Posttraumatic stress disorder

Definition

Acute and chronic psychological distress following traumatic events have long been recognized. The diagnostic criteria for posttraumatic stress disorders (PTSD), according to DSM-III.

PTSD is classified as either acute or chronic (or delayed). In the former, onset of symptoms begin within 6 months of the trauma, or the duration of the symptoms persist less than 6 months. In the latter, symptoms persist more than 6 months (chronic) or start more than 6 months after the trauma (delayed).

Etiology

Whether or not PTSD develops appears to depend upon the nature of the trauma, the characteristics of the individual, and the context in which these events take place. The trauma can be anticipated or not, acute or chronic, constant or repetitive, due to natural events (e.g., an earthquake) or malevolence (e.g., rape, child abuse, torture). PTSD can develop in individuals who were apparently healthy, successful, and well-adjusted prior to the traumatic experiences. Among the factors which influence the development of PTSD are (1) the extent to which the individual’s life-space is affected, (2) the duration of the impact, (3) the extent to which the individual perceives human malevolence behind the traumatic event (e.g., a fire attributed to arson will probably be more traumatic than one attributed to lightning), and (4) social isolation.

Epidemiology

It is difficult to gauge the extent of PTSD following a traumatic event because the studies that have been done have often followed subjects for only a short period of time, and the nature of the events is often so situation-specific. About 15 percent or more of the civilian population may experience mental distress severe enough to require treatment following a major natural disaster. For example, in a study that followed survivors of a shipboard tire for 31 to 51 years, one-third were found to be unable to return to sea because of psychological symptoms. Following extreme prolonged harsh conditions such as combat, prisoner-of-war camps, or Nazi death camps, a higher incidence of both acute and delayed FTSD is likely. Some evidence, based on follow-up of World War II veterans 20 years after the war, indicates an increasing incidence of new patients seeking psychiatric care for war-associated symptoms. The vicissitudes of normal aging may unmask a latent traumatic stress disorder.

Complications Anxiety, depression, alcoholism, drug abuse, impaired marital and occupational activities, and perhaps increased physical morbidity and mortality have been blamed on various forms of PTSD.

Differential

Diagnosis In adjustment disorder, symptoms such as reexperiencing the trauma are absent. Other considerations include major depressive disorder, generalized anxiety disorder, phobic disorder, organic mental disorders, and other conditions such as “compensation neurosis” and “postconcussion syndrome.”

Prophylaxis

Military experience suggests that PTSD can be prevented partially if soldiers are taught that a degree of fear and anxiety are normal concomitants of battle rather than signs of cowardice or mental illness. Furthermore, the development of chronic PTSD can often be prevented if the soldier with acute PTSD is seen close to the battle front under the principles of immediate treatment, expectancy of return to normal duties, and brevity of treatment contact.

Treatment

The treatment goals of PTSD are reduction of target symptoms, prevention of chronic disability, and occupational and social rehabilitation. An important therapeutic issue is the extent to which the victim of acute PTSD should be allowed to leave the traumatic situation, to regress, and to enjoy the secondary gains of the patient role. The caretakers’ unthinking natural sympathy, nurturing instincts, admiration, and, indeed, gratitude (for example, in the case of soldiers who are protecting the homeland) may be as detrimental as an unreasonably cynical, suspicious distrust of someone who is seen as trying to get attention and avoid responsibilities or hoping to collect money from the consequences of the traumatic experience. Successful treatment involves a combination of psychosocial support systems, psychotherapy, behavioral and conditioning techniques, and medications. Group therapy with others who have shared similar experiences may be beneficial.