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The National Institute of Mental Health (2008) states that 2.5 million people are hospitalized each year having sustained injuries during a traumatic event. As the literature is reviewed, however, it can be seen that most research has been focused on combat veterans (predominantly Vietnam and the Middle East) and female adult survivors of sexual abuse/assault. When clinicians engage with those who have been exposed to trauma, they are challenged to differentiate posttraumatic stress disorder (PTSD) from other clinical problems. Sometimes symptom presentation is simple (such as depression and/or anxiety), in other instances symptom presentation demonstrates multiple layers of comorbidity.
PTSD is a complex and often chronic disorder that has been found to be comorbid with numerous other disorders. While exposure to a traumatic event appears common, only a fraction of those exposed to trauma develop posttraumatic stress disorder. The symptoms of PTSD are indicative of a disturbance of the normal capacity to resolve cognitive and emotional responses to traumatic events (Yehuda and McFarlane, 1995). It is a disorder that involves a traumatic stressor, intrusive recollections, avoidant symptoms, and hyperarousal. Earlier diagnostic criteria set acute stress disorder (ASD) and PTSD apart from all other psychiatric diagnoses by including the requirement that one of the factors should be outside of the individual: "a traumatic stressor." Some patients diagnosed with chronic PTSD develop pervasive and persistent incapacitating mental illness which can negatively impact all areas of psychosocial functioning (marital/family, social, work/school). Van der Kolk (1996) highlights the most basic premise of the experience, stating that beliefs and cognitions give meaning to the emotion brought on by trauma. These thoughts activate the amygdala and trigger the emotions which, for many, become the central challenge of moving forward from their experience of a traumatic event. One of the potential consequences of trauma is that emotional memories of trauma get incompletely processed and are constantly being reactivated by triggers.
While the effects of psychological trauma have been acknowledged throughout history by mental health and medical professionals, PTSD was first suggested as a diagnostic category in the development of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. It was an extremely controversial diagnostic category at the time due to the required criterion for an external traumatic event. Nevertheless, the high rate of psychiatric casualties among Vietnam veterans inundating US Department of Veterans Affairs facilities helped to establish PTSD as a legitimate diagnosis. The diagnostic struggle continues, however, as researchers try to determine whether symptoms emerge only in relation to the trauma or are suggestive of a significant underlying psychiatric disorder(s).
Yehuda et al. (1998) emphasized the evidence of an abnormal acute stress response of a biological nature in those with PTSD. Many feel that the substantial experiential aspect of physiological effects have not been adequately considered diagnostically, which has limited and/or negatively impacted treatment as well as diagnosis. Darrel Regier, MD, MPH, executive director of the American Psychiatric Institute for Research and Education, states "It's very important to have a better paradigm than what we've been using to look at somatic presentations of mental disorders, and the relationship to disorders in other organ systems" (Regier, 2007). This illustrates the limitations of the tradition nomenclature of diagnostic criteria, highlighting the need to explore physical–mental associations, along with lifespan, gender and cultural issues.
Another view by Keane (2006) is that PTSD does not and should not describe all of the possible symptoms of the disorder, and therefore there is no need to expand the nomenclature to include complex PTSD.
Trauma is the consequence of exposure to an overwhelming and inescapable event which overcomes a person's coping ability, thus encapsulating the interaction between the individual and the traumatic event. In other words, no two people exposed to the same event will react in the same manner. The person's ability to cope with the traumatic exposure will be associated with factors, such as (1) their belief system, (2) prior experience(s) of trauma, (3) chronic stressful experiences, (4) level of support, (5) perception of their ability to cope with the event, (6) internal resources (coping mechanisms etc.), (7) genetic predisposition, and (8) other stressors in their life at the time of the event.
PTSD is a multifaceted and complex disorder which challenges the clinician in making an accurate diagnosis. Bearing in mind that there is significant controversy about the criteria written in the diagnostic nomenclature, this review will begin with the diagnostic criteria set by the diagnostic manual and expand from there to encompass the conceptual and practical challenges in evaluating trauma exposure. Currently, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) foundation for the PTSD syndrome includes 17 symptoms within three symptom clusters:
1. Re-experiencing the trauma
2. Avoidance and numbing
The first step in assessing trauma is to establish and identify exposure to an extreme stressor, Criterion A in the DSM diagnostic criteria. An extreme stressor is identified as having three elements:
The type of exposure (directly experienced, witnessed, informed indirectly)
Distinguishing traumatic stress from ordinary stress, i.e. the event presents a threat to life, serious injury, or threat of physical integrity to self or others.
