Keane and associates 10 , working with Vietnam war-zone Veterans, first developed both psychometric and psychophysiological assessment techniques that have proven to be both valid and reliable. These assessment techniques have been used in the epidemiological studies mentioned above and in other research protocols.
PTSD History and Overview
Neurobiological research indicates that PTSD may be associated with stable neurobiological alterations in both the central and autonomic nervous systems. Psychophysiological alterations associated with PTSD include hyperarousal of the sympathetic nervous system, increased sensitivity and augmentation of the acoustic-startle eye blink reflex, and sleep abnormalities. Neuropharmacological and neuroendocrine abnormalities have been detected in most brain mechanisms that have evolved for coping, adaptation, and preservation of the species.
These include the noradrenergic, hypothalamic-pituitary-adrenocortical, serotonergic, glutamatergic, thyroid, endogenous opioid, and other systems. Structural brain imaging suggests reduced volume of the hippocampus and anterior cingulate. Functional brain imaging suggests excessive amygdala activity and reduced activation of the prefrontal cortex and hippocampus.
ACST International, Anngwyn St. Just Ph. D. Traumatologist, Social Trauma
This information is reviewed extensively elsewhere Longitudinal research has shown that PTSD can become a chronic psychiatric disorder and can persist for decades and sometimes for a lifetime. Patients with chronic PTSD often exhibit a longitudinal course marked by remissions and relapses.
There is also a delayed variant of PTSD in which individuals exposed to a traumatic event do not exhibit the full PTSD syndrome until months or years afterward. DSM-IV 's "delayed onset" has been changed to "delayed expression" in DSM-5 to clarify that although full diagnostic criteria may not be met until at least 6 months after the trauma, the onset and expression of some symptoms may be immediate. Usually, the prompting precipitant is a situation that resembles the original trauma in a significant way for example, a war Veteran whose child is deployed to a war zone or a rape survivor who is sexually harassed or assaulted years later.
If an individual meets diagnostic criteria for PTSD, it is likely that he or she will meet DSM-5 criteria for one or more additional diagnoses Most often, these comorbid diagnoses include major affective disorders, dysthymia, alcohol or substance abuse disorders, anxiety disorders, or personality disorders. There is a legitimate question whether the high rate of diagnostic comorbidity seen with PTSD is an artifact of our current decision-making rules for the PTSD diagnosis since there are not exclusionary criteria in DSM In any case, high rates of comorbidity complicate treatment decisions concerning patients with PTSD since the clinician must decide whether to treat the comorbid disorders concurrently or sequentially.
PTSD is no longer considered an Anxiety Disorder but has been reclassified as a Trauma and Stressor-Related Disorder because it has a number of clinical presentations, as discussed previously. In addition, two new subtypes have been included in the DSM The Dissociative Subtype includes individuals who meet full PTSD criteria but also exhibit either depersonalization or derealization e.
Past trauma may haunt your future health
The Preschool Subtype applies to children six years old and younger; it has fewer symptoms especially in the "D" cluster because it is difficult for young children to report on their inner thoughts and feelings and also has lower symptom thresholds to meet full PTSD criteria.
Questions that remain about the syndrome itself include: what is the clinical course of untreated PTSD; are there other subtypes of PTSD; what is the distinction between traumatic simple phobia and PTSD; and what is the clinical phenomenology of prolonged and repeated trauma? With regard to the latter, Herman 14 has argued that the current PTSD formulation fails to characterize the major symptoms of PTSD commonly seen in victims of prolonged, repeated interpersonal violence such as domestic or sexual abuse and political torture. She has proposed an alternative diagnostic formulation, "complex PTSD," that emphasizes multiple symptoms, excessive somatization, dissociation, changes in affect, pathological changes in relationships, and pathological changes in identity.
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Although this formulation is attractive to clinicians dealing with individuals who have been repeatedly traumatized, scientific evidence in support of the complex PTSD formulation is sparse and inconsistent. It is possible that the Dissociative Subtype, which has firm scientific support, will prove to be the diagnostic subtype that incorporates many or all of the symptoms first described by Herman.
