Trauma and Posttraumatic Stress Disorder

Key Points

Incidence/Epidemiology

Exposure to events capable of causing posttraumatic stress disorder (PTSD) is the rule rather than the exception. Life-time incidence of exposure to events causing PTSD is greater than 50%. However, development of PTSD following a traumatic event is the exception rather than the rule.
The overall probability of developing PTSD following a traumatic event is less than 10%. However, assaults and other traumatic events of human design can lead to substantially higher rates. The life-time incidence of DSM-IV PTSD in the general community is approximately 8%.

Pathophysiology

PTSD is one of the few disorders in DSM-5 for which the cause is considered to be known, viz., exposure to actual or threatened death, serious injury, or sexual violence. Such exposure may set in motion psychological and biological processes including fear conditioning, sensitization, and negative alterations in cognitions and mood that may lead to PTSD symptoms.
Failure to recover from symptoms over time, e.g., deficient extinction, also plays an important role and likely has a psychological and biological basis.

Clinical Findings

In adults, PTSD symptomatology is conceptualized within the framework of four symptom clusters: intrusion (DSM-5 criterion B), avoidance (criterion C), negative alterations in cognitions and mood (criterion D), and hyperarousal/hyper(-re)activity (criterion E).
Duration must be more than 1 month (criterion F).
Some individuals who fail to meet criteria in all four clusters may nevertheless have clinically significant distress and/or impairment (criterion G).

Differential Diagnoses

These include adjustment disorder, as well as affective, anxiety, and dissociative disorders precipitated or exacerbated by a traumatic life event. The critical factor in distinguishing PTSD from other disorders (except adjustment disorder) is the presence of trauma-specific intrusion and avoidance symptoms in PTSD.
In patients who have experienced more than one traumatic event, differential diagnosis of which event(s) caused PTSD may be made by discerning to which event(s) the characteristic intrusion and avoidance symptoms pertain.

Treatment Options

Despite the presence of helpful psychotherapeutic and pharmacotherapeutic treatments, individuals with PTSD often delay or fail to seek treatment more often than with most other psychiatric disorders.
Current treatments for PTSD include cognitive-behavioral and other psychotherapeutic modalities, and psychopharmacology. Unfortunately these are typically only partially efficacious. Novel approaches are needed.

Complications

Complications of PTSD include major depression, substance abuse/dependence, and panic disorder.
Suicide is a rare outcome of uncomplicated PTSD, but the risk of suicide increases substantially in the presence of complications.

Prognosis

Recovery from PTSD is most pronounced within the first year following the traumatic event.
More than 30% of those diagnosed with PTSD fail to show remission and develop a chronic course.

Overview

The psychopathological impact of exposure to traumatic events has long been recognized, particularly in the context of war. Descriptions of the emotional sequelae of combat date back thousands of years as revealed, for example, in the epic account of Achilles in Homer's Iliad. Modern wars have engendered their own unique labels for these sequelae: for example, “nostalgia” or “soldier's heart” (Civil War), “shell shock” (World War I), “battle fatigue” or “combat neurosis” (World War II), and “delayed stress” (Vietnam War). However, stress disorders were largely ignored as a formal psychiatric nosological category and were relegated to “transient” phenomena until the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1980. Consistent with this history, the inclusion of posttraumatic stress disorder (PTSD) in the DSM-III appeared largely in response to the psychiatric difficulties experienced by war veterans, in this case, soldiers returning from Vietnam. As a result, much of the original work underlying the diagnosis of PTSD focused on combat veterans. Since that time, however, the conceptual and empirical basis of PTSD has broadened to include civilian trauma (e.g., assaults, childhood abuse, natural disasters, accidents). Indeed, the most recent editions of the DSM now recognize among the events capable of causing PTSD such things as witnessing the death or injury of others, or learning that the traumatic event occurred in a close family member or close friend. Because the diagnosis of PTSD is frequently associated with trauma that occurs within strong social (e.g., rape or child abuse), political (e.g., war), or legal (e.g., tort civil litigation) contexts, it has frequently engendered controversy; the diagnosis has even been considered by some to reflect a mere “social construction” or a form of “victim advocacy.” However, more than two decades of epidemiological, genetic, and biological research has established a firm empirical foundation for PTSD. It is now recognized as a major psychiatric condition with significant social and occupational impact.