The event triggers an intense emotional response of fear, horror, or helplessness.
As can be seen, the subjectivity of this criterion is the basis of the controversy, either viewed as personally restrictive (what is traumatic from one individual to another) or that the criterion is too broad, which allows too many stressors to be identified as traumatic. Whatever the view, the gatekeeper function of Criterion A is important for setting a parameter or threshold of what is identified as an extreme stressor warranting the diagnosis of PTSD.
Once it has been determined that a patient has experienced exposure to trauma, the therapist can consider, based upon symptom presentation, which diagnostic criteria are matched. The continuum of diagnoses associated with exposure to a trauma are commensurate with the range of emotional and psychological reactions experienced and are shown diagrammatically in Figure 1.1.
The next step in assessing for PTSD is to review the constellation of symptoms used to determine if the patient has the necessary number of symptoms in each symptom category to differentiate a diagnosis from diagnostic features (fewer symptoms than warranted for a diagnosis) from a diagnosis of PTSD. There are several noted difficulties regarding this mission:
The large number of symptoms that represent both overt and covert manifestations. A diagnosis requires:
(a) at least 1 of 5 re-experiencing symptoms;
(b) at least 3 of 7 avoidance and numbing symptoms; and
(c) at least 2 of 5 hyperarousal symptoms.
Some symptoms are vague in definition, leading to a lack of consensus as to what is exactly meant by the terminology. This leads to poor interpretation and significant variance in accuracy of symptom determination.
Symptom overlap between clusters, which can lead to what is called "double coding" of symptoms, meaning that they are given diagnostic credit for essentially the same symptom in different symptom categories.
Negative symptoms (such as emotional numbing or loss of interest) may be difficult to assess because the patient is focused on positive symptoms with notable associated distress.
Are the presented symptoms within the normal range of reaction to such an experience or is the symptom representative of a pathological or clinically significant problem?
Patients presenting for assessment or treatment following a current trauma exposure that present with prior trauma exposure and/or previous posttraumatic stress symptoms must present a clear and distinct change from their previous level of functioning.
Multiple practitioners are often involved. Often the patient may be referred from their primary care physician for depression or anxiety with an associated misinterpretation of origin or history of symptoms. This may result in an incorrect diagnosis.
With this brief review of potential diagnostic difficulties, one can see why developing diagnostic criteria for PTSD has been so arduous and factious. Just investigating one symptom can demonstrate the numerous questions posed that are often not easy to define by an accurate qualitative or quantitative answer. For example, Weathers et al. (2004) makes an excellent point in questioning the origin of a symptom such as amnesia in assessing for PTSD. If the patient is not able to recall aspects of their experience it may be difficult to determine whether it is the result of intense fear and associated avoidance, having been unconscious during part of the event, or poor memory which has another foundation (medical, function of time, etc.).
SYMPTOM CLUSTERS AND ADDITIONAL DIAGNOSTIC CRITERIA
In addition to Criterion A (defining the trauma exposure) there are five other criteria (B through F) and additional specifiers.
The Diagnostic Manual, DSM-IV-TR, describes the development of characteristic symptoms following exposure to an extreme traumatic stressor, through either direct experience, witnessing, or knowledge of an event that involved actual or perceived threat to life or physical integrity of self or others. In such a situation a person's response involves intense fear, helplessness, and/or horror. The symptoms, which cause significant distress or impairment in social or occupational functioning, must be present for at least one month. The diagnostic criteria or symptoms consist of three clusters (B, C, D):
CATEGORY B: PERSISTENT RE-EXPERIENCING OF THE TRAUMATIC EVENT (AT LEAST ONE SYMPTOM)
1. Recurrent and distressing recollection of the events (images, thoughts, impressions)
2. Recurrent distressing dreams of the event
3. Acting or feeling as if the traumatic event were recurring
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.
The patient experiences flashbacks, traumatic daydreams, or nightmares in which he or she relives the trauma as if it were recurring in the present. Intrusive symptoms result from an abnormal process of memory formation. Traumatic memories have two distinctive characteristics: (1) they can be triggered by stimuli that remind the individual of the traumatic event, (2) they can have a "frozen" or wordless quality, consisting of images and sensations rather than verbal descriptions.
