JAPA

June 2010

Post Traumatic Stress Disorder (PTSD): Part I

Partam Manalai, M.D.

One of the first things medical students learn is the concept of fight-or-flight. The term was suggested first by Walter B. Cannon in 1915 in his book Bodily changes in pain, hunger, fear and rage, an account of recent researches into the function of emotional excitement. He write that animals tend to fight when angered and escape when afraid. Humans do the same and fight-or-flight serves as a strong survival mechanism. The so-called fight-or-flight system is a complex system with several constituent elements (from endocrine to neurons to neuronal pathways to concerted behavioral response).

When someone (or an animal) is exposed to a danger, the person can respond in two ways. If there is immediate danger, the person uses evolutionary-wise older parts of the brain (e.g. amygdale). This response is at times termed “analog” response. There is little interpretation of the information by higher cortical structures in these conditions and the person or for that matter animal, either freezes or runs away. However, if the danger is not life threatening and doesn’t require reflexive response, humans and animals use neocortical areas of the brain to gauge their response. This is sometimes called “digital response” (the analog and digital terms have been borrowed from computational sciences).

During an acute stress, animals tend to be hypervigilant with increased sympathetic tone. Once the stress is over, the animal behavior returns to baseline. Sometimes in humans (and perhaps some animals), after a life threatening event, the psychophysiological status does not return to baseline. At time the so-called fight-or-flight response is altered dramatically and persistently by a life threatening event. Some people continue to experience stress related emotions in the absence of any acute stressors. This condition is termed posttraumatic stress disorder.

PTSD has been observed across the world and its incidence increases during and after major natural catastrophes, man-made disasters, and political and military conflicts. Considering Afghanistan’s recent history of 30-year-long war, logically the incidence of this disorder should be quite high. However, research is lacking on the incidence of the disorder due to nonconductive environment for research in the country. In a series of articles in next few editions, we will publish some introductory articles and diagnostic/therapeutic guidelines related to PTSD. In this issue I will suffice with DSM-IV-TR criteria for the disorder and a short historic background on the disorder.

DSM-IV-TR criteria for diagnosing PTSD

The diagnosis of posttraumatic disorder was included in the third edition of DSM in 1980. Table 1 shows the DSM-IV-TR diagnostic criteria and specifies of the disorder.

A. The person has been exposed to a traumatic event in which both of the following were present:
1. 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
2. the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
1. recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
2. recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
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 that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
4. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
5. physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. efforts to avoid activities, places, or people that arouse recollections of the trauma
3. inability to recall an important aspect of the trauma
4. markedly diminished interest or participation in significant activities
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving feelings)
7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
1. difficulty falling or staying asleep
2. irritability or outbursts of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

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

Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more

Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

Table 1. DSM-IV-TR Diagnostic criteria for PTSD

History:

As with many other psychiatric disorders, the diagnosis of PTSD has remained controversial since its inclusion in DSM-III. Since first systematic explorations of clusters of symptoms now called PTSD, political and scientific communities have questioned validity of this disorder. There are clearly, however, groups of people in whom the stress response system malfunctions dramatically as a result of exposure to extreme stressors. Although no apparent histological and anatomical changes are seen in the brain, severe traumatic experiences (at time single experience) affect individual’s emotional status, functional capacity, interpersonal and occupational functioning in long run. In this article we will summarize the historical data on the concepts and terminology leading to the clinical entity of PTSD.

For centuries, humans have observed changes in behavior in response to life-threatening events. Ancient Civilizations have written about psychological consequences of exposure to wars. Herodotus noted several cases of war related psychological trauma. He described a case of victim of suicide who could not bear the shame of being called “trembler” after psychological breakdown in a war.

In 1976 Hoffer wrote: “the disease is due essentially to a disordered imagination, whereby the part of the brain chiefly affected is that part in which the images… are located. This is the inner part of the brain where the vital spirits constantly surge back and forth through the nerve fibers in which the impressions… are stored. Once the vital spirits have made a path for themselves and widened it they find it easier, as in sleep, to take the same path again and again” (quoted from van der Koll et al.)

During the First World War (WWI), massive numbers of soldiers were exposed to repeated blasts for the first time in human history. There were large numbers of soldiers with head injuries. Some of them continued to have puzzling symptoms (amnesia, concentration problems, noise hypersensitivity, tremor, tinnitus and vertigo-like systems) after the head injury had healed. These soldiers were considered to suffer from “shell Shock”. To make matter worse for British army psychiatrists, there were groups of soldiers who did not have apparent head injury and experienced similar symptoms. Later, a group of soldiers with these symptoms puzzled neuropsyciatists even more. These soldiers had not been exposed to any head injury. Initially thought to ensue from “comotio cerebri”, the term “shell shock” became a controversy and was banned from use by the British at the end of WWI.

Although the use of the term “shell shock” was discouraged by British government as WWI came to a closure, the patients continued to bewilder psychiatrist and neurologists with their symptoms. For instance, in London, after psychotherapy a man could remember his being blown away by a blast that he had “forgotten about” (amnesia for the event). In 1939 the terms “psottrauma concussion state” and “posttrauma psychoneurotic state” were coined by Schaller in order to classify the patients presenting with post traumatic symptomatology. The anxiety and hypervigilance that was seen in some soldiers during and after WWII were considered defective character and cowardice on part the soldiers than a result of traumatic experience. With controversies associated with Vietnam War (VW), large numbers of soldiers were exposed to war trauma with a moral dilemma about the war. With the physical and psychological stresses they experience during VW, many soldiers suffered from symptoms of stress induced psychological problems. Eventually the diagnosis of Post-traumatic Stress disorder was suggested in 1970s. After its inclusion in DSM-III, it became apparent that a significant number of individuals suffer from the syndrome. Not only soldiers suffered from the syndrome, also civilian exposed to trauma (childhood abuse, rape, violence etc.) experience range of symptoms that war veterans had complained for centuries. The high prevalence of PTSD and popularization of the diagnosis, the spelling of the disorder also change. Now it is spelled as one word: Posttraumatic Stress Disorder. It is believed that over 8% of people in the United States suffer from the disorder. However, the diagnosis and political and economic consequences of PTSD still renders the diagnosis one of controversies in psychiatry.