PTSD in DSM 5 DSM-5 Criteria for PTSD In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders DSM!"# 1#$ The diagnostic criteria are s%ecified &elo'$ (ote that DSM!" introduced a %reschool su&ty%e of PTSD for children ages si) years and younger $ The criteria &elo' are s%ecific to adults, adolescents, and children older than si) years$ Diagnostic criteria for PTSD include a history of e)%osure to a traumatic event that meets s%ecific sti%ulations and sym%toms from each of four sym%tom clusters* intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity$ The si)th criterion concerns duration of sym%toms+ the seventh assesses functioning+ and, the eighth criterion clarifies sym%toms as not attri&uta&le to a su&stance or co!occurring medical condition$ T'o s%ecifications are noted including delayed e)%ression and a dissociative su&ty%e of PTSD, the latter of 'hich is ne' to DSM!"$ In &oth s%ecifications, the full diagnostic criteria for PTSD must &e met for a%%lication to &e 'arranted$
Criterion A: stressor The %erson 'as e)%osed to* death, threatened death, actual or threatened serious inury, or actual or threatened se)ual violence, as follo's* (one required) 1$
Direct e) e)%osure$
2$
-ittnessing, in -i in %e %erson$
3$
Indirectly Indir ectly,, &y learnin learning g that that a clos close e relativ relative e or clos close e friend friend 'as 'as e)%osed e)%osed to traum trauma$ a$ If the event involved actual or threatened death, it must have &een violent or accidental$
.$
/e%eated /e%ea ted or or e)trem e)treme e indirec indirectt e)%osure e)%osure to aversiv aversive e details details of the the events events#, #, usually usually in the the course course of %rofessional duties e$g$, first res%onders, collecting &ody %arts+ %rofessionals re%eatedly e)%osed to details of child a&use#$ This does not include indirect non!%rofessional e)%osure through electronic media, television, movies, or %ictures$
Criterion B: intrusion symptoms
The traumatic event is %ersistently re!e)%erienced in the follo'ing 'ays#* (one required) 1$
/ecurrent /ecur rent,, involunt involuntary ary,, and intrus intrusive ive memori memories$ es$ (ote* (ote* hil hildren dren older than si) may e)%re e)%ress ss this this sym%tom in re%etitive %lay$
2$
Traumati Tr aumatic c nightmar nightmares$ es$ (ote* (ote* hi hildren ldren may have have frigh frightenin tening g dreams dreams 'ith 'ithout out conten contentt related related to the the traumas#$
3$
Dissociat Diss ociative ive react reactions ions e$g e$g$, $, flash flash&acs# &acs# 'hic 'hich h may occur on a conti continuum nuum from &rie &rieff e%isodes e%isodes to com%lete loss of consciousness$ (ote* hildren may reenact the event in %lay$
.$
Intens Int ense e or %rol %rolong onged ed distr distress ess aft after er e)%o e)%osur sure e to tra trauma umatic tic rem remind inders ers$$
"$
Mared Mar ed %hys %hysiol iologi ogic c reacti reactivit vity y after after e)% e)%osu osure re to to traum trauma!r a!rela elated ted stim stimuli uli$$
Criterion C: avoidance Persistent effortful avoidance of distressing trauma!related stimuli after the event* (one required) 1$
Trau auma ma!r !rel elat ated ed tho thoug ught hts s or fe feel elin ings gs$$
2$
Trauma!r Tr auma!relat elated ed e)tern e)ternal al remind reminders ers e$g e$g$, $, %eo%le, %eo%le, %lace %laces, s, conver conversati sations, ons, activ activitie ities, s, o&ec o&ects, ts, or situations#$
Criterion D: negative alterations in cognitions cogni tions and mood (egative alterations in cognitions and mood that &egan or 'orsened after the traumatic event* (two required) 1$
Ina&ility Ina&i lity to recall recall ey featur features es of the trauma traumatic tic event usua usually lly disso dissociat ciative ive amnesi amnesia+ a+ not not due to head inury, alcohol, or drugs#$
2$
Persistent Persi stent and often disto distorted# rted# negat negative ive &elie &eliefs fs and and e)%ectat e)%ectations ions a&out onesel oneselff or the 'orld 'orld e$g e$g$, $, I am &ad, The 'orld is com%letely dangerous#$
3$
Persistent Persi stent dist distorted orted &lam &lame e of self or other others s for for causing causing the traum traumatic atic event or for for resul resulting ting conseuences$
.$
Persistent Persi stent negat negative ive traum trauma!rel a!related ated emoti emotions ons e$g$ e$g$,, fear, fear, horro horror, r, anger anger,, guilt guilt,, or shame# shame#$$
"$
Mared Mar edly ly dimin diminish ished ed inter interest est in in %re!t %re!trau raumat matic# ic# sign signifi ifican cantt activi activitie ties$ s$
4$
5eelin 5ee ling g alie alienat nated ed from from oth others ers e$ e$g$, g$, det detach achmen mentt or est estran rangem gement ent#$ #$
6$
onst on stric ricted ted aff affect ect** %ersis %ersisten tentt ina&il ina&ility ity to to e)%eri e)%erienc ence e %ositi %ositive ve emoti emotions ons$$
Criterion E: alterations in arousal and reactivity Trauma!related alterations in arousal and reactivity that &egan or 'orsened after the traumatic event* (two required) 1$
Irrrit Ir ita& a&le le or or aggr aggres essi siv ve &eha &ehav vio ior r
2$
Sellf! Se f!de dest stru ruct ctiv ive e or re rec cle less ss &e &eha havi vior or
The traumatic event is %ersistently re!e)%erienced in the follo'ing 'ays#* (one required) 1$
/ecurrent /ecur rent,, involunt involuntary ary,, and intrus intrusive ive memori memories$ es$ (ote* (ote* hil hildren dren older than si) may e)%re e)%ress ss this this sym%tom in re%etitive %lay$
2$
Traumati Tr aumatic c nightmar nightmares$ es$ (ote* (ote* hi hildren ldren may have have frigh frightenin tening g dreams dreams 'ith 'ithout out conten contentt related related to the the traumas#$
3$
Dissociat Diss ociative ive react reactions ions e$g e$g$, $, flash flash&acs# &acs# 'hic 'hich h may occur on a conti continuum nuum from &rie &rieff e%isodes e%isodes to com%lete loss of consciousness$ (ote* hildren may reenact the event in %lay$
.$
Intens Int ense e or %rol %rolong onged ed distr distress ess aft after er e)%o e)%osur sure e to tra trauma umatic tic rem remind inders ers$$
"$
Mared Mar ed %hys %hysiol iologi ogic c reacti reactivit vity y after after e)% e)%osu osure re to to traum trauma!r a!rela elated ted stim stimuli uli$$
Criterion C: avoidance Persistent effortful avoidance of distressing trauma!related stimuli after the event* (one required) 1$
Trau auma ma!r !rel elat ated ed tho thoug ught hts s or fe feel elin ings gs$$
2$
Trauma!r Tr auma!relat elated ed e)tern e)ternal al remind reminders ers e$g e$g$, $, %eo%le, %eo%le, %lace %laces, s, conver conversati sations, ons, activ activitie ities, s, o&ec o&ects, ts, or situations#$
Criterion D: negative alterations in cognitions cogni tions and mood (egative alterations in cognitions and mood that &egan or 'orsened after the traumatic event* (two required) 1$
Ina&ility Ina&i lity to recall recall ey featur features es of the trauma traumatic tic event usua usually lly disso dissociat ciative ive amnesi amnesia+ a+ not not due to head inury, alcohol, or drugs#$
2$
Persistent Persi stent and often disto distorted# rted# negat negative ive &elie &eliefs fs and and e)%ectat e)%ectations ions a&out onesel oneselff or the 'orld 'orld e$g e$g$, $, I am &ad, The 'orld is com%letely dangerous#$
3$
Persistent Persi stent dist distorted orted &lam &lame e of self or other others s for for causing causing the traum traumatic atic event or for for resul resulting ting conseuences$
.$
Persistent Persi stent negat negative ive traum trauma!rel a!related ated emoti emotions ons e$g$ e$g$,, fear, fear, horro horror, r, anger anger,, guilt guilt,, or shame# shame#$$
"$
Mared Mar edly ly dimin diminish ished ed inter interest est in in %re!t %re!trau raumat matic# ic# sign signifi ifican cantt activi activitie ties$ s$
4$
5eelin 5ee ling g alie alienat nated ed from from oth others ers e$ e$g$, g$, det detach achmen mentt or est estran rangem gement ent#$ #$
6$
onst on stric ricted ted aff affect ect** %ersis %ersisten tentt ina&il ina&ility ity to to e)%eri e)%erienc ence e %ositi %ositive ve emoti emotions ons$$
Criterion E: alterations in arousal and reactivity Trauma!related alterations in arousal and reactivity that &egan or 'orsened after the traumatic event* (two required) 1$
Irrrit Ir ita& a&le le or or aggr aggres essi siv ve &eha &ehav vio ior r
2$
Sellf! Se f!de dest stru ruct ctiv ive e or re rec cle less ss &e &eha havi vior or
3$
7y%ervigilance
.$
8)a )agg gger erat ated ed sta tarrtl tle e res res%o %ons nse e
"$
Pro&lems in in co concent ntrrat atiion
4$
Slee% distur&ance
Criterion : duration Persistence of sym%toms in riteria 9, , D, and 8# for more than one month$
Criterion !: functional significance Significant sym%tom!related distress or functional im%airment e$g$, social, occu%ational#$
Criterion ": e#clusion Distur&ance is not due to medication, su&stance use, or other illness$ Specify if : $it% dissociative symptoms&
In addition to meeting criteria for diagnosis, an individual e)%eriences high levels of either of the follo'ing in reaction to trauma!related stimuli* 1$
Depersonalization** e)%erience of &eing an outside o&server of or detached from oneself e$g$, Depersonalization feeling as if this is not ha%%ening to me or one 'ere in a dream#$
