
Acute Stress Disorder
Criterion A: Exposure Criteria
• Experienced or Witnessed an Event that involved actual or threatened death or serious injury or a threat to physical integrity
• Person’s response involved fear, helplessness, or horror or in children agitated behavior
Criterion B: Dissociative Criteria
• Subjective sense of numbing, detachment, or absence of emotional responsiveness
• Reduction in awareness of one’s surroundings (e.g., “being in a daze”)
• Derealization
• Depersonalization
• Dissociative amnesia
Criterion C: Re-experiencing Criteria
• Recurrent images
• Thoughts, dreams, illusions
• Flashback episodes, or a sense of reliving the experience
• Distress on exposure to reminders of the traumatic event
Criterion D: Avoidance Criterion
• Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people)
Criterion E: Physiological Criteria
• Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness)
Criterion F: Psychosocial Criteria
• Clinically significant distress or impairment in social, occupational, or other important areas of functioning
• Impaired ability to pursue some necessary task, such as obtaining personal assistance or mobilizing personal resources
Criterion G: Time Criteria
• Minimum of 2 days
• Maximum of 4 weeks
• Occurs within 4 weeks of the traumatic event
Inter-relationship between ASD and PTSD
Event ASD PTSD
2 days – 4 weeks
4 weeks and on
How does someone develop PTSD?
Classical Conditioning
Unconditioned Stimulus
Unconditioned Response
Car Jacking
Thoughts
Feelings
Behaviors
CS CR
Validity is Well Established
• PTSD has proven to be a useful and valid diagnosis after 25 years of clinical use
• Although there have been minor revisions to the diagnostic criteria the core concept has withstood the test of time
PTSD Prevalence in US Adults
• National Comorbidity Survey (1995); NCS-Replication (2005)– Large national probability samples (Ns > 5000)– Benchmark for prevalence of mental disorders in US
• Lifetime PTSD prevalence = 6.8% (NCS-R)– 9.7% women– 3.6% men
• Current PTSD prevalence = 3.6% (NCS-R)– 5.2% women– 1.8% men
The Burden of PTSD
• Individuals with PTSD have:– Elevated risk of mood, other anxiety, and substance abuse
disorders
– Elevated risk of suicide attempts
– Greater functional impairment
– Reduced quality of life
• PTSD had the greatest impact of all anxiety disorders on economic burden to society (Greenberg et al., 1999)
PTSD and Functioning in the NCS
In NCS, PTSD associated with: – 40% elevated odds of academic failure
– 30% elevated odds of teenage parenthood
– 60% elevated odds of marital problems
– 150% elevated odds of current unemployment