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National Center for Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder: An Overview

by Matthew J. Friedman, M.D., Ph.D.,
Executive Director, National Center for PTSD
Professor of Psychiatry and Pharmacology, Dartmouth Medical School

The risk of exposure to trauma has been a part of the human condition since we have evolved as a species. Attacks by saber tooth tigers or twentieth century terrorists have probably produced similar psychological sequelae in the survivors of such violence. Shakespeare's Henry IV appears to have met many, if not all, of the diagnostic criteria for post-traumatic stress disorder (PTSD), as have other heroes and heroines throughout the world's literature.

In 1980, the American Psychiatric Association added PTSD to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Although a controversial diagnosis, PTSD filled an important gap in psychiatric theory and practice. The significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual (i.e., the traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). The key to understanding the scientific basis and clinical expression of PTSD is the concept of "trauma."

In its initial DSM-III formulation, a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience. The framers of the original PTSD diagnosis had in mind events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters and human-made disasters. They considered traumatic events as clearly different from the very painful stressors that constitute the normal fluctuations of life such as divorce, failure, rejection, serious illness, and the like. (By this logic, adverse psychological responses to such "ordinary stressors" would, in DSM-III terms, be characterized as Adjustment Disorders rather than PTSD.) This division between traumatic and other stressors was based on the assumption that although most individuals have the ability to cope with ordinary stress, their adaptive capacities are likely to be overwhelmed when confronted by a traumatic stressor.

PTSD is unique among other psychiatric diagnoses because of the great importance placed upon the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion" where he or she has been exposed to an historical traumatic event. Clinical experience with the PTSD diagnosis has shown there are individual differences regarding the capacity to cope with catastrophic stress. While some people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have prompted a recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Like pain, the traumatic experience is filtered through mental and emotional processes before it can be appraised as an extreme threat. Because of individual differences in this evaluation process, different people appear to have different trauma thresholds, some more protected and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations. It must be emphasized that exposure to events such as rape, torture, genocide, and severe war zone stress, are experienced as traumatic events by nearly everyone.

Diagnostic criteria for PTSD include a history of exposure to a "traumatic event" and symptoms from each of three symptom clusters: unwelcome memories, avoidant/numbing symptoms and hyperarousal symptoms. A fifth criterion concerns duration of symptoms. One important finding is that it is relatively common. Recent data indicate PTSD prevalence rates are 5% and 10% respectively among American men and women (Kessler et al, 1996).

As noted above the "A" stressor criterion specifies that a person has been exposed to a catastrophic event involving actual or threatened death or injury, or a threat to the physical dignity of him/herself or others. During this traumatic exposure, the survivor's personal response was marked by intense fear, helplessness or horror.

The "B" or uninvited remembering criterion includes symptoms that are perhaps the most distinctive and readily identifiable. For individuals with PTSD, the traumatic event remains, sometimes for decades or a lifetime, a dominating psychological experience that keeps its power to cause panic, terror, dread, grief, or despair as seen in daytime fantasies, traumatic nightmares, and psychotic re-enactments known as PTSD flashbacks. Furthermore, traumamimetic stimuli that trigger recollections of the original event have the power to evoke mental images, emotional responses, and psychological reactions associated with the trauma. Researchers can reproduce PTSD symptoms in the laboratory by exposing affected individuals to auditory or visual traumamimetic triggers (Keane, et. al., 1987).

The "C" or avoidant/numbing criterion consists of symptoms showing behavioral, cognitive, or emotional strategies by which patients attempt to reduce the likelihood they will either expose themselves to traumamimetic events, or if exposed, will minimize the intensity of their psychological response. Behavioral strategies include avoiding any situation in which they perceive a risk of confronting such an event. In its most extreme manifestation, avoidant behavior may superficially resemble agoraphobia because the PTSD individual is afraid to leave the house for fear of confronting reminders of the traumatic event(s). Dissociation and psychological amnesia are included among avoidant/numbing symptoms. Finally, since individuals with PTSD cannot tolerate strong emotions, especially those associated with the traumatic experience, they separate the rational from the emotional aspects of psychological experience and perceive only the former. Such "psychic numbing" is an emotional anesthesia that makes it extremely difficult for people with PTSD to participate in meaningful interpersonal relationships.

