The purpose of this entry is to give an overview of the diagnosis of Posttraumatic Stress (PTSD). A mental health diagnosis is ideally made by a mental health professional through some combination of a clinical interview, assessment, and sometimes, over the course of treatment as the clinician may need more data and experience with the person to make a diagnosis.
The purpose of what follows is for psychoeducation not self-diagnosis; to give a framework, a standardized language to describe the ways in which trauma seems to affect people. Not everyone who experiences trauma develops PTSD.
PTSD, was not an official diagnosis in the Diagnostic & Statistical Manual of Mental Disorders (DSM) until 1980. The development and inclusion of the disorder was largely due to the activist efforts of Vietnam veterans in the 1970s. Previous incantations of PTSD were linked to war and combat and included: “shell shock”; “ battle fatigue”; “ war neurosis”; and perhaps the most poetic, from the American Civil War, “soldier’s heart.”
According to Allan Young, “The origins of the PTSD diagnosis are inextricably connected with the lives of American veterans of the Vietnam War, with their experience as combatants and later, as patients of the Veterans Administration (VA) Medical System” (1995). My own experience with PTSD is also inextricably linked to my training and employment at the VA since 2002.
From a feminist, historical analysis, one could argue that it took a substantive group of men to suffer with the effects of traumatic stress to receive the attention it deserved, despite a long-standing history of women suffering with similar symptoms from traumatic stress due to physical and sexual abuse , assault, and violence.
PTSD is currently classified as an Anxiety Disorder along with Panic Disorder, Agoraphobia, Specific Phobias, Obsessive Compulsive Disorder, and Generalized Anxiety Disorder. It is not uncommon for someone diagnosed with PTSD to have features of these other Anxiety Disorders.
The Diagnostic Criteria for PTSD in the DSM-IV-TR begins with the person being exposed to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and, the person’s response involved intense fear, helplessness, or horror. Sometimes these emotional responses are delayed, or perhaps not consciously present at the time of the traumatic event.
The diagnosis then moves into three clusters of symptoms:
A. And so the person was exposed to a traumatic event and that event is over, but it continues to haunt the person in the present in a specific range of ways, day and night, grouped under the rubric of persistent reexperiencing symptoms.
My own annotations are in the [bracketed sentences].
1. Recurrent and intrusive distressing recollection of the event, including images, thoughts, or perceptions [These intrusive distressing recollections come and go as they please and can make the person feel like they are not in control of their own mind, that they are going crazy].
2. Recurrent distressing dreams of the event [Nightmares are defined as dreams that involve anxiety and terror. They can be highly disruptive, distressing, disorienting, and are often thematically animated by feelings of fear, helplessness, or horror. Nightmares can also include tossing and thrashing and acting out dreams physically in one’s sleep].
3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those occur on awakening or when intoxicated) [Flashbacks involve a certain dissociation, disruption of reality, and can at times appear psychotic].
4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event [Triggers can come from inside the person’s body or mind, or in the external world through the various senses, smell seems especially powerful].
5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event [So not only psychological distress but physical, somatic reactivity, which can manifest in tension, trouble breathing, light headedness, sweating, tingling sensations, increased heart-rate, vomiting, and/or gastrointestinal issues].
B. The second cluster of symptoms, the avoidance symptoms, I have come to view as the person’s best efforts to cope with the traumatic event and the reexeperiencing symptoms. These symptoms are characterized by avoidance, numbing, and restriction of one’s engagement with the world, others, and themselves.
1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma [Don’t want to think about it, talk about it, be reminded of it, it is best to bury it].
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma.
3. Inability to recall an important aspect of the trauma [Sometimes the trauma leads to dissociation, leading to poor memory of the traumatic events, missing sections of the memory].
4. Markedly diminished interest or participation in significant activities [This symptom has a certain resonance with depression’s loss of interest in significant activities].
5. Feeling of detachment or estrangement from others [The person can feel disconnected from others even in their presence, feel unable to connect, feel like an alien, like a pane of glass is between them and the world of others].
6. Restricted range of affect (e.g. unable to have loving feelings). [Intimacy can feel overwhelming, vulnerable, risky; love can be difficult to express and give as well as receive from others].
7. Sense of forshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span). [There is a struggle living day-to-day, future plans feel ephemeral or irrelevant; there is sometimes a sense that they will die early due to illness, violence, or suicide].
C. The last cluster of persistent symptoms grouped under the arousal symptoms, are often the most prominent presenting concerns of patients presenting for care.
1. Difficulty falling or staying asleep [Perhaps one of the most debilitating symptoms, chronic sleep disturbance].
2. Irritability or outbursts of anger [Persistent trouble with anger from irritability to homicidal rage; anger often escalates swiftly, automatically; problems with aggression and violence].
3. Difficulty concentrating [Persistent problems with attention, focus, comprehension, short-term memory, often generates significant frustration in day-to-day life].
4. Hypervigilance [Always on guard, scanning, assessing, a persistent sense of danger, at times obsessive checking to make sure doors and windows are locked, uneasy in crowded places, and if one goes to a restaurant, prefers to sit with back against a wall].
5. Exaggerated startle response [An exaggerated mental and physical reactivity to sudden and loud noises, being surprised from behind or being awoken from sleep].
It is also defined that the duration of the symptoms is more than 1 month and causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
In the current proposed revisions of the PTSD diagnosis for the DSM-V, with a publication date of May 2013, they moved PTSD out of Anxiety Disorders and created a new classification, Trauma- and Stressor –Related Disorders; expanded the ways in which a person can be exposed to trauma; reorganized the symptom clusters; and, added 4 symptoms which expand and deepen the cognitive, emotional, and behavioral dimensions of the disorder:
1. Persistent and exaggerated negative beliefs of expectations about oneself, others, or the world (e.g. “I am bad,” “No one can be trusted, “The world is completely dangerous,”” I’ve lost my soul forever”).
2. Persistent, distorted blame of self or others about the cause or consequences of the traumatic event.
3. Persistent negative emotional state (e.g. fear, horror, anger, guilt, or shame).
4. Reckless or self-destructive behavior.
My own approach to the treatment of trauma usually begins with psychoeducation about common reactions to trauma, and I often use the PTSD diagnosis as part of that process; using the diagnostic framework for the person to begin to talk about their own experience with trauma and the effects of trauma. Often, it gives the person a language to talk about their subjective experiences, a language they may not yet have to put words to their individual suffering.
In a future blog entry I will discuss the limitations of this diagnosis and the categorical approach and discuss several alternative perspectives to thinking about PTSD and the effects of traumatic stress.