2$
Derealization** e)%erience of unreality, distance, or distortion e$g$, things are not real#$ Derealization
Specify if : $it% delayed e#pression&
5ull diagnosis is not met until at least si) months after the traumas#, although onset of sym%toms may occur immediately$
'eferences 1$
Amer Am eric ican an Ps Psyc ychi hiat atri ric c Ass ssoc ocia iati tion on$$ 2 2013 013## Diagnostic and statistical manual of mental disorders, disorders, "th ed$#$ -ashington, D* Author$
Dissociative Su(type of PTSD
/uth :anius, MD, PhD, Mar Miller, PhD, 8ria -olf, PhD, 9ethany 9rand, PhD, Paul 5re'en, PhD, 8ric ;ermetten, MD, PhD, < David S%iegel, MD The role of dissociation as the most direct defense against over'helming traumatic e)%erience 'as first documented in the seminal 'or of Pierre =anet$ /ecent research evaluating the relationshi% &et'een Posttraumatic Stress Disorder PTSD# and dissociation has suggested that there is a dissociative su&ty%e of PTSD, defined %rimarily &y sym%toms of dereali>ation i$e$, feeling as if the 'orld is not real# and de%ersonali>ation i$e$, feeling as if oneself is not real#$ onfrontation 'ith over'helming e)%erience from 'hich actual esca%e is not %ossi&le, such as childhood a&use, torture, as 'ell as 'ar trauma challenges the individual to find an esca%e from the e)ternal environment as 'ell as their internal distress and arousal 'hen no esca%e is %ossi&le$ States of de%ersonali>ation and dereali>ation %rovide striing e)am%les of ho' consciousness can &e altered to accommodate over'helming e)%erience that allo's the %erson to continue functioning under fierce conditions$ •
An ?out!of!&ody@ or depersonalization e)%erience during 'hich individuals often see themselves o&serving their o'n &ody from a&ove has the ca%acity to create the %erce%tion that ?this is not ha%%ening to me@ and is ty%ically accom%anied &y an attenuation of the emotional e)%erience$
•
Similarly, states of derealization derealization during during 'hich individuals e)%erience that ?things are not real+ it is ust a dream@ create the %erce%tion %erce%tion that ?this is not really ha%%ening to me@ and are often associated associated 'ith the e)%erience of decreased emotional intensity$
The addition of a dissociative su&ty%e to the PTSD diagnosis is e)%ected to further advance research e)amining the etiology, e%idemiology, neuro&iology, and treatment res%onse of this su&ty%e and facilitate the search for &iomarers of PTSD$
'ationale The recognition of a dissociative su&ty%e of PTSD as %art of the DSM-5 PTSD PTSD diagnosis 'as &ased on three converging lines of research* 1# sym%tom assessments, 2# treatment outcomes, and 3# %sycho&iological studies$ 8ven though dissociative sym%toms such as flash&acs and %sychogenic amnesia are included as %art of the core PTSD sym%toms, evidence suggests that a su&grou% of PTSD %atients e)hi&its additional sym%toms of dissociation, including de%ersonali>ation and dereali>ation, thus 'arranting a su&ty%e of PTSD s%ecifically focusing on these t'o sym%toms$ /ecogni>ing a dissociative su&ty%e
of PTSD has the %otential to im%rove the assessment and treatment outcome of PTSD$
Evidence The addition of a dissociative su&ty%e of PTSD in the u%coming DSM!" 'as &ased on three lines of evidence* 1$
Several Sever al studie studies s using using laten latentt class, class, ta)om ta)ometri etric, c, e%idem e%idemiolo iological gical,, and and confirm confirmatory atory fact factor or analyse analyses s conducted on PTSD sym%tom endorsements collected from ;eteran and civilian PTSD sam%les indicated that a su&grou% of individuals roughly 1" ! 30# suffering from PTSD re%orted sym%toms of de%ersonali>ation and dereali>ation 1!3#$ Individuals 'ith the dissociative su&ty%e 'ere more liely* to &e male, have e)%erienced re%eated traumati>ation and early adverse e)%eriences, have comor&id %sychiatric disorders, and evidenced greater suicidality and functional im%airment .#$ The su&ty%e also re%licated cross!culturally$ cross!culturally$
2$
(euro&iolo (euro &iological gical evide evidence nce sugge suggests sts de%er de%ersonal sonali>ati i>ation on and derea dereali>a li>ation tion res%o res%onses nses in PTS PTSD D are are distinct from re!e)%eriencingBhy%erarousal re!e)%eriencingBhy%erarousal reactivity$ reactivity$ Individuals 'ho re!e)%erienced their traumatic memory and sho'ed concomitant %sycho%hysiological hy%erarousal e)hi&ited reduced activation in the medial %refrontal! and the rostral anterior cingulate corte) and increased amygdala reactivity$ /eliving res%onses are, therefore, thought to &e mediated &y failure of %refrontal inhi&ition or to%! do'n control of lim&ic lim&ic regions$ In contrast, the grou% 'ho e)hi&ited e)hi&ited sym%toms of de%ersonali>ation de%ersonali>ation and dereali>ation sho'ed increased activation in the rostral anterior cingulate corte) and the medial %refrontal corte)$ De%ersonali>ationBdereali>ation De%ersonali>ationBdereali>ation res%onses are sug gested to &e mediated &y midline %refrontal inhi&ition of the lim&ic regions ",4#$
3$
8arly 8ar ly eviden evidence ce sugges suggests ts that that sym%tom sym%toms s of de%erso de%ersonal nali>a i>atio tion n and dereal dereali>a i>atio tion n in PTSD PTSD are relevant to treatment decisions in PTSD revie'ed in :anius et a l$, 2012+"#$ Individuals 'ith PTSD 'ho e)hi&ited sym%toms of de%ersonali>ation and dereali>ation tended to res%ond & etter to treatments that included cognitive restructuring and sills training in affective and inter%ersonal regulation in addition to e)%osure!&ased thera%ies 6,C#$ Additional research is needed to more fully evaluate the effects of de%ersonali>ation and dereali>ation on treatment res%onse$
Assessment The linician!Administered PTSD Scale APS# includes items assessing de%ersonali>ation 7ave there &een times 'hen you felt as if you 'ere outside of your &ody, 'atching yourself as if you 'ere another %erson# and dereali>ation 7ave there &een times 'hen things going on around you seemed unreal or very strange and unfamiliar#$ In addition, there are several self!re%ort rating scales that assess dissociative sym%tomatology$ These include the
Dissociative 8)%eriences Scale, the Multiscale Dissociation Inventory, the Traumatic Dissociation Scale, and the Stanford Acute Stress /eaction Euestionnaire$ Additional intervie's and scales s%ecific to the dissoci ative su&ty%e are currently under develo%ment$
Associated features and ris)s of t%e dissociative su(type As com%ared to individuals 'ith PTSD alone, %atients 'ith a diagnosis of the dissociative su&ty%e of PTSD sho'ed* •
/e%eated traumati>ation and early adverse e)%erience %rior to onset of PTSD
•
Increased %sychiatric comor&idity, in %articular s%ecific %ho&ia and &orderline and avoidant %ersonality disorders among 'omen, &ut not men
•
Increased functional im%airment
•
Increased suicidality including suicidal ideation, %lans, and attem%ts#
Treatment concerns Treatment studies s%ecifically designed to e)amine clinical outcomes of %sychological and %harmacological treatment of PTSD in those 'ith versus 'ithout the dissociative su&ty%e are needed$ 7o'ever, 'e do no' that individuals 'ith dissociative PTSD may reuire treatments designed to directly reduce de%ersonali>ation and dereali>ation$ 5or such individuals, e)%osure treatment can lead to further dissociation and inhi&ition of affective res%onse, rather than the goal of cognitive &ehaviouralBe)%osure thera%y, 'hich is desensiti>ation and cognitive restructuring$ There is %reliminary evidence that relative to e)%osure!&ased thera%ies alone, individuals 'ith PTSD 'ho e)hi&ited sym%toms of de%ersonali>ation and dereali>ation res%onded &etter to treatments that also included cognitive restructuring and sills training in affective and inter%ersonal regulation ",6,C#$ Author Note: Dr$ /uth :anius is a Professor of Psychiatry at -estern Fniversity of anada+ Drs$ Mar Miller and 8ria -olf are Psychologists at the (ational enter for PTSD at ;A 9oston 7ealthcare System+ Dr$ 9ethany 9rand is a Professor of Psychology at To'son Fniversity+ Dr$ Paul 5re'en is an Assistant Professor of Psychiatry at -estern Fniversity of anada+ Dr$ 8ric ;ermetten is the 7ead of /esearch Military Mental 7ealth, De%artment of Psychiatry, Fniversity Medical enter and /udolf Magnus Institute of (euroscience in Ftrecht+ Dr$ David S%iegel is Professor of Psychiatry at Stanford Fniversity$
'eferences
1$
Steu'e, $, :anius, /$ A$, < 5re'en, P$ A$ 2012#$ The role of dissociation in civilian %osttraumatic stress disorder* 8vidence for a dissociative su&ty%e &y latent class and confirmatory factor analysis$ Depression and Anxiety, 29,4CG!600$ doi* 10$1002Bda$21G..
2$
-olf, 8$ =$, :unney, $ A$, Miller, M$ -$, /esic, P$ A$, 5riedman, M$ =$, < Schnurr, P$ P$ 2012#$ The dissociative su&ty%e of PTSD* A re%lication and e)tension$ Depression and Anxiety, 29, 46G! 4CC$ doi* 10$1002Bda$21G.4
3$
-olf, 8$ =$, Miller, M$ -$, /eardon, A$ 5$, /ya&cheno, H$ A$, astillo, D$, < 5reund, /$ 2012#$ A latent class analysis of dissociation and %osttraumatic stress disorder* 8vidence for a dissociative su&ty%e$ /esearch Su%%ort, ($I$7$, 8)tramural /esearch Su%%ort, F$S$ JovKt, (on! P$7$S$L$ Archives of General sychiatry, !9, 4GC!60"$ doi* 10$1001Barchgen%sychiatry$2011$1"6.