Symptoms included in the "D" or hyperarousal criterion most closely resemble those seen in panic and generalized anxiety disorder. Whereas symptoms such as hypervigilance and startle are more unique. The hypervigilance may sometimes become so intense as to appear like frank paranoia. The startle response has a unique neurobiological substrate and may actually be the most pathognomonic symptom (Friedman, 1991,).

The "E" or duration criterion specifies how long symptoms must persist in order to qualify for the (chronic or delayed) PTSD diagnosis. In DSM-III-R the duration is one month.

The new "F" or significance criterion specifies that the survivor must experience significant social, occupational, or other distress as a result of these symptoms.

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 an increase of the acoustic-startle eye-blink reflex, a reducer pattern of auditory caused cortical potentials, and sleep abnormalities. Neuropharmacologic and neuroendocrine abnormalities have been detected in the noradrenergic, hypothalamic-pituitary-adrenocortical, and endogenous opioid systems.

Longitudinal research has shown that PTSD can become a chronic psychiatric disorder that 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 a delayed variant of PTSD in which individuals exposed to a traumatic event do not exhibit the PTSD syndrome until months or years afterwards. Usually, the immediate precipitant is a situation that resembles the original trauma in a significant way; (for example, 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-IV criteria for one or more additional diagnoses (Kulka, et. al., 1990; Davidson & Foa, 1993). Most often these co-morbid 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 co-morbidity seen with PTSD is a token of our current decision rules for making the PTSD diagnosis. In any case, high rates of co-morbidity complicate treatment decisions concerning patients with PTSD since the clinician must decide whether to treat the co-morbid disorders together or sequentially.

Although PTSD continues to be classified as an Anxiety Disorder, areas of disagreement about its medical science and phenomenology remain. Questions about the syndrome itself include: what is the clinical course of untreated PTSD; are there different 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 (1992) 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 that emphasizes: multiple symptoms, excessive somatization, dissociation, changes in affect, pathological changes in relationships and pathological changes in identity.

PTSD has also been criticized from the perspective of cross-cultural psychology and medical anthropology, because it has usually been diagnosed by clinicians from Western industrialized nations working with patients from a similar background. Major gaps remain in our understanding of the effects of ethnicity and culture on the clinical phenomenology of post-traumatic syndromes. We have only just begun to apply vigorous ethnocultural research strategies to delineate possible differences between Western and non-Western societies regarding the psychological impact of traumatic exposure and the clinical manifestations of such exposure (Marsella, et. al., 1996).

Before closing, it is necessary to discuss treatment. The most successful interventions are those implemented immediately after a civilian disaster or war zone trauma. This is often referred to as critical incident stress debriefing (CISD) or some variant of that term. It is clear that the best outcomes are obtained when the trauma survivor receives CISD within hours or days of exposure. Such interventions not only lessen the acute response to trauma but often forestall the later development of PTSD.

Results with chronic PTSD patients are often less successful. Perhaps the best therapeutic option for mild-to-moderately affected PTSD patients is group therapy. In such a setting the PTSD patient can discuss traumatic memories, PTSD symptoms and functional deficits with others who have had similar experiences. This approach has been most successful with war veterans, rape/incest victims and natural disaster survivors. For many severely affected patients with chronic PTSD a number of treatment options are available (often offered in combination) such as psychodynamic psychotherapy, behavioral therapy (direct therapeutic exposure) and pharmacotherapy. Results have been mixed and few well-controlled therapeutic trials have been published to date. It is important that therapeutic goals be realistic because in some cases, PTSD is a chronic and severely debilitating psychiatric disorder resistant to current available treatments. The hope remains that our growing knowledge about PTSD will enable us to design more effective interventions for all patients afflicted with this disorder.

