Trauma: Posttraumatic Stress Disorder (PTSD)

Introduction

• This post is the second on trauma and focuses on posttraumatic stress disorder (PTSD).  The first post provided an a overview of trauma.
• I became interested in treating PTSD in 1991. I had heard a report that 75,000 American veterans of the War in Vietnam had committed suicide from the official end of the war in 1975 to 1991. The figure shocked me because it was much greater than 58,000, the official American military death toll from the war itself.
• As I started providing services for patients living with PTSD, I soon realized that most of my patients were not veterans. Instead they were civilian survivors of maltreatment at the hands, often literally, of parents, of other family members, of intimate partners, and of other trusted adults. Other patients had developed PTSD from motor vehicle accidents, crimes perpetrated by strangers, and wars in their residential areas. Still other patients were first responders, and, yes, many were military veterans.
• This post is based on my clinical experience of serving patients with PTSD.

What is posttraumatic stress disorder (PTSD)?

A mental condition

• sometimes occurring in persons who have experienced extreme, often catastrophic, challenges that have shattered two core beliefs: the ability to care for themselves and their certainty that the world is safe ((A recent patient told me: “I don’t trust anything – I have lost the ability to trust myself.”)) and
• having many other characteristics (listed directly below).
• It is important to note that:
  • PTSD is only one kind of adverse traumatic mental condition that can result from an extreme challenge, and
  • not all persons who experience extreme challenges develop PTSD.

What are some of the characteristics of PTSD?

• The traumatic reaction lasts more than 30 days.
• Unwanted, intrusive reexperiencing of the traumatic episode (e.g.., flashbacks, distressing dreams)
• Avoiding or attempting to avoid actual or similar environmental reminders of the challenge
• Attempting to avoid emotions associated with the traumatic experience (i.e., anxiety itself)
• Intense psychological and physical distress when avoiding reminders is not possible
• Withdrawing from emotional life, i.e., dissociation
• Isolating from social support systems
• Pervasive shame
• Marked weakening of the basic mental health abilities of mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. ((Some readers may recognize that these skills, along with dialectical thinking, make up the core of dialectical behavior therapy (DBT).
• Anniversary reactions

What is the DSM-5® and what does it say about PTSD?

• The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a publication of the American Psychiatric Association.
• The United States uses the DSM-5 exclusively as the official list of psychiatric disorders and their descriptions.
• The DSM-5 has rigid, enumerated lists of criteria for every listed disorder, and patients must meet a set number of criteria for their behavior to meet a diagnosis.

What are the DSM-5 criteria for PTSD? ((This list is only an incomplete summary of the DSM-5 criteria. Accurate diagnosis of PTSD requires a qualified mental health provider.))

• The DSM-5 specifically limits the diagnosis of PTSD to trauma resulting from three specific types of challenges: “Exposure to actual or threatened death, serious injury, or sexual violence….” ((DSM-5))
• Intrusive symptoms such as distressing memories, distressing dreams, flashbacks, emotional distress and/or physiological reactions to internal or environmental reminders of the original challenge
• Strong motivation to avoid any reminders of the original challenge
• Extremely negative evaluation of one’s personal abilities
• Belief that the world is overwhelmingly dangerous
• Increases or decreases in arousal and activity levels related to the unresolved trauma.
• The traumatic symptoms must last last longer than one month and “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” ((DSM-5.))

What is the ICD-10 and what does it say about PTSD?

• The ICD-10 Classification of Mental and Behavioural Disorders (ICD-10) is a publication of the World Health Organization (WHO).
• The DSM-5 is closely modeled on the ICD-10 (just as the DSM-IV was modeled on the ICD-9).
• Almost all mental health practitioners outside the United States use the ICD-10.
• Here is the ICD-10 diagnostic description for PTSD (F43.1): (PTSD) arises as a delayed and/or protracted response to a stressful event or situation (either short-or long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone (e.g. natural or man-made (sic) disaster, combat, serious accident, witnessing the violent death of others or being the victim of torture, terrorism, rape, or other crime).
• The ICD-10 then has several paragraphs highlighting possible symptoms without the enumerated list of the DSM-5. The ICD-10 has a more elastic feel for clinicians matching behavior to diagnoses. ((As with the DSM-5, all ICD-10 diagnoses including PTSD must be left to qualified mental health providers.))

Are the DSM-5 and the ICD-10 too restrictive?

• In my opinion they are too restrictive because challenges besides death, injury, and sexual violence can result in pervasive, debilitating traumatic reactions.
• The DSM-5 and the ICD-10 do recognize the traumatic reactions to other challenges and call them adjustment disorders.
• But adjustment disorders are “lightweight” diagnoses, and American insurance companies often limit paying for treatment.

What are some challenges besides death, injury, and sexual violence that can result in PTSD-like reactions?

• Being subjected to distant, rejecting, and self-absorbed parenting during childhood and adolescence
• Experiencing microaggressions based on externally imposed membership in a less privileged category of society
• Experiencing infidelity in an intimate relationship
• Loss of social status (through change of relationship status, job loss, financial setbacks, aging, etc.)

What is complex PTSD (C-PTSD)?

• C-PTSD is not included in the DSM-5 or the ICD-10.
• C-PTSD is a subset of PTSD characterized by the extreme severity of symptoms and/or the chronic reexperiencing.
• Hypothesis: The people most likely to be targeted for chronic adverse challenges are the members of society with the least access to political, financial, and cultural power.
• Recommendation for future editions of the DSM and ICD: Broaden the criteria for PTSD so that
  • more people who live with the condition can receive treatment and
  • societal practices that allow PTSD to develop in the first place can be highlighted and eliminated.

What are the risk factors for PTSD?

• Failure of self-soothing skills
• Failure of social support systems (e.g., family, ecclesiastical, school, business, and government) ((These two failures coincide with my view that self-soothing and peer relations are the two primary developmental goals for children and adolescents.))

Summary

• PTSD is an interaction between the degree of the challenge and the vulnerability of the person experiencing the challenge.
• Not all persons who experience extreme, even catastrophic, challenges will develop PTSD.
• Society plays an outsized role in setting up conditions conducive to individuals acquiring PTSD.
• Governments could do much more to pressure the other institutions of society (family, religion, school, and business) to promote a more inclusive society.
• PTSD is not the only possible outcome of a traumatic experience.
• PTSD is not always curable, but it is almost always treatable.

Good mental health,

Dr. Michael DeCaria

(The featured image is a pond at the International Center, an industrial park just west of the Salt Lake International Airport. Photograph by the author.)