“What is’t that takes from theeThy stomach, pleasure, and thy golden sleep? ...And thus hath so bestirr’d thee in thy sleep, That beads of sweat have stood upon thy brow...”

- Henry IV, Part 1

widely diagnosed among returning soldiers.

“Survivors”

No doubt they'll soon get well; the shock and strain

Have caused their stammering, disconnected talk.

Of course they're "longing to go out again,"--

These boys with old, scared faces, learning to walk,

They'll soon forget their haunted nights; their cowed

Subjection to the ghosts of friends who died,--

Their dreams that drip with murder; and they'll be proud

Of glorious war that shatter'd all their pride ...

Men who went out to battle, grim and glad;

Children, with eyes that hate you, broken and mad.

Sigfried SassoonOct. 1917.

After World War I, "shell shock" was entirely banned as a diagnosis in the British

Army, and mentions of it were censored, even in medical journals.

Meanwhile, Alexandra Adler published seminal papers on the psychological effects of stress on

civilian populations, working with the survivors of the Cocoanut Grove Fire, the second most

deadly building fire in U.S. History

And then came World War II…

“gross stress reaction.”

response to “exceptional physical or mental stress”-- patient is “otherwise normal”-- must subside in days to weeks

Two Early Conceptual Frameworks for Understanding How Stress Relates to Mental Illness

The “Biological School”

Hans Selye: Father of Stress

--stress mediated by the hypothalmic-pituitary-adrenal (HPA) axis

--emphasized role of physical mechanisms

--”traumatic neuroses” consequence of chronic or severe stress

The “Psychological School”

--rooted in psychodynamic tradition

--stress caused by repressed memories and childhood traumata

--led to descriptions of defense mechanisms and role in producing/preventing disease

DSM-II was published in 1968. With no explanation, GSR was omitted from this version, and not replaced with any similar diagnosis.

And then came the Tet Offensive…

After 22 years of absence of a diagnostic category for stress syndromes, DSM III (1980) adds

Post-Traumatic Stress Disorder to its diagnoses.

But first, three things had to be defined:

So severe that it would produce symptoms in almost anyoneCould be physical, psychological or both

No pre-condition of “normality” necessary

Divided into 3 general categories:Re-experiencing (including dissociative-like states)Numbing of responsivenessCognitive/Autonomic

Onset could be acute or delayed

DSM III-TR (1987) Changes to Diagnostic Criteria:

Stressor no longer defined as “so severe that it would produce symptoms in almost anyone”

Psychological rather than physical nature of stressor emphasized

Stronger emphasis on dissociative symptoms

Eliminated the acute form of the disorder

DSM IV (1994) Changes to Diagnostic Criteria:

Stressor no longer limited to that experienced by patient (“a threat to physical integrity of self or others”)

Acute Stress Disorder added as a diagnosis, with emphasis on dissociative symptoms

Criterion A: stressorThe person has been exposed to a traumatic event in which both of the following have been present: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.The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior.

Criterion B: intrusive recollectionThe traumatic event is persistently re-experienced in at least one of the following ways: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.Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable contentActing 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.Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Criterion C: avoidant/numbingPersistent 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:

Efforts to avoid thoughts, feelings, or conversations associated with the traumaEfforts to avoid activities, places, or people that arouse recollections of the traumaInability to recall an important aspect of the traumaMarkedly diminished interest or participation in significant activitiesFeeling of detachment or estrangement from othersRestricted range of affect (e.g., unable to have loving feelings)Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Criterion D: hyper-arousalPersistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:

Difficulty falling or staying asleepIrritability or outbursts of angerDifficulty concentratingHyper-vigilanceExaggerated startle response

Criterion E: durationDuration of the disturbance (symptoms in B, C, and D) is more than one month.

Criterion F: functional significanceThe 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: With or Without delay onset: Onset of symptoms at least six months after the stressor

In one large study of individuals with PTSD, 92% met criteria for another Axis I disorder (Brown et al., 2001); more specifically, the following disorders were present at the following rates:

1. Major depression 77%2. Generalized anxiety disorder 38%

3. Alcohol abuse/dependence 31%

Co-morbidity with Other Disorders

Women and PTSD(some statistics)

Most of the preliminary research on PTSD was done on male veterans

Half of all women will be exposed to a traumatic event in their lifetime

Studies suggest that women experience rates of PTSD that are twice those of men

Sexual assault is a high risk factor for development of PTSD

A recent study found that 78% of women in the military have been sexually harassed and 6% have been raped

Proposed changes to PTSD diagnosis in DSM-V

--Wording changes to criterion A--PTSD in preschool children proposed as subtype instead of separate diagnosis--Proposed dissociative symptom subtype--Change of name of Disorder to “Post-Traumatic Stress Injury” under consideration

“Combat stress reactions are normal, predictable responses to abnormal,

psychologically traumatic, sometimes terrifying and horrible

experiences.”

--U.S. Military Report

http://www.youtube.com/watch?v=NkWwZ9ZtPEI