This page was last updated on 27 March 1997 by the National Center for PTSD. For more information send email to ptsd@dartmouth.edu

Anxiety Disorders

Anxiety is as much a part of life as eating and sleeping. Under the right circumstances, anxiety is beneficial. It heightens alertness and readies the body for action. Faced with an unfamiliar challenge, a person is often spurred by anxiety to prepare for the upcoming event. For example, many people practice speeches and study for tests as a result of mild anxiety. Likewise, anxiety or fear and the urge to flee are a protection from danger.

Fears are not normal, however, when they become overwhelming and interfere with daily living. They are symptoms of an anxiety disorder, the most common and most successfully treated form of mental illness.

As a group, anxiety disorders afflict nearly nine percent of Americans during any six-month period. Symptoms can be so severe that patients are almost totally disabled--too terrified to leave their homes, to enter the elevator that takes them to their offices, to attend parties or to shop for food.

"Anxiety" is a word so commonly used that many people don't understand what it means in mental health care. Complicating matters, is the fact that "anxiety" and fear are often used to describe the same thing. When the word "anxiety" is used to discuss a group of mental illnesses, it refers to an unpleasant and overriding mental tension that has no apparent identifiable cause. Fear, on the other hand, causes mental tension due to a specific, external reason, such as when your car skids out of control on ice.

Post-Traumatic Stress Disorder (PTSD)

Often associated with war veterans, post-traumatic stress disorder can occur in anyone who has experienced a severe and unusual physical or mental trauma. People who have witnessed a mid-air collision or survived a life-threatening crime may develop this illness. The severity of the disorder increases if the trauma was unanticipated. For that reason, not all war veterans develop PTSD, despite prolonged and brutal combat. Soldiers expect a certain amount of violence. Rape victims, however, are unsuspecting of the attack on their lives.

People who suffer from PTSD re-experience the event that traumatized them through:

1) Nightmares, night terrors or flashbacks of the event. In rare cases, the person falls into a temporary dislocation from reality in which he or she relives the trauma. This can last for seconds or days.

2) "Psychic numbing," or emotional anesthesia(loss of bodily sensation with or without loss of consciousness). Victims have decreased interest in or involvement with people or activities they once enjoyed.

3) Excessive alertness and highly sharpened startle reaction. A car backfiring may cause people once subjected to gunfire to instinctively drop to the ground.

4) General anxiety, depression, inability to sleep, poor memory, difficulty concentrating or completing tasks, survivor's guilt.

Theories About Causes:

Probably no single situation or condition causes anxiety disorders. Rather, physical and environmental triggers may combine to create a particular anxiety illness.

Psychoanalytic theory suggests that anxiety stems from unconscious conflicts that arose from discomfort during infancy or childhood. For example, a person may carry the unconscious conflict of sexual feelings toward the parent of the opposite sex. Or the person may have developed problems from experiencing an illness, fright or other emotionally laden event as a child. By this theory, anxiety can be resolved by identifying and resolving the unconscious conflict. The symptoms that symbolize the conflict would then disappear.

Learning theory says that anxiety is a learned behavior that can be unlearned. People who feel uncomfortable in a given situation or near a certain object will begin to avoid it. However, such avoidance can limit a patient's ability to live a normal life.

More recently, research has indicated that biochemical imbalances are culprits. Many scientists say all thoughts and feelings result from complex electrochemical interactions in the central nervous system. Moreover, some studies indicate that infusions of certain biochemicals can cause a panic attack in some people. According to this theory, treatment of anxiety should correct these biochemical imbalances. Although medications first come to mind with this theory, remember that studies have found biochemical changes can occur as a result of emotional, psychological or behavioral changes.

Treatments

Generally, anxiety disorders are treated by a combination approach. Phobias and obsessive-compulsive disorders often are treated by behavior therapy. This involves exposing the patient to the feared object or situation under controlled circumstances, until the fear is cured or significantly reduced. Successfully treated with this method, many phobia patients have long-term recovery.

Medications are effective treatments, sometimes used alone and often in combination with behavior therapy or other psychotherapy techniques. In addition to behavior modification techniques and medication, talking issues out in psychotherapy can be crucial.