.$
Stein, D$ =$, Hoenen, H$ $, 5riedman, M$ =$, 7ill, 8$, Mc:aughlin, H$ A$, Petuhova, M$, /uscio, A$ M$, Shahly, $, S%iegel, D$, 9orges, J$, 9unting, 9$, alsa!de!Almeida, =$ M$, de Jirolamo, J$, Demyttenaere, H$, 5lorescu, S$, 7aro, =$ M$, Haram, 8$ J$, Hovess!Masfety, ;$, :ee, S$, Matshinger, 7$, Mladenova, M$, Posada!;illa, =$, Tachimori, 7$, ;iana, M$ $, < Hessler, /$ $ 2013#$ Dissociation in posttraumatic stress disorder" #vidence from the $orld mental health surveys%, &', 302!312$ doi* 10$1014B$&io%sych$2012$0C$022
"$
:anius, /$ A$, 9rand, 9$, ;ermetten, 8$, 5re'en, P$ A$, < S%iegel, D$ 2012#$ The dissociative su&ty%e of %osttraumatic stress disorder* rationale, clinical and neuro&iological evidence, and im%lications$ Depression and Anxiety, 29, 1!C$ doi* 10$1002Bda$21CCG
4$
:anius, /$ A$, ;ermetten, 8$, :oe'enstein, /$ =$, 9rand, 9$, Schmahl, $, 9remner, =$ D$, < S%iegel, D$ 2010#$ 8motion modulation in PTSD* linical and neuro&iological evidence for a dissociative su&ty%e$ American (ournal of sychiatry, )!&, 4.0!4.6$ doi* 10$1164Ba%%i$a%$200G$0G0C114C
6$
loitre, M$, Petova, 8$, -ang, =$, < :u :assell, 5$ 2012#$ An e)amination of the influence of a seuential treatment on the course and im%act of dissociation among 'omen 'ith PTSD related to childhood a&use$Depression and Anxiety, 29, 60G!616$ doi* 10$1002Bda$21G20
C$
/esic, P$ A$, Suva, M$ H$, =ohnides, 9$ D$, Mitchell, H$ S$, < Iverson, H$ M$ 2012#$ The im%act of dissociation on PTSD treatment 'ith cognitive %rocessing thera%y$ Depression and Anxiety, 29, 61C!630$ doi* 10$1002Bda$21G3C
PTSD for C%ildren * +ears and +ounger
Michael Scheeringa, MD A challenge for the Diagnostic and Statistical Manual DSM# ta)onomy has al'ays &een to consider develo%mental differences in the e)%ressions of disorders in different age grou%s$ /esearch has suggested that individuals of different ages may e)%ress features of the same criteria some'hat differently$ 5urthermore, there may &e sufficient differences in the e)%ressions of some disorders to ustify an age!related su&ty%e of the disorder$ This is im%ortant to consider %articularly in Posttraumatic Stress Disorder PTSD# &ecause, although PTSD has &een 'idely re%orted in children and adolescents, the DSM!I; criteria 'ere develo%ed &efore su&stantial num&ers of studies had &een conducted on young children 1#$ The 5ifth 8dition of the DSM DSM!"# includes a ne' develo%mental su&ty%e of PTSD called Posttraumatic Stress Disorder in %reschool children$ As the first develo%mental su&ty%e of an e)isting disorder, this re%resents a significant ste% for the DSM ta)onomy$ Since an alternative diagnostic set of criteria 'as initially %ro%osed &y Michael Scheeringa and harles eanah 2#, the criteria have &een refined em%irically 3,.#, and endorsed &y a tas force of e)%erts on early childhood mental health "#$ -hile the &ul of the em%irical research that su%%orts this disorder 'as conducted on three! to si)!year!old %reschool children, the studies often included one! to t'o!year!old toddlers$ These studies sho'ed that 'hen a develo%mentally!sensitive set of criteria 'ere used a%%ro)imately three to eight times more children ualified for the diagnosis com%ared to the DSM!I; 3,4#$
$%at types of trauma do young c%ildren e#perience, Noung children are e)%osed to many ty%es of traumatic e)%eriences, %lacing them at ris for PTSD$ These include* •
A&use 6#
•
-itnessing inter%ersonal violence C#
•
Motor vehicle accidents G#
•
8)%eriences of natural disasters 10#
•
onditions of 'ar 11#
•
Dog &ites
•
Invasive medical %rocedures 12#
"o is t%e diagnosis different in presc%ool PTSD, 9ecause young children have emerging a&stract cognitive and ver&al e)%ression ca%acities, research has sho'n that the criteria need to &e more &ehaviorally anchored and develo%mentally sensitive to detect PTSD in %reschool children 2,13#$
Immediate reaction to traumatic event criterion The criterion that the childrenKs reactions at the time of the traumatic events sho'ed e)treme distress has &een deleted$ If children 'ere too young to ver&ali>e their acute reactions to traumatic e)%eriences, and there 'ere no adults %resent to 'itness their reactions, there 'as no feasi&le 'ay to no' a&out these reactions$ This criterion, 'hich has &een sho'n to lac %redictive validity for &oth adult 1.# and %reschool %o%ulations 4#, has also &een deleted for the regular PTSD criteria in DSM!"$
Intrusion symptoms The change to the re!e)%eriencing sym%toms is a relatively minor change in 'ording to increase face validity and, there&y, lo'er the sym%tom detection threshold$ The old sym%tom of recurrent and intrusive distressing recollections of the event $$$ reuired three conditions* 1# recurrent, 2# intrusive, and 3# distressing$ /esearch sho'ed em%irically that %reschool children do not al'ays manifest overt distress 'ith their intrusive, un'anted thoughts$ Some children 'ere neutral or over &right 2,13#$ -hile distressed reactions are common, %arents also commonly re%orted no affect or 'hat a%%eared to &e e)citement 4#$ 5urthermore, there 'ere no differences in PTSD severity for those 'ith overtly distressing recollections com%ared to those 'ho sho'ed other emotions 'ith their recollections$
Avoidance symptoms and negative alterations in cognitions and mood 9ecause many of the avoidance and negative cognition sym%toms are highly internali>ed %henomena, the most significant changes in the criteria for %reschool children are in this section$
The maor change 'as to reuire only one sym%tom in either the avoidance sym%toms or negative alterations in cognitions and mood, instead of the DSM!I; threshold of three sym%toms$ The num&er of these sym%toms that are %ossi&le to detect is sim%ly fe'er com%ared to adults$ The sym%toms of loss of interests, restricted range of affect, detachment from loved ones, and avoidance of thoughts or feelings related to the trauma manifest in young children &ut are consistently raned as some of the least freuent among the PTSD sym%toms 1"#$ The sym%toms of sense of a foreshortened future and ina&ility to recall an im%ortant as%ect of the event 'ere deleted &ecause of the develo%mental challenges in manifesting andBor detecting them$ The 'ording of t'o sym%toms 'as modified to enhance face validity and sym%tom detection$ Diminished interest in significant activities may manifest as constricted %lay$ 5eelings of detachment or estrangement may &e manifest more &ehaviorally as social 'ithdra'al$
Increased arousal symptoms 9eing the most &ehavioral and o&serva&le ty%es of sym%toms, fe' changes seem to &e needed for these %ro&lems$ The sym%toms irrita&ility or out&ursts of anger 'as modified to include e)treme tem%er tantrums to enhance face validity$
.alidation of presc%ool PTSD 8vidence su%%orts the criterion, convergent, discriminant, and %redictive validities of the %reschool PTSD criteria revie'ed in Scheeringa et al$, 2011+4#$ Perha%s most convincingly, even 'hen the threshold for the avoidance and num&ing criterion 'as lo'ered from three sym%toms to one sym%tom, the diagnosed cases 'ere still highly sym%tomatic, 'ith means of 4 to 10 sym%toms across studies$ Mared functional im%airment across a range of domains has also &een documented$ Pros%ective longitudinal studies have also documented the longer!term sta&ility of diagnoses and im%airment over time G,14,16#$
Assessment and treatment for presc%ool PTSD
Standardi>ed screening and assessment instruments have &een develo%ed for caregivers of this age grou%, 'ith &oth self!administered checlists and diagnostic intervie's revie'ed in 1C#$ 8vidence!&ased treatments for PTSD, such as cognitive &ehavioral thera%y, are effective 6,1G,20#$ A long!term, relationally!&ased treatment has sho'n effectiveness follo'ing inter%ersonal violence C#$ Play thera%y, eye movement desensiti>ation and re%rocessing 8MD/#, and other modalities may &e effective if the traumatic memories can &e engaged in develo%mentally!a%%ro%riate methods$ Author Note *
Dr$ Michael Scheeringa is the /emigio Jon>ale>, MD Professor of hild Psychiatry, Tulane Fniversity School of Medicine, (e' Orleans, :A$
'eferences 1$
Hil%atric, D$, /esnic, 7$, 5reedy, =$, Pelcovit>, D$, /esic, P$, /oth, S$, < van der Hol, 9$ 1GGC#$ Posttraumatic Stress Disorder 5ield Trial* 8valuation of the PTSD construct ! criteria A through 8$ In T$ -idiger, A$ 5rances, 7$ Pincus, /$ /oss, M$ 5irst, -$ Davis < M$ Hline 8ds$#, DSM*+ Sourceoo ;ol$ ., %%$ C03!C..#$ -ashington, D* American Psychiatric Association$
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Scheeringa, M$ S$, eanah, $ 7$, Drell, M$ =$, < :arrieu, =$ A$ 1GG"#$ T'o a%%roaches to the diagnosis of %osttraumatic stress disorder in infancy and early childhood$ (ournal of the American Academy of .hild and Adolescent sychiatry, '/ 2#, 1G1!200$ doi* 10$10G6B0000."C3!1GG"02000! 0001.
