Post-traumatic Stress Disorder (PTSD) (309.89)

Diagnostic and Statistical Manual of Mental Disorders (Third Edition - Revised)

DSM-III-R

Published by the American Psychiatric Association Washington, DC, 1987.

Extract:

Pages 247-251.

309.89 Post-traumatic Stress Disorder

The essential feature of this disorder is the development of characteristic symptoms following a psychologically distressing event that is outside the range of unusual human experience (i. e., outside the range of such common experience as simple bereavement, chronic illness, business losses, and marital conflict). The stressor producing this syndrome would be markedly stressing to almost anyone, and is usually experienced with intense fear, terror and helplessness. The characteristic symptoms involve reexperiencing the traumatic event, avoidance of stimuli associated with the event or numbing of general responsiveness, and increased arousal. The diagnosis is not made in the disturbance lasts less than one month.

The most common traumata involve either a serious threat to one's life or physical integrity; a serious threat or harm to one's children, spouse, or other close relatives and friends; sudden destruction of one's home or community; or seeing another person who has been, or is being, seriously injured or killed as the result of physical violence. In some cases the trauma may be learning about a serious threat or harm to a close friend or relative, e. g., that one's child has been kidnapped, tortured, or killed.

The trauma may be experienced alone (e. g., rape or assault) or in the company of groups of people (e. g., military combat). Stressor producing the disorder include natural disasters (e. g., floods, earthquakes) accidental disasters (e. g., car accidents with serious physical injury, airplane crashes, large fires, collapse of physical structures), or deliberately caused disasters (e. g. bombing, torture, death camps). Sometimes there is a comcomitant physical component of the trauma, which may even involve direct damage to the central nervous system (e.g., malnutrition, head injury). The disorder is apparently more severe and longer lasting when the stressor is of human design. The specific stressor and its severity should be recorded on Axis IV (p. 18).

The traumatic event may be experienced in a variety of ways. Commonly the person has recurrent and intrusive recollections of the event or recurrent distressing dreams during which the event is reexperienced. In rare instances there are dissociative states, lasting from a few seconds to several hours, or even days, during which components of the event are relived, and the person behaves as though experiencing the event at that moment. There is often intense psychological distress when the person is exposed to events that resemble an aspect of the traumatic event or than symbolize the traumatic event, such as anniversaries of the event.

In addition to the reexperiencing of the trauma, there is persistent avoidance of stimuli associated with it, or a numbing of general responsiveness that was not present before the trauma. The person commonly makes deliberate efforts to avoid thoughts or feelings about the traumatic event and about activities or situations that arouse recollections of it. This avoidance of reminders of the trauma may include psychogenic amnesia for an important aspect of the traumatic event.

Diminished responsiveness to the outside world, referred to as psychic numbness or emotional anesthesia, usually begins soon after the traumatic event. A person may complain of feeling detached or estranged from other people, that he or she has lost the ability to become interested in previously enjoyed activities, or that the ability to feel emotions of any type, especially those associated with intimacy, tenderness, and sexuality, is markedly decreased.

Persistent symptoms of increased arousal that were not present before the trauma include difficulty falling or staying asleep (recurrent nightmares during which the traumatic event is relived are sometimes accompanied by middle or terminal sleep disturbance), hypervigilance, and exaggerated startle response. Some complain of difficulty in concentrating or completing tasks. Many report changes in aggression. In mild cases this may take the form of irritability with fear of losing control.

In more severe forms, particularly in cases in which the survivor has actually committed acts of violence (as in war veterans), the fear is conscious and pervasive, and the reduced capacity for modulation may express itself in unpredictable explosions of aggressive behavior or an inability to express angry feelings.

Symptoms characteristic of Post-traumatic Stress Disorder, or physiologic reactivity, are often intensified or precipitated when the person is exposed to situations or activities that resemble or symbolize the original trauma (e.g., cold snowy weather or uniformed guards for survivors of death camps in cold climates; hot humid weather for veterans of the South Pacific).