Nightmares assocated with trauma exposure are generally classified according to being thematically related dreams (re-experiencing symptoms).
Contrary to general belief, flashbacks are not intrusive recollections but rather dissociative episodes in which the individual believes, or responds as if, the traumatic experience was actually occurring. This means that the individual is reliving, not just recalling, the traumatic experience. Additionally, flashbacks may involve hallucinatory perceptual disturbance (American Psychiatric Association, 2000). While dissociation can be a symptom of PTSD it is also a diagnostic category.
Trauma cues may be obvious or subtle and difficult to identify. For example, the survivor of a sexual assault finds the trauma triggered by sexual arousal. In fact, there is increased likelihood of such a trigger if they were aroused during the assault.
Recurrent, intrusive recollections and dreams are the most usual re-experienced symptoms (American Psychiatric Association, 2000). Intrusive recollections may also include other somatosensory experiences in addition to emotions experienced at the time of the trauma associated with taste, smell, touch, and sound.
There is some controversy as to the origin of somatosensory recollections. These bodily sensations could be body memory (van der Kolk, 1994; Rothchild, 2000), or manifestations of an individual's psychophysiological reactions to the trauma cue or other trauma stressors (McNally, 2003). According to Lanius et al. (2006), bodily sensations experienced during trauma might be triggered by a trauma cue at a later time and they are typically accompanied by conscious recollections of the trauma (therefore, not a body memory). Lindauer et al. (2006) reported results similar to previous studies on combat veterans, demonstrating heightened physiological responses as seen in civilians and police with PTSD when presented with trauma-specific stimuli. Regehr et al. (2007) concluded that prior trauma and decreased social supports were associated with continued psychological distress as well as physiological responses.
CATEGORY C: EMOTIONAL NUMBING AND AVOIDANCE
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness as indicated by at least three of the following (which were not present prior to the trauma):
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 (i.e. unable to have loving feelings)
7. Sense of a foreshortened future (i.e. does not expect to have a career, marriage, children, or a normal lifespan).
The patient attempts to reduce the possibility of exposure to anything that might trigger memories of the trauma, and to minimize his or her reactions to such memories. This cluster of symptoms includes feeling disconnected from other people, psychic numbing, and avoidance of places, people, or things associated with the trauma. Note that patients with PTSD are at increased risk of substance abuse as a form of self-medication to numb distress and painful memories, or to feel alive and engaged in life/to counter flat affect (McFall et al., 1992; Breslau et al., 1997; Kilpatrick et al., 2003; Brady and Sinha, 2005).
The individual who experiences emotional numbing may not be able to experience feelings of love, joy, humor, or pleasure considered appropriate to significant relationships, activities, or experiences which previously elicited positive emotions. Some would describe this emotional experience as "feeling bad" or their range of emotional experience being restricted. They may feel like a spectator or experience a sense of unreality. Estrangements can result from the experience that others cannot understand what they have lived through. For example, when an individual makes an effort to explain their experience to others who are not able to understand they may experience increased feelings of alienation or isolation (Rothchild, 2007).
Lindauer et al. (2006) reports studies of the psychophysiological aspects of PTSD in which patients provoked by script-driven imagery reacted with heightened physiological responses and commensurate increases in autonomic and muscular activity. This physiological reactivity on exposure to external or internal cues resembles an aspect of the traumatic event, and they often develop into points of avoidance. Wald and Taylor (2005) state that physiological sensations that commonly occur shortly after a traumatic experience such as extreme hyperarousal (palpitations, shortness of breath, dizziness, etc.) may take the form of (symptoms) posttraumatic panic attacks. As a result, these sensations, become cues to avoid. It is worth noting that avoidance is not always a maladaptive response; for example, where avoidance cues are associated with potential danger.
CATEGORY D: HYPERAROUSAL
Persistent symptoms of increased arousal (not experienced prior to 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
5. Exaggerated startle response.
Hyperarousal is a condition in which the patient's nervous system is always on alert for the return of danger. This symptom cluster includes hypervigilance, insomnia, difficulty concentrating, general irritability, and an extreme startle response. Some clinicians believe that this abnormally intense startle response may be the most characteristic symptom of PTSD (Levine, 1998; Rothchild, 2000).
Excerpted from Therapist's Guide to Posttraumatic Stress Disorder Intervention by SHARON L. JOHNSON Copyright © 2009 by Elsevier Inc. . Excerpted by permission of Academic Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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