One does not have to be a soldier, or visit a refugee camp in Syria or the Congo, to encounter trauma. Trauma happens to our friends, our families, and our neighbors.
B.A. Van Der Kolk, 2014
The Body Keeps the Score
Clinical symptoms of PTSD typically appear within the first three months of a traumatic event, but in some cases may appear months or years later. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders, such as generalized anxiety disorder, panic disorder, or social anxiety disorder.
Everyone experiences stress and trauma throughout life; however, when the stressful event interferes with normal daily function and relationships, it becomes identified as PTSD, which requires treatment to restore the ability to adapt and cope.
Clinical Presentation of PTSD
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), symptoms of PTSD are grouped into four categories:
- Intrusion Symptoms (formerly called re-experiencing symptoms)
- Intrusive thoughts
- Emotional distress after exposure to traumatic reminders
- Physical reactivity to traumatic reminders
- Avoidance Symptoms (avoiding trauma-related stimuli)
- Trauma-related thoughts or feelings
- Trauma-related reminders
- Negative Alterations in Cognition and Mood (negative thoughts or feelings that began or worsened after the trauma)
- Inability to recall key features of the trauma
- Overly negative thoughts and assumptions about oneself or the world
- Exaggerated blame of self or others for causing the trauma
- Negative or flat affect
- Decreased interest in activities
- Feeling isolated
- Difficulty experiencing positive affect
- Alterations in Arousal and Reactivity (trauma-related arousal and reactivity and reactivity that began or worsened after the trauma)
- Irritability or aggression
- Risk or destructive behaviors
- Heightened startle reaction
- Difficulty concentrating
- Difficulty sleeping
Criteria for Diagnosis of PTSD
A diagnosis of PTSD is based on criteria established by the American Psychiatric Association. These criteria were revised in 2013 and appear in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). They are included in a new category: Trauma-and Stressor-Related Disorders, which involves exposure to a traumatic or stressful event and include reactive attachment disorder, acute stress disorder, adjustment disorders, and post traumatic stress disorders. All of the conditions included in this classification require exposure to a traumatic or stressful event as a diagnostic criterion.
To be diagnosed with PTSD, DSM-5 criteria require that:
- The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):
- Direct exposure
- Witnessing the trauma
- Learning that a relative or close friend was exposed to a trauma
- Indirect exposure to aversive details of the trauma, usually in the course of professional duties (eg, first responders, medics)
- Symptoms last for more than 1 month
- Symptoms create distress or functional impairment (eg, social, occupational)
- Symptoms are not due to medication, substance use, or other illness
In addition to meeting criteria for the PTSD diagnosis, an individual who experiences high levels of the following in reaction to a trauma-related stimuli may have the diagnosis further differentiated:
- Depersonalization: Experience of being an outside observer of or detached from oneself (eg, feeling as if “this is not happening to me” or one were in a dream)
- Derealization: Experience of unreality, distance, or distortion (eg, “things are not real”)
- Delayed specification: Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately
Risk Factors for PTSD
Each day’s news media makes us all witnesses to trauma somewhere in the world. The images are graphic and disturbing. All too often, trauma and violence become personal, putting anyone at risk for PTSD.
Factors that increase risk for PTSD include:
- Living through dangerous events and traumas
- Being physically injured
- Seeing another person hurt or killed
- Adult memories of childhood trauma
- Feeling horror, helplessness, or extreme fear
- Receiving little or no social support after the event
- Dealing with extra stress after the event, such as unexpected loss of a loved one, pain and injury, or loss of a job or home
- Having a history of mental illness or lapses in perception of reality
- Substance abuse
Risk Reducers for PTSD
Resilience factors that may reduce the risk of PTSD include:
- Seeking support from other people, such as friends, family, and community
- Finding a support group after a traumatic event
- Learning to feel good about one’s own actions in the face of danger
- Having a positive coping strategy, or a way of getting through the bad event and learning from it
- Being able to act and respond effectively despite feeling fear (NIMH, 2016)
Test Your Knowledge
Which of the following is NOT a clinical presentation of PTSD?
- Difficulty sleeping and eating.
- Frequent infections and fatigue.
- Nightmares and flashbacks.
- Negative or flat affect and depression.
Apply Your Knowledge
Q: How do the clinical manifestations differ between PTSD and depression?
A: Although people with PTSD may manifest with depression, the etiology of PTSD comes from a traumatic event or stressor. PTSD may cause depression but depression does not cause PTSD.