Post Traumatic Stress Disorder

(Expanded version of an article first published in the November 1995 issue of For the Defense, the monthly journal of the Defense Research Institute, Chicago, Illinois.)

Partial Reprint of a 1996 article on PTSD   “ legalese”

Stressing The Point: When is a Post Traumatic Stress Disorder Claim Legitimate… and When Is It Not

PTSD is a condition that arises from exposure to life-threatening circumstances and it was first diagnoses among some of the survivors of wartime combat. Throughout W.W.I the syndrome was known as "Shell Shock" and was thought to be primarily motivated by the soldier's effort at self preservation. In World War II it was called "War Neurosis" or "Combat Fatigue." The modern diagnosis of PTSD, a by-product of the Viet Nam War, falls within the general DSM-IV category of "Anxiety Disorders," sub-category of "Stress Disorders." Listed below are the DSM-IV's diagnostic criteria for PTSD, followed by my detailed discussion of these criteria.

PTSD is a Discreet Phenomenon, not a Continuum

Like pregnancy, PTSD is defined as something one has or does not have: for medical-legal purposes, there are no "shades of PTSD gray" (even though in actuality and in some current research, the condition is viewed more in terms of a gradient of symptoms). Medical-legally, however, one is either in or out of the diagnosis, according to whether or not the individual fulfills the six specific, detailed criteria, the so-called "A-F" criteria.

b>The "A" Criteria, the Event: A Threshold Concept

In a nutshell, the "A" criteria require an individual to have been exposed to a life-threatening circumstance. Earlier incarnations of the DSM used a broad and overly inclusive yardstick, "outside of the range of normal human experience," but this criterion was considered too loose and was easily abused in its interpretation. With the recent publication of DSM-IV , the "A" criteria have been tightened considerably. The new wording requires that "the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death (emphasis added) ." Even the secondary phrase, "or serious injury, or a threat to the physical integrity of self or others" implies a grave degree of bodily threat. It was the intention of the DSM-IV subcommittee to tighten the "A" criteria so that it conformed more closely to the kind of actual life-threatening circumstances, such as combat, where PTSD was first observed. In essence, the trauma must be sufficiently severe that it ruptures a person's "bubble of invulnerability." Most of the time people avoid thinking about the possibility of death in order to carry on their daily lives without constant, high levels of anxiety.

b>The Re-Experiencing or "B" Criteria

PTSD victims re-experience the trauma over and over and over again, in a variety of different ways. This results from the psyche's effort to "master" overwhelming perceptual stimuli. The event is revisited repeatedly in an effort to manage and eventually integrate the traumatic stimuli that originally overwhelmed the victim's psychological equilibrium. The "B" criteria include five different re-experiencing phenomena, any one of which is deemed sufficient to meet this diagnostic criterion.

Recurrent or 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

PTSD victims are never able to quite "forget" the event which traumatized them. They think/dream about it intermittently throughout their waking (and sleeping) hours and often feel persecuted by their inability to repress the recurrent distressing images.

Recurrent or Distressing Dreams of the Event.

Note: In Children there may be frightening dreams without recognizable content.

These recurrent images of the trauma intrude upon the victim's sleep in the form of disturbing dreams and nightmares. Unlike normal dreams, which utilize symbolism to conceal from consciousness the dreamer's actual life conflicts and concerns, PTSD dreams are often literal representations of the traumatic event. The starkly realistic presentation of the dreamer's traumatic experience reflects the psyche's inability to master, process and integrate these overwhelming stimuli, through the disguising processes of sublimation and symbol formation.

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.

The victim frequently feels a sense of deja vu as if reliving the experience, sometimes in the form of illusions or hallucinations, frequently when in physiologically altered states of consciousness such as those induced by alcohol, drugs or sleep. Young children may actually re-enact the traumatic events in their play behavior, alone or with others.

Intense Psychological Distress At Exposure To Internal Or External Cues That Symbolize Or Resemble An Aspect Of The Traumatic Event.

PTSD victims may experience extreme anxiety or even panic upon exposure to circumstances that either literally or symbolically remind them of the traumatic circumstances.