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Scheeringa, M$ S$, Myers, :$, Putnam, 5$ -$, < eanah, $ 7$ 2012#$ Diagnosing PTSD in early childhood* an em%irical assessment of four a%%roaches$ (ournal of 0raumatic Stress, 25 .#, 3"G! 346$
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Scheeringa, M$ S$, eanah, $ 7$, Myers, :$, < Putnam, 5$ -$ 2003#$ (e' findings on alternative criteria for PTSD in %reschool children$ (ournal of the American Academy of .hild and Adolescent sychiatry, /2 "#, "41!"60$ doi* 10$10G6B01$7I$00000.4C22$G".4.$1.$
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Tas 5orce on /esearch Diagnostic riteria* Infancy and Preschool$ 2003#$ /esearch diagnostic criteria for infants and %reschool children* The %rocess and em%irical su%%ort$ (ournal of the American Academy of .hild and Adolescent sychiatry, /2, 1"0.!1"12$
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Scheeringa, M$ S$, eanah, $ 7$, < ohen, =$ A$ 2011#$ PTSD in children and adolescents* To'ards an em%irically &ased algorithm$ Depression and Anxiety, 21 G#, 660!6C2$ 10$1002Bda$20634$
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ohen, =$, < Mannarino, A$ 1GG4#$ A treatment outcome study for se)ually a&used %reschool children* Initial findings$ (ournal of the American Academy of .hild and Adolescent sychiatry, '5, .2!"0$
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:ie&erman, A$, I%%en, $, < ;an 7orn, P$ 2004#$ hild!%arent %sychothera%y* 4!month follo'!u% of a randomi>ed controlled trial$ (ournal of the American Academy of .hild and Adolescent sychiatry, /5 C#, G13!G1C$ doi* 10$10G6B01$chi$00002226C.$0363"$G2
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Meiser!Stedman, /$, Smith, P$, Jlucsman, 8$, Nule, -$, < Dalgleish, T$ 200C#$ The %osttraumatic stress disorder diagnosis in %reschool! and elementary school!age children e)%osed to motor vehicle accidents$ American (ournal of sychiatry, )!5 10#, 1324!1336$ doi* 10$1164Ba%%i$a%$200C$060C12C2
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Scheeringa, M$ S$, < eanah, $ 7$ 200C#$ /econsideration of harmKs 'ay* Onsets and comor&idity %atterns in %reschool children and their caregivers follo'ing 7urricane Hatrina$ (ournal of .linical .hild and Adolescent sychology, '& 3#, "0C!"1C$
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:aor, ($, -olmer, :$, Mayes, :$ $, Jolom&, A$, Silver&erg, D$ S$, -ei>man, /$, < ohen, D$ =$ 1GG4#$ Israeli %reschoolers under Scud missile attacs$ Archives of General sychiatry, 5', .14! .23$
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De Noung, A$ $, Henardy, =$ A$, < o&ham, ;$ 8$ 2011#$ Diagnosis of %osttraumatic stress disorder in %reschool children$ (ournal of .linical .hild a nd Adolescent sychology, / 3#, 36"! 3C.$ doi* 10$10C0B1"36..14$2011$"43.6.
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Scheeringa, M$ S$, Pee&les, $ D$, oo, $ A$, < eanah, $ 7$ 2001#$ To'ard esta&lishing %rocedural, criterion, and discriminant validity for PTSD in early childhood$ (ournal of the American Academy of .hild and Adolescent sychiatry, / 1#, "2!40$ doi* 10$10G6B0000."C3!200101000! 00014
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5riedman, M$ =$, /esic, P$ A$, 9ryant, /$ A$, < 9re'in, $ /$ 2011#$ onsidering PTSD for DSM! "$ Depression and Anxiety, 21 G#, 6"0!64G$
1"$
Scheeringa, M$ S$ 2004#$ Posttraumatic stress disorder* linical guidelines and research findings$ In =$ :$ :u&y 8d$#, 3andoo of reschool Mental 3ealth" Development, Disorders, and 0reatment %%$ 14"!1C"#$ (e' Nor* The Juilford Press$
14$
Ohmi, 7$, Hoima, S$, A'ai, N$, Hamata, S$, Sasai, H$, Tanaa, N$, $ $ $ 7ata, A$ 2002#$ Post! traumatic stress disorder in %re!school aged children after a gas e)%losion$ #uropean (ournal of ediatrics, )!), 4.3!4.C$
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Scheeringa, M$, eanah, $, Myers, :$, < Putnam, 5$ 200"#$ Predictive validity in a %ros%ective follo'!u% of PTSD in %reschool children$ (ournal of the American Academy of .hild and Adolescent sychiatry, // G#, CGG!G04$ doi* 10$10G6B01$chi$000014G013$C1"34$61
1C$
De Noung, A$ $, Drury, S$S$, Scheeringa, M$S$ in %ress#$ Assessing trauma!related sym%toms during early childhood$ In / Del armen!-iggins, A arter 8ds$#, 7and&oo of Infant, Toddler, and Preschool Mental 7ealth Assessment, 2nd edition$ (e' Nor, (N* O)ford Fniversity Press$
1G$
De&linger, 8$, Stauffer, :$, < Steer, /$ 2001#$ om%arative efficacies of su%%ortive and cognitive &ehavioral grou% thera%ies for young children 'ho have &een se)ually a&used and their nonoffending mothers$ .hild Maltreatment, !, 332!3.3$
20$
Scheeringa, M$ S$, -eems, $ 5$, ohen, =$ A$, Amaya!=acson, :$, < Juthrie, D$ 2011#$ Trauma! focused cognitive!&ehavioral thera%y for %osttraumatic stress disorder in three through si) year!old children* A randomi>ed clinical trial$ (ournal of .hild sychology and sychiatry, 52 C#, C"3!C40$
DSM-5 Diagnostic Criteria for PTSD 'eleased The Diagnostic and Statistical Manual of Mental Disorders %rovides standard criteria and common language for the classification of mental disorders$ It is %u&lished &y the American Psychiatric Association$ The fifth revision DSM!"# 'as released in May 2013$ This revision includes changes to the diagnostic criteria for PTSD and Acute Stress Disorder$ The reason the PTSD diagnostic criteria 'ere revised is to tae into account things 'e have learned from scientific research and clinical e)%erience$
$%at are t%e ma/or revisions to t%e PTSD diagnosis, Classification PTSD as 'ell as Acute Stress Disorder# moved from the class of an)iety disorders into a ne' class of trauma and stressor!related disorders$ All of the conditions included in this classification reuire e)%osure to a traumatic or stressful event as a diagnostic criterion$ The rationale for the creation of this ne' class is &ased u%on clinical recognition of varia&le e)%ressions of distress as a result of traumatic e)%erience$ The necessary criteria of e)%osure to trauma lins the conditions included in this class+ the homogeneous e)%ression of an)iety or fear!&ased sym%toms, anhedonic and dys%horic sym%toms, e)ternali>ing anger
or aggressive sym%toms, dissociative sym%toms, or some com&ination of those listed differentiates the diagnoses 'ithin the class 1#$
Diagnostic criteria Overall, the sym%toms of PTSD are mostly the same in DSM!" as com%ared to DSM!I;$ A fe' ey alterations include* •
The three clusters of DSM!I; sym%toms are divided into four clusters in DSM!"* intrusion, avoidance, negative alterations in cognitions a nd mood, and alterations in arousal and reactivity$ DSM!I; riterion , avoidance and num&ing, 'as se%arated into t'o criteria* riteria avoidance# and riteria D negative alterations in cognitions and mood#$ The rationale for this change 'as &ased u%on factor analytic studies, and no' reuires at least one avoidance sym%tom for PTSD diagnosis$
•
Three ne' sym%toms 'ere added* riteria D negative alterations in cognitions and mood#* %ersistent and distorted &lame of
•
self or others, and %ersistent negative emotional state •
riteria 8 alterations in arousal and reactivity#* recless or destructive &ehavior
•
Other sym%toms 'ere revised to clarify sym%tom e)%ression$
•
riterion A2 reuiring fear, hel%lessness, or horror ha%%en right after the trauma# 'as removed in DSM!"$ /esearch suggests that riterion A2 did not im%rove diagnostic accuracy 2#$
•
A clinical su&ty%e 'ith dissociative sym%toms 'as added$ The dissociative su&ty%e is a%%lica&le to individuals 'ho meet the criteria for PTSD and e)%erience additional de%ersonali>ation and dereali>ation sym%toms 3#$
•
Se%arate diagnostic criteria are included for children ages 4 years or younger %reschool su&ty%e# .#$
$%at are t%e implications of t%ese revisions, Assessment PTSD assessment measures, such as the P!PTSD, APS, and P:, are &eing revised &y the (ational enter for PTSD to &e made availa&le u%on validation of the instruments$ Please see our Assessments section for more information$
Prevalence rates 9ased on initial analyses of the DSM!" criteria, the %revalence of PTSD 'ill &e similar to 'hat it is currently in DSM!I; ",4#$ /esearch also suggests that similarly to DSM!I;, %revalence of PTSD for DSM!" 'as higher among 'omen than men, and %revalence increased 'ith multi%le traumatic event e)%osure 4#$ (ational estimates of PTSD %revalence suggest that DSM!" rates 'ere slightly lo'er than DSM!I; 4#$ Discordant findings in diagnostic %revalence 'ere attri&uta&le to three maor changes in the DSM!" criteria for PTSD* •
The revision of riterion A1 in DSM!" narro'ed ualifying traumatic events such that the une)%ected death of family or a close friend due to natural causes is no longer included$ /esearch suggests this is the greatest contri&utor "0# to discre%ancy for meeting DSM!I; &ut not DSM!" PTSD criteria$
•
S%litting DSM!I; riterion into t'o criteria in DSM!" no' reuires that a PTSD diagnosis must include at least one avoidance s ym%tom$
•
riterion A2, res%onse to traumatic event involved intense fear, ho%elessness, or horror, 'as removed from DSM!"$
Sign u% for the PTSD Monthly F%date to
&e informed 'hen the ne' criteria and assessment measures are officially released$ The APA summary of changes to the PTSD diagnosis can &e accessed here* Posttraumatic Stress Disorder PD5#$Q
Sources 1$
American Psychiatric Association$ 2013#$ Diagnostic and statistical manual of mental disorders% "th ed$#$ -ashington, D* Author$
2$