PTSD has also been criticized from the perspective of cross-cultural psychology and medical anthropology, especially with respect to refugees, asylum seekers, and political torture victims from non-Western regions.
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Some clinicians and researchers working with such survivors argue that since PTSD has usually been diagnosed by clinicians from Western industrialized nations working with patients from a similar background, the diagnosis does not accurately reflect the clinical picture of traumatized individuals from non-Western traditional societies and cultures.
It is clear however, that PTSD is a valid diagnosis cross-culturally On the other hand, there is substantial cross-cultural variation and the expression of PTSD may be different in different countries and cultural settings, even when DSM-5 diagnostic criteria are met The most successful interventions are cognitive-behavioral therapy CBT and medication.
Excellent results have been obtained with CBT approaches such as prolonged exposure therapy PE and Cognitive Processing Therapy CPT , especially with female victims of childhood or adult sexual trauma, military personnel and Veterans with war-related trauma, and survivors of serious motor vehicle accidents. Other antidepressants are also effective and promising results have recently been obtained with the alpha-1 adrenergic antagonist, prazosin A frequent therapeutic option for mildly to moderately affected PTSD patients is group therapy, although empirical support for this is sparse.
In such a setting, the PTSD patient can discuss traumatic memories, PTSD symptoms, and functional deficits with others who have had similar experiences. It is important that therapeutic goals be realistic because, in some cases, PTSD is a chronic, complex e. Resick, Nishith, and Griffin have shown however, that very good outcomes utilizing evidence-based Cognitive Processing Therapy CPT can be achieved, even with such complicated patients 19 ; and, more recently, group CPT has shown promising results A remarkable recent finding is the effectiveness of group CPT, adapted for illiteracy and risk of ongoing violence, with sexual trauma survivors in the Democratic Republic of Congo The hope remains, however, that our growing knowledge about PTSD will enable us to design other effective interventions for patients afflicted with this disorder.
There is great interest in rapid interventions for acutely traumatized individuals, especially with respect to civilian disasters, military deployments, and emergency personnel medical personnel, police, and firefighters. This has become a major policy and public health issue since the massive traumatization caused by the September 11 terrorist attacks on the World Trade Center, Hurricane Katrina, the Asian tsunami, the Haitian earthquake, the wars in Iraq and Afghanistan and other large-scale traumatic events.
Currently, there is controversy about which interventions work best during the immediate aftermath of a trauma. Research on critical incident stress debriefing CISD , an intervention used widely, has brought disappointing results with respect to its efficacy to attenuate posttraumatic distress or to forestall the later development of PTSD.
On the other hand, brief cognitive behavioral therapy has proved very effective in randomized clinical trials Friedman, M. Journal of Traumatic Stress, 26 , Brewin, C. Maercker, A.
Kilpatrick, D. Go To Patient Version. Veterans Crisis Line: Press 1. Complete Directory. If you are in crisis or having thoughts of suicide, visit VeteransCrisisLine. Quick Links. Share this page. How mental health organizations prioritize issues related to trauma policies and practices also varies widely. The reluctance of some organizations to embrace the trauma movement wholeheartedly is the result in part of a lingering fear of the accepted view until the s that the cold, withholding mother caused schizophrenia.
This painful past still resides in the psyche of many families who were blamed for the mental illnesses of their children, making them understandably wary of opening a door to trauma-based constructs that may feel unpleasantly familiar.
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Fortunately, there appears to be a growing recognition that trauma-informed practices are beneficial to their loved ones, especially in the prevention of re-traumatizing experiences in the healthcare system. She writes that few clinicians talk anymore about cold, rejecting mothers but they do talk about stress, trauma and culture. Increasingly, the valuable research is done not only in the laboratory but in the field, by epidemiologists and even anthropologists. A greater understanding of the universality of trauma only enhances the potential of ACEs research to fully realize that health revolution.
Thanks Jeff. You make a very good point Oh NO not "pretraumatic" events too! Made me think of Munch's The Scream. Thank you for the thoughtful review! If trauma is perceived as a universal human condition, will communities step up to support those in need? Home Blog If trauma is perceived as a universal human condition, will communities step up to support those in need?
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