Age-specific features. Occasionally, a child may be mute or refuse to discuss the trauma, but this should not be confused with inability to remember what occurred. In younger children, distressing dreams of the event may, within several weeks, change into generalized nightmares of monsters, of rescuing others, or of threats to self or others. Young children do not have the same sense that they are reliving the past; reliving the trauma occurs in action, though repetitive play.

Children may exhibit various physical symptoms, such as stomachaches and headaches, in addition to the specific symptoms of increased arousal noted above.

Associated features. Symptoms of depression and anxiety are common, and in some instances may be sufficiently severe to be diagnosed as an Anxiety or Depressive Disorder. Impulsive behavior can occur, such as suddenly changing place of residence, unexplained absences, or other changes in life-style. There may be symptoms of an Organic Mental Disorder, such as failing memory, difficulty in concentrating, emotional lability, headache, and vertigo. In the case of life-threatening trauma shared with others, survivors often describe painful guilt feelings about surviving when others did not, or about the things they had to do in order to survive.

Age of onset. The disorder can occur at any age, including during childhood.

Course and subtypes. Symptoms usually begin immediately or soon after the trauma. Reexperiencing symptoms may develop after a latency period of months or years following the trauma, though avoidance symptoms have usually been present during this period.

Impairment and complications. Impairment may be either mild or severe and affect nearly every aspect of life. Phobic avoidance of situations or activities resembling or symbolizing the original trauma may interfere with interpersonal relations such as marriage or family life. Emotional lability, depression, and guilt may result in self-defeating behavior or suicidal actions. Psychoactive Substance Abuse Disorders are common complications.

Predisposing factors. Several studies indicate that preexisting psychopathological conditions predispose to the development of this disorder. However, the disorder can develop in people without any such preexisting conditions, particularly if the stressor is extreme.

Prevalence, sex ratio, and familial pattern. No information.

Differential Diagnosis. If an Anxiety, Depressive, or Organic Mental Disorder develops following the trauma, the diagnoses should also be made. In Adjustment Disorder, the stressor is usually less severe and within the range of common experience; and the characteristic symptoms of Post-traumatic Stress Disorder, such as reexperiencing the trauma are absent.

DIAGNOSTIC CRITERIA FOR 309.89 POST-TRAUMATIC STRESS DISORDER.

1. The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e. g., serious threat to one's life or physical integrity; serious threat or harm to one's children, spouse, or other close relatives and friends; sudden destruction of one's home or community; or seeing another person who has been or is being, seriously injured or killed as the result of an accident or physical violence.
2. The traumatic event is persistently reexperienced in at least one of the following ways:
1. recurrent and intrusive disturbing recollections of the event (in young children, repetitive play in which themes or aspects of the trauma are expressed).
2. recurrent distressing dreams of the event
3. sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative [flashback] episodes, even those that occur upon awakening or when intoxicated)
4. intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma
3. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
1. efforts to avoid thoughts or feelings associated with the trauma
2. efforts to avoid activities or situations that arouse recollections of the trauma
3. inability to recall an important aspect of the trauma (psychogenic amnesia)
4. markedly diminished interest in significant activities (in young children loss of recently acquired developmental skills such as toilet training or language skills.
5. feeling of detachment or estrangement from others
6. restricted feeling of affect, e.g. unable to have loving feelings
7. sense of a foreshortened future, e. g. does not expect to have a career, marriage, or children, or a long life
4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:
1. difficulty falling or staying asleep
2. irritability or outbursts of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response
6. physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event (e.g., a woman who was raped in an elevator breaks out in a sweatwhen entering any elevator)

5. Duration of the disturbance (symptoms in B, C, and D of at least one month.

   Specify delayed onset if the onset of symptoms was at least six months after the trauma.

• Post-traumatic Stress Disorder. In: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. - revised. (DSM-III-R). American Psychiatric Association, Washington, 1987.

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