5riedman, Matthe' =+ /esic, Patricia A+ 9ryant, /ichard A+ 9re'in, hris / Se% 2011#$ onsidering PTSD for DSM!"$ Depression and Anxiety 21% 9 * 6"0! 64G$ htt%*BB'''$%tsd$va$govB%rofessionalBarticlesBarticle!%dfBid3".G0$%df
3$
:anius, /$, 9rand, 9$, ;ermetten, 8$, 5ree'n, P$ A$, < S%iegel, D$ 2012#$ The dissociative su&ty%e of %osttraumatic stress disorder* /ationale, clinical and neuro&iological evidence, and im%lications$ Depression and Anxiety, 29, 601!60C$ doi* 10$1002Bda$21CCG
.$
Scheeringa, M$ S$, eanah, $ 7$, < ohen, =$ A$ 2011#$ PTSD in children and adolescents* to'ard an em%irically &ased algorithm$ Depression and Anxiety, 21 , 660!6C2$ doi*10$1002Bda20634
"$
Miller, Mar -+ -olf, 8ria =ane+ Hil%atric, Dean J+ /esnic, 7eidi S+ Mar), 9rian P+ et al$ Se% 3, 2012#$ The %revalence and latent structure of %ro%osed DSM!" %osttraumatic stress disorder sym%toms in F$S$ national and veteran sam%les$ sychological 0rauma" 0heory, 4esearch, ractice, and olicy% htt%*BB'''$%tsd$va$govB%rofessionalBarticlesBarticle!%dfBid3G3C2$%df
4$
Hil%atric, D$, /esnic, 7$ S$, Milana, M$ 8$, Miller, M$ -$, Heyes, H$ M$, < 5riedman, M$ =$ 2013#$ ational #stimates of #xposure to 0raumatic #vents and 0SD revalence 6sing DSM-*+ and roposed DSM-5 .riteriaManuscri%t su&mitted for %u&licationL$
PTSD "istory and 0vervie Matthe' =$ 5riedman, MD, PhD
A (rief %istory of t%e PTSD diagnosis The ris of e)%osure to trauma has &een a %art of the human condition since 'e evolved as a s%ecies$ Attacs &y sa&er tooth tigers or t'enty!first century terrorists have %ro&a&ly %roduced similar %sychological seuelae in the survivors of such violence$ Shaes%eareKs 7enry I; a%%ears to meet many, if not all, of the diagnostic criteria for Posttraumatic Stress Disorder PTSD#, as have other heroes and heroines throughout the 'orldKs literature$ The history of the develo%ment of the PTSD conce%t is descri&ed &y Trim&le 1#$ In 1GC0, the American Psychiatric Association APA# added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders DSM!III# nosologic classification scheme 2#$ Although controversial 'hen first introduced, the PTSD diagnosis has filled an im%ortant ga% in %sychiatric theory and %ractice$ 5rom an historical %ers%ective, the significant change ushered in &y the PTSD conce%t 'as the sti%ulation that the etiological agent 'as outside the individual i$e$, a traumatic event# rather than an inherent individual 'eaness i$e$, a traumatic neurosis#$ The ey to understanding the scientific &asis and clinical e)%ression of PTSD is the conce%t of trauma$
Importance of traumatic events In its initial DSM!III formulation, a traumatic event 'as conce%tuali>ed as a catastro%hic stressor that 'as outside the range of usual human e)%erience$ The framers of the original PTSD diagnosis had in mind events such as 'ar, torture, ra%e, the (a>i 7olocaust, the atomic &om&ings of 7iroshima and (agasai, natural disasters such as earthuaes, hurricanes, and volcano eru%tions#, and human!made disasters such as factory e)%losions, air%lane crashes, and automo&ile accidents#$ They considered traumatic events to &e clearly different from the very %ainful stressors that constitute the normal vicissitudes of life such as divorce, failure, reection, serious illness, financial reverses, and the lie$ 9y this logic, adverse %sychological res%onses to such ordinary stressors 'ould, in DSM!III terms, &e characteri>ed as Adustment Disorders rather than PTSD$# This dichotomi>ation &et'een traumatic and other stressors 'as &ased on the assum%tion that, although most individuals have the a&ility to co%e 'ith ordinary stress, their ada%tive ca%acities are liely to &e over'helmed 'hen confronted &y a traumatic stressor$ PTSD is uniue among %sychiatric diagnoses &ecause of the great im%ortance %laced u%on the etiological agent, the traumatic stressor$ In fact, one cannot mae a PTSD diagnosis unless the %atient has actually met the stressor criterion, 'hich means that he or she has &een e)%osed to an event that is considered traumatic$ linical e)%erience 'ith the PTSD diagnosis has sho'n, ho'ever, that there are individual differences regarding the ca%acity to co%e 'ith catastro%hic stress$ Therefore, 'hile most %eo%le e)%osed to traumatic events do not develo% PTSD, others go on to develo% the full!&lo'n syndrome$ Such o&servations have %rom%ted the recognition that trauma, lie %ain, is not an e)ternal %henomenon that can &e com%letely o&ectified$ :ie %ain, the traumatic e)%erience is filtered through cognitive and emotional %rocesses &efore it can &e a%%raised as an e)treme threat$ 9ecause of individual differences in this a%%raisal %rocess, different %eo%le a%%ear to have different trauma thresholds, some more %rotected from and some more vulnera&le to develo%ing clinical sym%toms after e)%osure to e)tremely stressful situations$ Although there is currently a rene'ed interest in su&ective as%ects of traumatic e)%osure, it must &e em%hasi>ed that events such as ra%e, torture, genocide, and severe 'ar >one stress are e)%erienced as traumatic events &y nearly everyone$
Revisions to PTSD diagnostic criteria The DSM!III diagnostic criteria for PTSD 'ere revised in DSM!III!/ 1GC6#, DSM! I; 1GG.#, and DSM!I;!T/ 2000# 2!"#$ A very similar syndrome is classified in ID!10 The ID!10 lassification of Mental and 9ehavioural Disorders* linical Descri%tions and Diagnostic Juidelines# 4#$ One im%ortant finding, 'hich 'as not a%%arent 'hen PTSD 'as first %ro%osed as a diagnosis in 1GC0, is that it is relatively common$ /ecent data from the (ational omor&idity Survey /e%lication indicates lifetime PTSD %revalence rates are 3$4 and G$6 res%ectively among American men and 'omen 6#$ /ates of PTSD are much higher in %ost!conflict settings such as Algeria 36#, am&odia 2C#, 8thio%ia 14#, and Ja>a 1C# C#$ DSM!I; Diagnostic criteria for PTSD included a history of e)%osure to a traumatic event and sym%toms from each of three sym%tom clusters* intrusive recollections, avoidantBnum&ing sym%toms, and hy%er!arousal sym%toms$ A fifth criterion concerned duration of sym%toms+ and, a si)th criterion sti%ulated that PTSD sym%toms must cause significant distress or functional im%airment$ The latest revision, the DSM!" 2013#, has made a num&er of nota&le evidence! &ased revisions to PTSD diagnostic criteria, 'ith &oth im%ortant conce%tual and clinical im%lications G#$ 5irst, &ecause it has &ecome a%%arent that PTSD is not ust a fear!&ased an)iety disorder as e)%licated in &oth DSM!III and DSM! I;#,PTSD in DSM!" has e)%anded to include anhedonicBdys%horic %resentations, 'hich are most %rominent$ Such %resentations are mared &y negative cognitions and mood states as 'ell as disru%tive e$g$ angry, im%ulsive, recless and self!destructive# &ehavioral sym%toms$ 5urthermore, as a result of research! &ased changes to the diagnosis, PTSD is no longer categori>ed as an An)iety Disorder$ PTSD is no' classified in a ne' category, Trauma! and Stressor! /elated Disorders, in 'hich the onset of every disorder has &een %receded &y e)%osure to a traumatic or other'ise adverse environmental event$ Other changes in diagnostic criteria 'ill &e descri&ed &elo'$
DSM-5 Criteria for PTSD diagnosis As noted a&ove, the "A" stressor criterion s%ecifies that a %erson has &een e)%osed to a catastro%hic event involving actual or threatened death or inury, or a threat
to the %hysical integrity of himBherself or others such as se)ual violence#$ Indirect e)%osure includes learning a&out the violent or accidental death or %er%etration of se)ual violence to a loved one$ 8)%osure through electronic media e$g$ televised images the GB11 attacs on the -orld Trade enter# is not considered a traumatic event$ On the other hand, re%eated, indirect e)%osure usually as %art of oneKs %rofessional res%onsi&ilities# to the gruesome and horrific conseuences of a traumatic event e$g$ %olice %ersonnel, &ody handlers, etc$# is considered traumatic$ 9efore descri&ing the 9!8 sym%tom clusters, it is im%ortant to understand that one ne' feature of DSM!" is that all of these sym%toms must have had their onset or &een significantly e)acer&ated after e)%osure to the traumatic event$ The "B" or intrusive recollection criterion includes sym%toms that are %erha%s the most distinctive and readily identifia&le sym%toms of PTSD$ 5or individuals 'ith PTSD, the traumatic event remains, sometimes for decades or a lifetime, a dominating %sychological e)%erience that retains its %o'er to evoe %anic, terror, dread, grief, or des%air$ These emotions manifest during intrusive daytime images of the event, traumatic nightmares, and vivid reenactments no'n as PTSD flash&acs 'hich are dissociative e%isodes#$ 5urthermore, trauma!related stimuli that trigger recollections of the original event have the %o'er to evoe mental images, emotional res%onses, and %hysiological reactions associated 'ith the trauma$ /esearchers can use this %henomenon to re%roduce PTSD sym%toms in the la&oratory &y e)%osing affected individuals to auditory or visual trauma!related stimuli 10#$ The "" or avoidance criterion consists of &ehavioral strategies PTSD %atients use in an attem%t to reduce the lielihood that they 'ill e)%ose themselves to trauma! related stimuli$ PTSD %atients also use these strategies in an attem%t to minimi>e the intensity of their %sychological res%onse if they are e)%osed to such stimuli$ 9ehavioral strategies include avoiding any thought or situation 'hich is liely to elicit distressing traumatic memories$ In its e)treme manifestation, avoidance &ehavior may su%erficially resem&le agora%ho&ia &ecause the PTSD individual is afraid to leave the house for fear of confronting reminders of the traumatic events#$