Diagnosis

Etiology

The diagnosis of PTSD is nearly unique among psychiatric disorders in that the criteria incorporate a presumptive cause (i.e., a traumatic event) in addition to the typical symptom constellation (see Box 34-1 for the DSM-5 PTSD diagnostic criteria). For this reason, in DSM-5 PTSD has shifted from classification among the anxiety disorders to a new category, “trauma and stressor-related disorders.” The stressor criterion in DSM-IV and DSM-5 significantly broadened the concept of a traumatic event from an earlier version of the DSM, which had required that it be “outside the range of usual human experience” (DSM-III-R). This change may have increased the number of stressors that qualify for inclusion by nearly 60%. DSM-5 has also abolished the previously-required subjective element of the stressor criterion, i.e., a response to the traumatic event of intense fear, helplessness, or horror, on the grounds that a substantial minority of persons who don't experience such a subjective response at the traumatic event nevertheless go on to develop the PTSD syndrome.

Box 34-1

DSM-5 Diagnostic Criteria

Posttraumatic Stress Disorder (309.81)

Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below.

A.
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
- 1.
  Directly experiencing the traumatic event(s)
- 2.
  Witnessing, in person, the event(s) as it occurred to others
- 3.
  Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental
- 4.
  Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
  
  Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.
B.
Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
- 1.
  Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
  
  Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
- 2.
  Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).
  
  Note: In children, there may be frightening dreams without recognizable content.
- 3.
  Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
  
  Note: In children, trauma-specific reenactment may occur in play.
- 4.
  Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
- 5.
  Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C.
Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
- 1.
  Avoidance of, or efforts to avoid, distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
- 2.
  Avoidance of, or efforts to avoid, external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D.
Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- 1.
  Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
- 2.
  Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
- 3.
  Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
- 4.
  Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
- 5.
  Markedly diminished interest or participation in significant activities.
- 6.
  Feelings of detachment or estrangement from others.
- 7.
  Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
E.
Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- 1.
  Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
- 2.
  Reckless or self-destructive behavior.
- 3.
  Hypervigilance.
- 4.
  Exaggerated startle response.
- 5.
  Problems with concentration.
- 6.
  Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F.
Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H.
The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Specify whether:

With dissociative symptoms: The individual's symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:
- Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
- Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

Posttraumatic Stress Disorder for Children 6 Years and Younger

A.
In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
- 1.
  Directly experiencing the traumatic event(s).
- 2.
  Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers.
  
  Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures.
- 3.
  Learning that the traumatic event(s) occurred to a parent or caregiving figure.
B.
Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
- 1.
  Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
  
  Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.
- 2.
  Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).
  
  Note: It may not be possible to ascertain that the frightening content is related to the traumatic event.
- 3.
  Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in play.
- 4.
  Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
- 5.
  Marked physiological reactions to reminders of the traumatic event(s).
C.
One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):

Persistent Avoidance of Stimuli

- 1.
  Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).
- 2.
  Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).

Negative Alterations in Cognitions

- 3.
  Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).
- 4.
  Markedly diminished interest or participation in significant activities, including constriction of play.
- 5.
  Socially withdrawn behavior.
- 6.
  Persistent reduction in expression of positive emotions.
D.
Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- 1.
  Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums).
- 2.
  Hypervigilance.
- 3.
  Exaggerated startle response.
- 4.
  Problems with concentration.
- 5.
  Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
E.
The duration of the disturbance is more than 1 month.
F.
The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior.
G.
The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition.