There is good reason for optimism about treatment of even the most severe anxiety disorders. Research indicates that 65 percent of the phobic and obsessive-compulsive patients who can cooperate with the therapist and conscientiously follow instructions will recover with behavior therapy. Studies have shown that while they are taking the medications, 70 percent of the patients who suffer from panic attacks improve. Medication is effective for about half of those suffering from obsessive-compulsive disorder.

Post-Traumatic Stress Disorder (PTSD)

Although the understanding of post-traumatic stress disorder is based primarily on studies of trauma in adults, PTSD also occurs in children as well. It is known that traumatic occurrences--sexual or physical abuse, loss of parents, the disaster of war--often have a profound impact on the lives of children. In addition to PTSD symptoms, children may develop learning disabilities and problems with attention and memory. They may become anxious or clinging, and may also abuse themselves or others.

Symptoms

The symptoms of PTSD may initially seem to be part of a normal response to an overwhelming experience. Only if those symptoms persist beyond three months do we speak of them being part of a disorder. Sometimes the disorder surfaces months or even years later. Psychiatrists categorize PTSD's symptoms in three categories: intrusive symptoms, avoidant symptoms, and symptoms of hyperarousal.

Intrusive Symptoms

Often people suffering from PTSD have an episode where the traumatic event "intrudes" into their current life. This can happen in sudden, vivid memories that are accompanied by painful emotions. Sometimes the trauma is "re-experienced." This is called a flashback - a recollection that is so strong that the individual thinks he or she is actually experiencing the trauma again or seeing it unfold before his or her eyes. In traumatized children, this reliving of the trauma often occurs in the form of repetitive play.

At times, the re-experiencing occurs in nightmares. In young children, distressing dreams of the traumatic event may evolve into generalized nightmares of monsters, of rescuing others or of threats to self or others.

At times, the re-experience comes as a sudden, painful onslaught of emotions that seem to have no cause. These emotions are often of grief that brings tears, fear or anger. Individuals say these emotional experiences occur repeatedly, much like memories or dreams about the traumatic event.

Symptoms of Avoidance

Another set of symptoms involves what is called avoidance phenomena. This affects the person's relationships with others, because he or she often avoids close emotional ties with family, colleagues and friends. The person feels numb, has diminished emotions and can complete only routine, mechanical activities. When the symptoms of "re-experiencing" occur, people seem to spend their energies on suppressing the flood of emotions. Often, they are incapable of mustering the necessary energy to respond appropriately to their environment:

PTSD Diagnosis and Treatment for Mental Health Clinicians

by Matthew J. Friedman, M.D., Ph.D.
Executive Director, National Center for PTSD
Professor of Psychiatry and Pharmacology, Dartmouth Medical School

Abstract

This article focuses on four issues: PTSD assessment, treatment approaches, therapist issues, and current controversies. Important assessment issues include the trauma history, comorbid disorders, and chronicity of PTSD. Effective intervention for acute trauma usually requires a variant of critical incident stress debriefing. Available treatments for chronic PTSD include group, cognitive-behavioral, psychodynamic, and pharmacological therapy. Therapist self-care is essential when working with PTSD patients since this work may be functionally disruptive and psychologically destabilizing. Current controversies include advocacy vs. therapeutic neutrality, eye movement desensitization and reprocessing (EMDR), the so-called false memory syndrome, and the legitimacy of complex PTSD as a unique diagnostic entity.

Originally published in Community Mental Health Journal 32(2): 173-189, (April 1996).

Making the Diagnosis

The switch from DSM-III-R (American Psychiatric Association, 1987) to DSM-IV (American Psychiatric Association, 1994) will bring few changes in the diagnostic criteria for PTSD. The stressor criterion (A1) will no longer characterize trauma as outside the range of normal human experience since we have been forced to recognize that exposure to catastrophic stress is an unwelcome but not unusual aspect of the human condition. Furthermore, the stressor criterion (A2) now requires that in addition to exposure, the patient need also have an intense emotional reaction to the traumatic event such as panic, terror, grief, or disgust.