Sym%toms included in the "D" or negative cognitions and !ood criterion reflect %ersistent alterations in &eliefs or mood that have develo%ed after e)%osure to the traumatic event$ Peo%le 'ith PTSD often have erroneous cognitions a&out the causes or conseuences of the traumatic event 'hich leads them to &lame themselves or others$ A related erroneous a%%raisal is the common &elief that one is inadeuate, 'ea, or %ermanently changed for the 'orse since e)%osure to the traumatic event or that oneKs e)%ectations a&out the future have &een %ermanently altered &ecause of the event e$g$, nothing good can ha%%en to me, no&ody can &e trusted, the 'orld is entirely dangerous, %eo%le 'ill al'ays try to control me#$ In addition to negative a%%raisals a&out %ast, %resent and future, %eo%le 'ith PTSD have a 'ide variety of negative emotional states such as anger, guilt, or shame$ Dissociative %sychogenic amnesia is included in this sym%tom cluster and involves cutting off the conscious e)%erience of trauma! &ased memories and feelings$ Other sym%toms include diminished interest in significant activities and feeling detached or estranged from others$ 5inally, although individuals 'ith PTSD suffer from %ersistent negative emotions, they are una&le to e)%erience %ositive feelings such as love, %leasure or enoyment$ Such constricted affect maes it e)tremely difficult to sustain a close marital or other'ise meaningful inter%ersonal relationshi%$ Sym%toms included in the "" or alterations in arousal or reactivit# criterion most closely resem&le those seen in %anic and generali>ed an)iety disorders$ -hile sym%toms such as insomnia and cognitive im%airment are generic an)iety sym%toms, hy%ervigilance and startle are more characteristic of PTSD$ The hy%ervigilance in PTSD may sometimes &ecome so intense as to a%%ear lie fran %aranoia$ The startle res%onse has a uniue neuro&iological su&strate and may actually &e the most %athognomonic PTSD sym%tom$ DSM!I;Ks riterion D2, irrita&ility or out&ursts of anger, has &een se%arated into em otional e$g$, D.# and &ehavioral e$g$, 81# com%onents in DSM!"$ Irrita&le and angry out&ursts may sometimes &e e)%ressed as aggressive &ehavior$ 5inally recless and self! destructive &ehavior such as im%ulsive acts, unsafe se), recless driving and suicidal &ehavior are ne'ly included in DSM!", as riterion 82$ The "$" or duration criterion s%ecifies that sym%toms must %ersist for at least one month &efore PTSD may &e diagnosed$
The "%" or functional significance criterion s%ecifies that the survivor must e)%erience significant social, occu%ational, or other distress as a result of these sym%toms$ The "&" or e'clusion criterion s%ecifies that the sym%toms are not due to medication, su&stance use, or other illness$
Assessing PTSD Since 1GC0, there has &een a great deal of attention devoted to the develo%ment of instruments for assessing PTSD$ Heane and associates 10#, 'oring 'ith ;ietnam 'ar!>one ;eterans, first develo%ed &oth %sychometric and %sycho%hysiological assessment techniues that have %roven to &e &oth valid and relia&le$ Other investigators have modified such assessment instruments and used them 'ith natural disaster survivors, ra%eBincest survivors, and other traumati>ed individuals$ These assessment techniues have &een used in the e%idemiological studies mentioned a&ove and in other research %rotocols$
Neurobiology (euro&iological research indicates that PTSD may &e associated 'ith sta&le neuro&iological alterations in &oth the central and autonomic nervous systems$ Psycho%hysiological alterations associated 'ith PTSD include hy%erarousal of the sym%athetic nervous system, increased sensitivity and augmentation of the acoustic!startle eye &lin refle), and slee% a&normalities$ (euro%harmacological and neuroendocrine a&normalities have &een detected in most &rain mechanisms that have evolved for co%ing, ada%tation, and %reservation of the s%ecies$ These include the noradrenergic, hy%othalamic!%ituitary!adrenocortical, serotonergic, glutamatergic, thyroid, endogenous o%ioid, and other systems$ Structural &rain imaging suggests reduced volume of the hi%%ocam%us and anterior cingulate$ 5unctional &rain imaging suggests e)cessive amygdala activity and reduced activation of the %refrontal corte) and hi%%ocam%us$ This information is revie'ed e)tensively else'here 11!12#$
Longitudinal expression :ongitudinal research has sho'n that PTSD can &ecome a chronic %sychiatric disorder and can %ersist for decades and sometimes for a lifetime$ Patients 'ith
chronic PTSD often e)hi&it a longitudinal course mared &y remissions and rela%ses$ There is also a delayed variant of PTSD in 'hich individuals e)%osed to a traumatic event do not e)hi&it the full PTSD syndrome until months or years after'ard$ DSM!I;Ks delayed onset has &een changed to delayed e)%ression in DSM!" to clarify that although full diagnostic criteria may not &e met until at least 4 months after the trauma, the onset and e)%ression of some sym%toms may &e immediate$ Fsually, the %rom%ting %reci%itant is a situation that resem&les the original trauma in a significant 'ay for e)am%le, a 'ar ;eteran 'hose child is de%loyed to a 'ar >one or a ra%e survivor 'ho is se)ually harassed or assaulted years later#$
Cooccurring conditions If an individual meets diagnostic criteria for PTSD, it is liely that he or she 'ill meet DSM!" criteria for one or more additional diagnoses 13#$ Most often, these comor&id diagnoses include maor affective disorders, dysthymia, alcohol or su&stance a&use disorders, an)iety disorders, or %ersonality disorders$ There is a legitimate uestion 'hether the high rate of diagnostic comor&idity seen 'ith PTSD is an artifact of our current decision!maing rules for the PTSD diagnosis since there are not e)clusionary criteria in DSM!"$ In any case, high rates of comor&idity com%licate treatment decisions concerning %atients 'ith PTSD since the clinician must decide 'hether to treat the comor&id disorders concurrently or seuentially$
Classification and subtypes PTSD is no longer considered an An)iety Disorder &ut has &een reclassified as a Trauma and Stressor!/elated Disorder &ecause it has a num&er of clinical %resentations, as discussed %reviously$ In addition, t'o ne' su&ty%es have &een included in the DSM!"$ The Dissociative Su&ty%e includes individuals 'ho meet full PTSD criteria &ut also e)hi&it either de%ersonali>ation or dereali>ation e$g$ alterations in the e)%erience of oneKs self and the 'orld, res%ectively#$The Preschool Su&ty%e a%%lies to children si) years old and younger+ it has fe'er sym%toms es%ecially in the D cluster &ecause it is difficult for young children to re%ort on their inner thoughts and feelings# and also has lo'er sym%tom thresholds to meet full PTSD criteria$
!uestions to consider Euestions that remain a&out the syndrome itself include* 'hat is the clinical course of untreated PTSD+ are there other su&ty%es of PTSD+ 'hat is the distinction &et'een traumatic sim%le %ho&ia and PTSD+ and 'hat is the clinical %henomenology of %rolonged and re%eated trauma -ith regard to the latter, 7erman 1.# has argued that the current PTSD formulation fails to characteri>e the maor sym%toms of PTSD commonly seen in victims of %rolonged, re%eated inter%ersonal violence such as domestic or se)ual a&use and %olitical torture$ She has %ro%osed an alternative diagnostic formulation, com%le) PTSD, that em%hasi>es multi%le sym%toms, e)cessive somati>ation, dissociation, changes in affect, %athological changes in relationshi%s, and %athological changes in identity$ Although this formulation is attractive to clinicians dealing 'ith individuals 'ho have &een re%eatedly traumati>ed, scientific evidence in su%%ort of the com%le) PTSD formulation is s%arse and inconsistent$ 5or this reason, it 'as not included in the DSM!" as su&ty%e of PTSD$ It is %ossi&le that the Dissociative Su&ty%e, 'hich has firm scientific su%%ort, 'ill %rove to &e the diagnostic su&ty%e that incor%orates many or all of the sym%toms first descri&ed &y 7erman$ PTSD has also &een critici>ed from the %ers%ective of cross!cultural %sychology and medical anthro%ology, es%ecially 'ith res%ect to refugees, asylum seeers, and %olitical torture victims from non!-estern regions$ Some clinicians and researchers 'oring 'ith such survivors argue that since PTSD has usually &een diagnosed &y clinicians from -estern industriali>ed nations 'oring 'ith %atients from a similar &acground, the diagnosis does not accurately reflect the clinical %icture of traumati>ed individuals from non!-estern traditional societies and cultures$ It is clear ho'ever, that PTSD is a valid diagnosis cross!culturally 1"#$ On the other hand, there is su&stantial cross!cultural variation and the e)%ression of PTSD may &e different in different countries and cultural settings, eve n 'hen DSM!" diagnostic criteria are met 14#$
Treatment for PTSD "ost effective treatments for PTSD The many thera%eutic a%%roaches offered to PTSD %atients are %resented in 5oa, Heane, 5riedman and ohenKs 200G# com%rehensive &oo on treatment
