The European Network for Traumatic StressTraining & Practice

www.tentsproject.eu

The diagnosis of Posttraumatic Stress Disorder (PTSD)

Ask Elklit, Denmark

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Glimpses of the history of trauma • ‘Railway spine’ (1866) was a diagnosis given

after railway accidents to describe emotional and personality impact

• Pierre Janet (1889) developed a dynamic understanding of trauma that is still valid

• Various wars gave name to ‘soldiers’ heart’, ‘shell shock’, ‘combat neurosis’, ‘KZ-syndrom’, ‘Vietnam syndrom’ etc.

• This knowledge disappeared in the years following the wars and was ‘reinvented’

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Horowitz (1976)

• In the book, ”Stress Response Syndrom”, Mardi Horowitz described what he saw as the core dynamics after a traumatic experience:

• A long-lasting oscilliation between intrusive reexperiences and denial/avoidance

• As Horowitz mainly worked with bereaved people, he paid little attention to arousal symptoms

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Split

EmotionsHyperstateParalysed

Perceptions

Cognitions

Actions

Model of the consciousness in shock

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Scenes in a fixed order

Amnesia for

Intervening details

Model of the perceptual condensation (”etching”) after trauma

Demografis

Personality Social group Life events

Traumatic event(situational factors)

Original shock / defence reflexes(dissociation)

Primary appraisal (cognitive-emotional)

Social support(secondaryvictimization)

Defence Coping (action possibilities)

Hypervigiilance

Avoidance

Intrusive recollections

Psychiatric syndromes(ASD, PTSD etc.)

Personality disorders /dysfunctional traits

Psycho-physiologicaldisorders

Social changes

Attribu-tions

Body state

*PLEASE ADD AN EXPLANANTION FOR TEACHERS:

The DSM-III (a)

• Before DSM-III, clinicians and scientists met and tried to find common ground in the symptoms of veterans, rape victims, and battered women.

• In 1980, the APA published the first version of PTSD with the three core symptom clusters

• Re-experiencing (”intrusive”)• Avoidance• Hypervigiliance (”arousal”)

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DSM-III (b)

• The clusters consist of items that are descriptive; so are the clusters and there are no expectations about the inherent dynamics as suggested by Horowitz

• The Hypervigiliance cluster is a substantial development and addition to the work of Horowitz acknowledging the psychosomatic aspects of experiencing an extreme and threatening situation

• Confer the Kardiner (1941) concept of trauma as a ”psychoneurosis”

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PTSD today (DSM-IV)

• The stressor criteria (both A1 and A2):

• A1 ”a life threatening situation, injury or threat to physical integrity”

• This can be direct exposure or indirect – witnessing events

• The subjective experience is what counts

• A2 The person reacts with fear or help-lessness

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Re-experiencing (1 symptom)

• 1) Recurrent thoughts or perceptions of the event

• 2) Recurrent dreams of the event

• 3) Acting or feeling as if the event were recurring (flashbacks)

• 4) Intense psychological distress and

• (5) physiological reactivity when exposed to cues resembling the event

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Avoidance 1 (3/7 symptoms)

• 1) Avoiding trauma thoughts and feelings

• 2) Avoiding activities, places, and people that remind of the trauma

• 3) Inability to recall important parts of trauma

• 4) Lack of interest in significant activities

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Avoidance 2

• 5) Feeling of detachment from others

• 6) Restricted affect (no loving feelings)

• 7) Sense of a foreshortened future• Note: The two first symptoms are conscious

efforts; 4-6 are called ’numbness’ (inability to express feelings and plan for a future). Symptoms not present before the trauma

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Hypervigiliance (2/5 symptoms)

1) Difficulties falling or staying asleep

2) Irritability or outburst of anger

3) Difficulty concentrating

4) Hypervigiliance*

5) Exaggerated startle response*Note: Symptoms not present before the trauma.

The three first may be considered less specific than the two last symptoms*

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Duration

• Duration of symptoms more than one month

• Acute PTSD (less than 3 months)

• Chronic (3 months or more)

• Delayed (if onset is at least 6 months after the trauma)

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Functional impairment

• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

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PTSD according to WHO

• In the ICD-10 diagnostic system, F 43.1 describes PTSD quite differently

• The stressor criterion is normative• ”exposed to an unusual threatening or

catastrophe stressor that in almost everyone would result in extensive and very distressing reactions”

• This downplays the traumas in everyday life

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ICD-10 (cont.)

• The re-experiencing symptoms corresponds to DSM-IV 2,3, and 4

• Avoidance demands one symptom

• Hypervigiliance is like DSM-IV (2/5 symptoms

• Amnesia can substitute the hypervigiliance symptoms

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ICD-10 (cont.)

• Duration: symptoms must be present before 6 months

• No functional impairment demands.

• The diagnosis can be given after a few days

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ICD-10 and DSM-IV compared

• Very little research has used the ICD-10• It is easier to get a PTSD diagnosis from

ICD-10 than from DSM-IV• There is little (35%) concordance between

diagnoses given by the two systems due to fewer demands in the ICD-10 avoidance clusters and lack of impairment criterion

• Epidemiological studies using ICD-10 reveal very few cases of PTSD

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Empirical analyses of PTSD

• No study has replicated the PTSD structure with the three symptom clusters

• Many have suggested that the avoidance group should be divided in conscious avoidance and numbing.

• Numbing seems to be closely associated with hypervigiliance where conscious avoidance is associated with re-experiencing

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Empirical analyses of PTSD - 2

• Recently, several have suggested that numbing symptoms together the non-specific hypervigiliance symptoms constitute a dysphoria factor not specific to PTSD

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Subclinical PTSD

• A large number of clients miss one symptom to get the full diagnosis

• They typically miss one avoidance symptom

• They are often described as having ’sub-syndromal’, ’partial’, or ’subclinical’ PTSD

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Subclinical PTSD - 2

• This group often requires clinical attention

• It is important to distinguish between those who once had PTSD and are now in partial remission and those never exceeded the full PTSD threshold

• For this group is important to consider the functional impairment criterion

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PTSD remission

• PTSD symptoms often decrease in the weeks and months following a trauma

• After three to six months a stabilisation (= little or no change) often comes about

• One third will recover fully

• One third will have a number of symptoms

• One third will become chronic cases

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PTSD and other disorders

• Having PTSD means that 4 out of 5 will have comorbid (= at the same time) disorders; the most common being:

• Anxiety (and phobias)

• Depression

• Somatoform disorders

• Alcohol and drug abuse

• Some also develop a personality disorder27