PTSD patients are stuck in time and are continually re-exposed to the traumatic event through daytime memories that persistently interrupt ongoing thoughts, actions, or feelings. They are assaulted by terrifying nightmares that awaken them and make them afraid to go back to sleep. They cannot tolerate any reminders of the trauma since these often trigger intense fear, anxiety, guilt, rage, or disgust. In some cases, they suffer PTSD flashbacks, psychotic episodes in which reality dissolves and they are plunged back into the apparent reality of a traumatic event that has haunted them for years or decades. During such episodes they find themselves fighting off rapists, being attacked by enemies, or fleeing from explosions with the same intense feelings they experienced during the initial trauma. Such intrusive recollections (Criterion B) can persist for over 50 years (Schnurr, 1992) and may get worse, rather than better, with time (Archibald and Tuddenham, 1965).

PTSD patients develop avoidant/numbing symptoms (Criterion C) to ward off the intolerable emotions and memories recurrently stirred up by these intrusive recollections. Sometimes they develop dissociative or amnestic symptoms which buffer them from painful feelings and recollections. They also adopt obsessional defenses and other behavioral strategies such as drug and alcohol abuse, eating disorders, sexual acting out and workaholism, to ward off intrusive recollections.

Finally, PTSD patients suffer from autonomic hyperarousal (Criterion D). Such symptoms include insomnia, irritability that may progress to rage, agitation and jumpiness manifested by an exaggerated startle response, and hypervigilence that may become indistinguishable from frank paranoia. PTSD patients are always on guard, dedicated to avoiding ever being re-exposed to the terrifying circumstances that changed their lives forever. It is difficult for them to trust other people or the environment. The need for safety and protection may outweigh all other considerations including intimacy, socialization and other pleasurable pursuits.

In other words, the clinician attempting to engage the PTSD patient in treatment is asking the patient to take a tremendous risk. S/he is asking the patient to give up all the protective behaviors and psychological strategies that have emerged to ward off intrusive recollections and hyperarousal symptoms. Therefore, the therapist must recognize that assessment and treatment are potentially destabilizing. Therapy can only succeed in an environment of sensitivity, trust, and safety (Herman 1992). Therapists must recognize that it may take a long time for patients to shed the many layers of protective symptoms that have evolved over countless years since the trauma. It is important for the therapist to let the patient know as soon as possible that s/he recognizes that the prospect of therapy is frightening and painful. It is also important that therapists suppress their own need to get a trauma history as soon as possible and set a pace that the patient can tolerate.

Some patients may be so relieved that they finally have an opportunity to discuss long-suppressed, painful, and possibly shameful past events, that they cannot wait to review such material with a therapist. A second group may be equally motivated but may appear resistant because of fears that therapy will stir up intolerable feelings. They require the safety mentioned earlier. A third group may have sought treatment for depression, anxiety, chemical dependency, eating disorders, somatic complaints, or adjustment disorders rather than for PTSD. Indeed, among cohorts of treatment seeking PTSD patients, up to 80% have at least one additional psychiatric diagnosis including affective disorders (26-65%), anxiety disorders (30-60%), alcoholism or drug abuse (60-80%), or personality disorders (40-60%) (Friedman, 1990; Jordan, et al., 1991; Kulka, et al., 1990). For such patients, PTSD sometimes emerges as a diagnostic possibility only after the clinician has obtained a careful trauma history as part of a comprehensive assessment. Finally, there is a group of difficult patients who present, because of disruptive or self-destructive behaviors and who initially appear to suffer primarily from a personality disorder. Patients in this latter category may be adult survivors of protracted childhood sexual abuse whose trauma history may be obscured by DSM-III-R labels such as borderline personality disorder (BPD), multiple personality disorder (MPD), and somatoform disorder. In addition to PTSD symptoms, they often present with problems of affect regulation, impulsive behavior, dissociative symptoms, problems of trust, inappropriate sexual behavior, and a wide variety of somatic complaints (Herman, 1992). These latter problems may demand the lion's share of therapy. Treatment of these patients may be further complicated by fragmented thought processes, incomplete memories, and dissociative symptoms.

The trauma history is essential. Given high rates of co-morbidity mentioned earlier, and given a significant amount of overlap between symptoms seen in PTSD, depres

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