Physiological Reactivity On Exposure Or Internal Or External Cues That Symbolize Or Resemble An Aspect Of The Traumatic Event.

Traumatized Viet Nam War combat veterans, for example, frequently confuse their perceptions from ordinary experiences of every day life with those that date back to the traumatic event. For example, a traumatized combat veteran hearing an automobile muffler backfiring, may experience the sound as if it is wartime gunfire. Accordingly, the person may re-experience the full range of psycho-physiological responses known as "combat alert" (akin to "fight or flight reactions") as if he were back on the battlefield.

b>The Numbing And Avoidance Or "C" Criteria

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: As a psychological defense against being overwhelmed and feeling helpless, traumatized individuals are constantly oscillating between re-experiencing the trauma and trying to avoid it. Their efforts to avoid may take many forms, of which any three listed below fulfills the "C" criteria.

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Efforts To Avoid Thoughts, Feelings, Or Conversations Associated With The Trauma

An airline stewardess who was brutally raped and beaten in a hotel during a work related "layover," for several weeks told no one about the assault, not her fellow employees nor her family, and only admitted the assault when her grown daughter pressed her to explain why her mood was so different.

Efforts To Avoid Activities, Places Or People That Arouse Recollections Of The Trauma

Typically, someone who suffers from PTSD will avoid revisiting the site of the trauma. A young woman who was savagely beaten, kicked in the head, and believed she was going to be killed by hoodlums who assaulted her in the parking lot of a well known national restaurant chain, avoided ever revisiting not just the particular restaurant where the assault occurred but any other facility with the chain's name on it.

Inability To Recall An Important Aspect Of The Trauma

Not infrequently, a seriously traumatized person will be amnesic for particular events or periods of time during the trauma. They may say that their memory is like a stop-frame movie from which moments or extended periods of time are lost and the memory jumps from before to after the missing segments.

Markedly Diminished Interest Or Participation In Significant Activities

Another young woman who was beaten in the restaurant parking lot incident referred to above underwent a dramatic personality change following the assault: she was transformed from an outgoing, vivacious, independent and "feisty" young person, someone who performed publicly in an entertainment group, to a frightened, withdrawn, isolated girl who would not even leave her house to go food shopping without the protective companionship of family members. In her withdrawn state, she gained fifty pounds, creating an additional "buffer zone" around herself that shielded her from the outside world.

Feeling Of Detachment Or Estrangement From Others

More than simple detachment or loneliness, PTSD victims tend to experience themselves as "outside looking in," as though they are no longer a part of life's events but are beyond a transparent barrier, restricted to the role of an observer.

Restricted Range Of Affect (e.g., Unable To Have Loving Feelings)

It is very common for those suffering from PTSD to suddenly lose the ability to experience strong feelings, for example an inability to love or to care about others who are dear to them. This disconnectedness can seriously damage marital, parent-child or workplace relationships.

Sense Of Foreshortened Future (e.g., Does Not Expect To Have A Career, Marriage, Children, Or A Normal Life Span)

Not infrequently, people with PTSD no longer think of themselves as having a future. This is not the same as having suicidal feelings, since the victim has neither the plan nor the intention of killing himself. Rather, these thoughts result from the sudden rupture of their "bubble of invulnerability." Having experienced a close encounter with death, it's ever presence can no longer be effectively denied. PTSD victims may simply resign themselves to the belief that sooner rather than later, life will end.

b>Symptoms Of Increased Arousal, The "D" Criteria

Due to the effects of adrenaline directly upon the central nervous system, PTSD is always associated with signs of increased arousal (not present before the trauma) as indicated by two (or more) of the following:

Difficulty Falling Or Staying Asleep

Sleep disturbances usually begin immediately after the trauma, although in some cases upsetting dreams may not occur for days, weeks or even months. Typically, the PTSD patient has difficulty falling asleep or staying asleep, fearing that something terrible may again happen to them if they relax their guard against sleep. Instead of sleeping, they remain alert. One traumatized woman compromised between her conflicting impulses to remain awake and needing sleep by setting her alarm clock to awaken her every two hours, throughout the night, in order to inspect all the rooms of her house and reassure herself that no intruders were present. Soon, however, she awakened throughout the night at two hourly intervals before the alarm sounded. This practice continued for years after the trauma.