16#$ The most successful interventions are cognitive!&ehavioral thera%y 9T# and medication$ 8)cellent results have &een o&tained 'ith 9T a%%roaches such as %rolonged e)%osure thera%y P8# and ognitive Processing Thera%y PT#, es%ecially 'ith female victims of childhood or adult se)ual trauma, military %ersonnel and ;eterans 'ith 'ar!related trauma, and survivors of serious motor vehicle accidents$ Success has also &een re%orted 'ith 8ye Movement Desensiti>ation and /e%rocessing 8MD/# and Stress Inoculation Thera%y SIT#$ Sertraline oloft# and %aro)etine Pa)il# are selective serotonin reu%tae inhi&itors SS/Is# that are the first medications to have received 5DA a%%roval as indicated treatments for PTSD$ Other antide%ressants are also effective and %romising results have recently &een o&tained 'ith the al%ha!1 adrenergic antagonist, %ra>osin 1C#$ A freuent thera%eutic o%tion for mildly to moderately affected PTSD %atients is grou% thera%y, although em%irical su%%ort for this is s%arse$ In such a setting, the PTSD %atient can discuss traumatic memories, PTSD sym%toms, and functional deficits 'ith others 'ho have had similar e)%eriences$ This a%%roach has &een most successful 'ith 'ar ;eterans, ra%eBincest victims, and natural disaster survivors$ It is im%ortant that thera%eutic goals &e realistic &ecause, in some cases, PTSD is a chronic, com%le) e$g$, 'ith many comor&id diagnoses and sym%toms#, and severely de&ilitating %sychiatric disorder that does not al'ays res%ond to current availa&le treatments$ /esic, (ishith, and Jriffin 2003# have sho'n ho'ever, that very good outcomes utili>ing evidence!&ased ognitive Processing Thera%y PT# can &e achieved, even 'ith such com%licated %atients 1G#+ and, more recently, grou% PT has sho'n %romising results 20!21#$ A remara&le recent finding is the effectiveness of grou% PT, ada%ted for illiteracy and ris of ongoing violence, 'ith se)ual trauma survivors in the Democratic /e%u&lic of ongo 22#$ The ho%e remains, ho'ever, that our gro'ing no'ledge a&out PTSD 'ill ena&le us to design other effective interventions for %atients afflicted 'ith this disorder$
Rapid interventions for trauma survivors There is great interest in ra%id interventions for acutely traumati>ed individuals, es%ecially 'ith res%ect to civilian disasters, military de%loyments, and emergency %ersonnel medical %ersonnel, %olice, and firefighters#$ This has &ecome a maor
%olicy and %u&lic health issue since the massive traumati>ation caused &y the Se%tem&er 11 terrorist attacs on the -orld Trade enter, 7urricane Hatrina, the Asian tsunami, the 7aitian earthuae, the 'ars in Ira and Afghanistan and other large!scale traumatic events$ urrently, there is controversy a&out 'hich interventions 'or &est during the immediate aftermath of a trauma$ /esearch on critical incident stress de&riefing ISD#, an intervention used 'idely, has &rought disa%%ointing results 'ith res%ect to its efficacy to attenuate %osttraumatic distress or to forestall the later develo%ment of PTSD$ The (ational enter for PTSD and the (ational enter for hild Traumatic Stress have develo%ed an alternative early intervention, Psychological 5irst Aid that is availa&le online, &ut 'hich has yet to &e su&ected to rigorous evaluation$ On the other hand, &rief cognitive &ehavioral thera%y has %roved very effective in randomi>ed clinical trials 23#$
'eferences 1$
Trim&le, M$D$ 1GC"#$ Post!traumatic Stress Disorder* 7istory of a conce%t$ In $/$ 5igley 8d$#, 0rauma and its $ae" 0he study and treatment of ost-0raumatic Stress Disorder $ (e' Nor* 9runnerBMa>el$ /evised from 8ncyclo%edia of Psychology, /$ orsini, 8d$ (e' Nor* -iley, 1GC., 1GG.#
2$
American Psychiatric Association$ 1GC0#$ Diagnostic and statistical manual of mental disorders, 3rd ed$#$ -ashington, D* Author$
3$
American Psychiatric Association$ 1GC6#$ Diagnostic and statistical manual of mental disorders, /evised 3rd ed$#$ -ashington, D* Author$
.$
American Psychiatric Association$ 1GG.#$ Diagnostic and statistical manual of mental disorders, .th ed$#$ -ashington, D* Author$
"$
American Psychiatric Association$ 2000#$ Diagnostic and statistical manual of mental disorders, /evised .th ed$#$ -ashington, D* Author$
4$
-orld 7ealth Organi>ation$ 1GG2#$ 0he *.D-) classification of mental and ehavioural disorders$ Jeneva, S'it>erland* Author$
6$
Hessler, /$$, hiu, -$ T$, Demler, O$, Meriangas, H$ /$, -alters, 8$ 8$ 200"#$ Prevalence, severity, and comor&idity of 12!month DSM!I; disorders in the (ational omor&idity Survey /e%lication$ Archives of General sychiatry , 42, 416!426$ doi* 10$1001Barch%syc$42$4$416
C$
De =ong, =$, Hom%roe, T$;$M$, Ivan, 7$, von Ommeren, M$, 8l Masri, M$, Araya, M$, Hhaled, ($,van de Put, -$, < Somasundarem, D$=$ 2001#$ :ifetime events and Posttraumatic Stress Disorder in . %ostconflict settings$(ournal of the American Medical Association, 2C4, """!"42$ doi* 10$1001Bama$2C4$"$"""
G$
American Psychiatric Association$ 2013#$ Diagnostic and statistical manual of mental disorders, "th ed$#$ -ashington, D* Author$
10$
Heane, T$M$, -olfe, =$, < Taylor, H$I$ 1GC6#$ Post!traumatic Stress Disorder* 8vidence for diagnostic validity and methods of %sychological assessment$(ournal of .linical sychology , .3, 32! .3$ doi* 10$1002B10G6!.46G1GC601#.3*1R32**AID!=:P2260.301043$0$O+2!
11$
5riedman, M$=$, harney, D$S$ < Deutch, A$N$ 1GG"# euroiological and clinical conse7uences of stress" 8rom normal adaptation to 0SD$ Philadel%hia* :i%%incott!/aven$
12$
Shiromani, P$ =$, Heane, T$ M$, < :eDou), =$ 8$ 8ds$#$ 200G#$ ost-0raumatic Stress Disorder" asic science and clinical practice$ (e' Nor* 7umana Press$
13$
5riedman, M$ =$, /esic, P$ A$, 9ryant, /$ A$, < 9re'in, $ /$ 2011#$ .onsidering 0SD for DSM5% Depression and Anxiety , 2C, 6"0!64G$ doi* 10$1002Bda$20646
1.$
7erman, =$:$ 1GG2#$ 0rauma and recovery $ (e' Nor* 9asic 9oos$
1"$
7inton, D$ 8$, < :e'is!5ernande>, /$ 2011#$ The cross!cultural validity of Posttraumatic Stress Disorder* Im%lications for DSM!"$ Depression and Anxiety , 2C, 6C3!C01$ doi* 10$1002Bda$206"3
14$
Marsella, A$=$, 5riedman, M$=$, Jerrity, 8$ < Scurfield /$M$ 8ds$#$ 1GG4#$ #thnocultural aspects of ost-0raumatic Stress Disorders" *ssues, research and applications$ -ashington, D* American Psychological Association$
16$
5oa, 8$9$, Heane, T$M$, 5riedman, M$=$, < ohen, =$A$ 8ds$#$ 200G#$ #ffective treatments for 0SD, Second #dition% (e' Nor, (N* Juilford$
1C$
/asind, M$ A$, Peterson, H$, -illiams, T$, 7off, D$ =$, 7art, H$, 7olmes, 7$, 7omas, D$, 7ill, =$, Daniels, $, alohan, =$, Millard, S$ P$, /ohde, H$, OKonnell, =$, Prit>l, D$, 5eis>li, H$, Petrie, 8$ $, Jross, $, Mayer, $ :$, 5reed, M$ $$, 8ngel, $, < Pesind, 8$ /$ 2013#$ A trail of %ra>osin for com&at trauma PTSD 'ith nightmares in active!duty soldiers returned from Ira and Afghanistan$ American (ournal of sychiatry, Advance online %u&lication$ doi* 10$1164Ba%%i$a%$2013$120C1133
1G$
/esic, P$ A$, (ishith, P$, < Jriffin, M$ J$ 2003#$ 7o' 'ell does cognitive!&ehavioral thera%y treat sym%toms of com%le) PTSD An e)amination of child se)ual a&use survivors 'ithin a clinical trial$ .S Spectrums, C, 3.0!3""$
20$
Alvare>, =$, Mc:ean, $, 7arris, A$ 7$ S$, /osen, $ S$, /u>e, =$ I$, < Himerling, /$ 2011#$ The com%arative effectiveness of cognitive %rocessing thera%y for male ;eterans treated in a ;7A Posttraumatic Stress Disorder residential reha&ilitation %rogram$ (ournal of .onsulting and .linical sychology , 6G, "G0!"GG$ doi* 10$1036Ba002..44
21$
hard, H$ M$, /icsecer, 8$ J$, 7ealy, 8$ T$, Harlin, 9$ 8$, < /esic, P$ A$ 2011#$ Dissemination and e)%erience 'ith cognitive %rocessing thera%y$(ournal of 4ehailitation 4esearch and Development , .G, 446!46C$ doi* 10$14C2B=//D$2011$10$01GC
22$
9ass, =$ H$, Annan, =$, McIvor Murray, S$, Haysen, D$, Jriffiths, S$, etinoglu, T$, -achter, H$, Murray, :$ H$, < 9olton, P$ A$ 2013#$ ontrolled trial of %sychothera%y for ongolese survivors of se)ual violence$ e$ #ngland (ournal of Medicine, 34C, 21C2!21G$ doi*10$10"4B(8=Moa1211C"3
23$
9ryant, /$A$, Mastrodomenico, =$, 5elmingham, H$:$, 7o%'ood, S$, Henny, :$, Handris, 8$, ahill, $ < reamer, M$ 200C#$ Treatment of acute stress disorder* A randomi>ed controlled trial$ Archives of General sychiatry , 4", 4"G!446$ doi*10$1001Barch%syc$4"$4$4"G
Comple# PTSD Many traumatic events e$g$, car accidents, natural disasters, etc$# are of time! limited duration$ 7o'ever, in some cases %eo%le e)%erience chronic trauma that continues or re%eats for months or years at a time$ The current PTSD diagnosis often does not fully ca%ture the severe %sychological harm that occurs 'ith %rolonged, re%eated trauma$ Peo%le 'ho e)%erience chronic trauma often re%ort additional sym%toms alongside formal PTSD sym%toms, such as changes in their self!conce%t and the 'ay they ada%t to stressful events$ Dr$ =udith 7erman of 7arvard Fniversity suggests that a ne' diagnosis, om%le) PTSD, is needed to descri&e the sym%toms of long!term trauma 1#$ Another name sometimes used to descri&e the cluster of sym%toms referred to as om%le) PTSD is Disorders of 8)treme Stress (ot Other'ise S%ecified D8S(OS#2#$ A 'or grou% has also %ro%osed a diagnosis of Develo%mental Trauma Disorder DTD# for children and adolescents 'ho e)%erience chronic traumatic events 3#$ 9ecause results from the DSM!I; 5ield Trials indicated that G2 of individuals 'ith om%le) PTSDBD8S(OS also met diagnostic criteria for PTSD, om%le) PTSD 'as not added as a se%arate diagnosis classification .#$ 7o'ever, cases that involve %rolonged, re%eated trauma may indicate a need for s%ecial treatment considerations$
$%at types of trauma are associated it% Comple# PTSD, During long!term traumas, the victim is generally held in a state of ca%tivity, %hysically or emotionally, according to Dr$ 7erman 1#$ In these situations the