Specify whether:

With dissociative symptoms: The individual's symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following:
- Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
- Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

Clinical Features

In addition to the requisite traumatic event (criterion A) in DSM-5, the symptomatology of PTSD is conceptualized within the framework of four symptom clusters (see Box 34-1 ): intrusion (criterion B), avoidance (criterion C), negative alterations in cognitions and mood (criterion D), and hyperarousal/hyper(-re)activity (criterion E), with duration of more than 1 month (criterion F). However, some individuals who fail to meet criteria in all four clusters may still have clinically significant distress and/or impairment (criterion G). The requirement that different minimal symptom numbers from different clusters be met in order to qualify for the diagnosis is obviously arbitrary. It may be that this arbitrariness results from the attempt to convert what is in nature a continuum or spectrum of posttraumatic psychopathology into a categorical (present vs. absent) classification (i.e., PTSD). Such taxometric research evidence as exists supports the dimensional model.

In recognition of findings that dissociation, which may operate to minimize the awareness of aversive emotions, is implicated in a substantial minority (perhaps up to 30%) of PTSD cases, DSM-5 has added the optional qualifier, “with dissociative symptoms.” In recognition that in a minority of PTSD cases (about 10%), the manifestation may be delayed, DSM-5 has also added the optional qualifier, “with delayed expression.” Whereas DSM-IV characterized delayed PTSD as having a symptom onset at least 6 months after the trauma, this has been found to be rare. Presently DSM-5 only requires that the diagnostic threshold be exceeded more than 6 months after the event. Previous sub-threshold levels of symptomatology may be triggered to threshold levels as a result of new stressful events that re-evoke the original trauma. Delayed onsets that represent exacerbations or re-activations of prior symptoms have been found to account for 38.2% and 15.3%, respectively, of military and civilian cases of PTSD. DSM-5 has also introduced a new diagnostic classification for PTSD in children younger than 6 years. This is the first developmental subtype of an existing disorder in the DSM. It recognizes that young children's expression of their reaction to traumatic events may be more behavioral than verbal, that traumatic re-enactments in play may not necessarily be distressing, and that dreams may be generally fearful rather than trauma-specific. Only a single symptom pertaining to avoidance or negative alterations in mood and cognitions is required. Research has suggested that with the new criteria, up to eight times more children would meet the DSM-5 diagnosis compared to DSM-IV. There is still debate as to whether so-called “complex PTSD,” which attempts to capture the putative pervasive and negative impact of chronic and repetitive trauma, usually during childhood, should be recognized as a PTSD subtype.

Acute Stress Disorder

DSM-IV introduced a new diagnostic category, acute stress disorder (ASD), to recognize brief stress reactions to traumatic events that are manifest in the first month. Conception was heavily influenced by the theoretical concept of dissociation. To qualify for the ASD diagnosis, both posttraumatic and dissociative symptoms were required ( Box 34-2 ). Because subsequent research has questioned the essential role of dissociation in the short-term psychopathological response to trauma, in DSM-5 symptoms in the dissociative symptom cluster still count towards the diagnosis but are no longer required. Presently any 9 out of the 14 possible intrusion, dissociation, avoidance, and/or arousal symptoms are required, in accordance with the heterogeneity of the condition.

Box 34-2

DSM-5 Diagnostic Criteria

Acute Stress Disorder (308.3)

A.
Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:
- 1.
  Directly experiencing the traumatic event(s).
- 2.
  Witnessing, in person, the event(s) as it occurred to others.
- 3.
  Learning that the event(s) occurred to a close family member or close friend.
  
  Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
- 4.
  Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).
  
  Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B.
Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

Intrusion Symptoms

- 1.
  Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
  
  Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
- 2.
  Recurrent distressing dreams in which the content and/or effect of the dream are related to the event(s).
  
  Note: In children, there may be frightening dreams without recognizable content.
- 3.
  Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
  
  Note: In children, trauma-specific reenactment may occur in play.
- 4.
  Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Negative Mood

- 5.
  Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
- 6.
  Dissociative symptoms.
- 7.
  An altered sense of the reality of one's surroundings or oneself (e.g., seeing oneself from another's perspective, being in a daze, time slowing).
- 8.
  Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

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