Irritability Or Outbursts Of Anger

Irritability and sometimes rapid fluctuations of mood occur with most people who suffer from this disorder. Sometimes it is experienced as "waves of emotion" that cause the PTSD patient to rapidly shift between focused attention and tearfulness. At other times, tempers are short and the victim "snaps" angrily and inappropriately at friends, family or colleagues. This lability of mood is worsened by the ingestion of alcohol or intoxicating drugs.

Difficulty Concentrating

Typically, PTSD patients have difficulty reading. If they can read, it is only for very brief intervals, or only illustrated magazines. Even watching television, although easier than reading, may be marked by lapses of attention and difficulty staying focused. The attention difficulties are likely to be the result of intrusive thoughts or images that both distract attention and increase feelings of anxiety. The entire process feels "out of control" which, in a self reinforcing manner, further increases anxiety and decreases attention.

Hypervigilance

Hypervigilance, or the state of being in extreme alert, is partially driven by the central nervous system's response to increased adrenaline and partially by the confusion of perceptions described above as the re-experiencing or "B" criteria.

Exaggerated Startle Response

This is also a symptom of the physiologically stimulated central nervous system anticipating further frightening experiences , similar to the original overwhelming trauma. In certain natural catastrophes, such as earthquakes, victims are repeatedly re-traumatized for days or weeks as aftershocks recur. Marked anxiety results in brisk physiological reflex responses including an exaggerated startle response. One individual originally traumatized by the San Francisco Loma Prieta Earthquake of 1989 and subsequently by aftershocks, eventually developed large reactions to shocks of even minute magnitude. Eventually, his nervous system was so tense in anticipation of the possibility of another large quake that he remained in a state of high alert: he startled easily, and his feet left the ground if anyone closed a door behind him or made a noise unexpectedly.

b>The Duration Or "E" Criterion

The duration of the disturbance (i.e. the symptoms in criteria b,c and d) lasts longer than one month. This is a somewhat arbitrary criterion. However, its purpose is to distinguish between brief, transient stress response reactions (called in the DSM-IV Acute Stress Disorder) and the more serious, lasting, Post-Traumatic Stress Disorder. Nevertheless, for practical clinical purposes, if a psychiatrist or other mental health professional strongly suspects a diagnosis of PTSD because of the enormity of the trauma and the presence of sufficient B,C and D criteria symptoms, it would be irrational and medically inappropriate to delay treatment for 30 days until the duration criterion had been fulfilled, especially since the best recoveries from PTSD occur when therapeutic measures are introduced early. For litigation purposes, however, "premature" PTSD diagnoses can be attacked when they are applied to symptoms that have not lasted for a minimum of one month. Often these are Acute Stress Reactions that will resolve spontaneously within a short time.

b>Clinically Significant Distress Or Impairment In Social, Occupational Or Other Important Areas Of Functioning, The "F" Criterion

The "F" criterion means that simply fulfilling the "A - E" criteria is not, in itself, enough to make the diagnosis of PTSD. In addition, the condition must cause clinically significant distress or impairment in social, occupational or other important areas of functioning. Of course, "clinically significant" is a broad concept that is subject to a wide range of interpretations based upon the examining clinician's experience and judgment. However, the individual's family, work, school and social lives are explored in detail to determine if this criterion is met. For practical purposes, it is difficult to conceive of a situation in which the Event Criterion is met and the "B - F" criteria are adequately met and the individual does not demonstrate clinically significant distress or functional impairment in these other areas of their life. If a claimant shows no significant impairment of functioning in work, social or family life, it is highly unlikely that they are suffering from genuine PTSD.

Acute, Chronic Or Delayed Onset

Finally, the PTSD diagnosis requires a specification of "Acute" (if the duration of symptoms is less than three months), "Chronic" (if the duration of symptoms is three months or more), or "Delayed Onset" (if the onset of symptoms is at least six months after the stressor).

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