victim is under the control of the %er%etrator and una&le to get a'ay from the danger$ 8)am%les of such traumatic situations include* •
oncentration cam%s
•
Prisoner of -ar cam%s
•
Prostitution &rothels
•
:ong!term domestic violence
•
:ong!term child %hysical a&use
•
:ong!term child se)ual a&use
•
Organi>ed child e)%loitation rings
$%at additional symptoms are seen in Comple# PTSD, An individual 'ho e)%erienced a %rolonged %eriod months to years# of chronic victimi>ation and total control &y another may also e)%erience the follo'ing difficulties* •
!otional egulation May include %ersistent sadness, suicidal thoughts, e)%losive anger, or inhi&ited anger$
•
onsciousness Includes forgetting traumatic events, reliving traumatic events, or having e%isodes in 'hich one feels detached from oneKs mental %rocesses or &ody dissociation#$
•
Self*+erception May include hel%lessness, shame, guilt, stigma, and a sense of &eing com%letely different from other human &eings$
•
Distorted +erceptions of the +erpetrator 8)am%les include attri&uting total %o'er to the %er%etrator, &ecoming %reoccu%ied 'ith the relationshi% to the %er%etrator, or %reoccu%ied 'ith revenge$
•
elations with ,thers 8)am%les include isolation, distrust, or a re%eated search for a rescuer$
•
,ne-s S#ste! of Meanings May include a loss of sustaining faith or a sense of ho%elessness and des%air$
$%at ot%er difficulties are faced (y t%ose %o e#perienced c%ronic trauma, 9ecause %eo%le 'ho e)%erience chronic trauma often have additional sym%toms not included in the PTSD diagnosis, clinicians may misdiagnose PTSD or only diagnose a %ersonality disorder consistent 'ith some sym%toms, such as 9orderline, De%endent, or Masochistic Personality Disorder$ are should &e taen during assessment to understand 'hether sym%toms are characteristic of PTSD or if the survivor has co!occurring PTSD and %ersonality
disorder$ linicians should assess for PTSD s%ecifically, ee%ing in mind that chronic trauma survivors may e)%erience any of the follo'ing difficulties* •
Survivors may avoid thining and taling a&out trauma!related to%ics &ecause the feelings associated 'ith the trauma are often over'helming$
•
Survivors may use alcohol or other su&stances as a 'ay to avoid and num& feelings and thoughts related to the trauma$
•
Survivors may engage in self!mutilation and other forms of self!harm$
•
Survivors 'ho have &een a&used re%eatedly are sometimes mistaen as having a 'ea character or are unustly &lamed for the sym%toms they e)%erience as a result of victimi>ation$
Treatment for Comple# PTSD Standard evidence!&ased treatments for PTSD are effective for treating PTSD that occurs follo'ing chronic trauma$ At the same time, treating om%le) PTSD often involves addressing inter%ersonal difficulties and the s%ecific sym%toms mentioned a&ove$ Dr$ 7erman contends that recovery from om%le) PTSD reuires restoration of control and %o'er for the traumati>ed %erson$ Survivors can &ecome em%o'ered &y healing relationshi%s 'hich create safety, allo' for remem&rance and mourning, and %romote reconnection 'ith everyday life 1#$
'eferences 1$
7erman, =$ 1GG6#$ 0rauma and recovery" 0he aftermath of violence from domestic ause to political terror $ (e' Nor* 9asic 9oos$
2$
5ord, =$ D$ 1GGG#$ Disorders of e)treme stress follo'ing 'ar!>one military trauma* Associated features of Posttraumatic Stress Disorder or comor&id &ut distinct syndromes (ournal of .onsulting and .linical sychology , 46, 3!12$
3$
van der Hol, 9$ 200"#$ Develo%mental trauma disorder$ sychiatric Annals, '5:5;, .01!.0C$
.$
/oth, S$, (e'man, 8$, Pelcovit>, D$, van der Hol, 9$, < Mandel, 5$ S$ 1GG6#$ om%le) PTSD in victims e)%osed to se)ual and %hysical a&use* /esults from the DSM!I; field trial for Posttraumatic Stress Disorder$ (ournal of 0raumatic Stress, ) , "3G!"""$
Epidemiology of PTSD =aimie :$ Jradus, DSc, MP7
$%at is epidemiology, 8%idemiology is the study of the distri&ution and determinants of disease in a %o%ulation$ (umerous studies have &een conducted to assess the %revalence of PTSD across different %o%ulations$ 9elo' is a &rief revie' of some of the maor studies that have assessed the %revalence of PTSD in nationally re%resentative sam%les as 'ell as in sam%les of ;eterans$
$%at is prevalence, Prevalence is the %ro%ortion of %eo%le in a %o%ulation that have a given disorder at a given time$ It re%resents the e)isting cases of a disorder in a %o%ulation or grou%$ Prevalence estimates can &e influenced &y many factors including disorder occurrence if ne' disorder occurrences increase, %revalence 'ill increase# and the duration of the disorder the longer %eo%le live 'ith a disorder, the higher the %revalence#$ These estimates can also differ &y demogra%hic factors such as age and gender$ It is im%ortant to ualify %revalence estimates 'ith the time at 'hich they 'ere measured, as %revalence estimates can shift over time$ Similarly, 'hen inter%reting %revalence estimates, it is im%ortant to ee% in mind that %revalence is dynamic ! it can change over %eo%le, %laces, and time$ Often %revalence is discussed in terms of lifetime %revalence$ Other times, statistics 'ill &e given on current %revalence of PTSD in a given time frame, usually one year$ At the end of this fact sheet you 'ill find descri%tions of other terms commonly used in e%idemiology$
Prevalence of PTSD #$S$ National Comorbidity Survey Replication The (ational omor&idity Survey /e%lication (S!/#, conducted &et'een 5e&ruary 2001 and A%ril 2003, com%rised intervie's of a nationally re%resentative sam%le of G,2C2 Americans aged 1C years and older$ PTSD 'as assessed among ",4G2 %artici%ants, using DSM!I; criteria$ The (S!/ estimated the lifetime %revalence of PTSD among adult Americans to &e 4$C 1#$ urrent %ast year PTSD %revalence 'as estimated at 3$" 2#$The lifetime
%revalence of PTSD among men 'as 3$4 and among 'omen 'as G$6$ The t'elve month %revalence 'as 1$C among men and "$2 among 'omen 3#$ These findings are very similar to those of the first (ational omor&idity Survey$ The original survey 'as conducted in the early 1GG0s and com%rised intervie's of a re%resentative national sam%le of C,0GC Americans aged 1" to ". years$ In this earlier sam%le, the estimated %revalence of lifetime PTSD 'as 6$C in the general %o%ulation$ -omen 10$.# 'ere more than t'ice as liely as men "# to have PTSD at some %oint in their lives .#$
PTSD among c%ildren and adolescents To date, no %o%ulation!&ased e%idemiological study has e)amined the %revalence of PTSD among children$ 7o'ever, studies have e)amined the %revalence of PTSD among high!ris children 'ho have e)%erienced s%ecific traumatic events, such as a&use or natural disasters$ Prevalence estimates from studies of this ty%e vary greatly+ ho'ever, research indicates that children e)%osed to traumatic events may have a higher %revalence of PTSD than adults in the general %o%ulation "#$ Hil%atric and colleagues 2003# assessed the %revalence of PTSD among adolescents &ased on data from the (ational Survey of Adolescents, 'hich included a household %ro&a&ility sam%le of .,023 adolescents &et'een the ages of 12 and 16$ Fsing DSM!I; criteria for PTSD, the si)!month %revalence 'as estimated to &e 3$6 for &oys and 4$3 for girls 4#$
PTSD in ot%er countries In the late 1GG0s the -orld 7ealth Organi>ation -7O# &egan collecting e%idemiological information on mental health disorders around the 'orld$ As of 200C, the research consortium had collected data from nearly 200,000 res%ondents in 26 countries 6#$ Pu&lished estimates are availa&le of PTSD lifetime %revalence in most of the first 16 countries to com%lete the -orld Mental 7ealth Surveys$ In general, the estimates for lifetime PTSD %revalence range from a lo' of 0$3 in hina to 4$1 in (e' ealand$ 7o'ever, statistics re%orted from various countries are not directly com%ara&le due to methodological differences in survey administration and sam%ling strategies$
National &ietnam &eterans Read'ustment Study The (ational ;ietnam ;eterans /eadustment Study (;;/S# , conducted &et'een (ovem&er 1GC4 and 5e&ruary 1GCC, com%rised intervie's of 3,014 American ;eterans selected to %rovide a re%resentative sam%le of those 'ho served in the armed forces during the ;ietnam era$ The estimated lifetime %revalence of PTSD among these ;eterans 'as 30$G for men and 24$G for 'omen$ Of ;ietnam theater ;eterans, 1"$2 of males and C$1 of females 'ere currently diagnosed 'ith PTSD at the time the study 'as conducted C#$
(ulf )ar &eterans Hang and others conducted a study to estimate the %revalence of PTSD in a %o%ulation!&ased sam%le of 11,..1 Julf -ar ;eterans from 1GG" to 1GG6$ PTSD 'as assessed using the PTSD heclist P:+G# rather than intervie's, 'ith those scoring "0 or higher considered to have met criteria for PTSD$ The %revalence of current PTSD in this sam%le of Julf -ar ;eterans 'as 12$1$ 5urther, the authors estimated the %revalence of PTSD among the total Julf -ar ;eteran %o%ulation to &e 10$1 10#$
*peration +nduring ,reedom-*peration Ira.i ,reedom In 200C, the /A(D or%oration, enter for Military 7ealth Policy /esearch, %u&lished a %o%ulation!&ased study that e)amined the %revalence of PTSD among %reviously de%loyed O%eration 8nduring 5reedom and O%eration Irai 5reedom Afghanistan and Ira# service mem&ers 11#$ PTSD 'as assessed using the P:, as in the Julf -ar ;eterans study$ Among the 1,G3C %artici%ants, the %revalence of current PTSD 'as 13$C$
Commonly-used epidemiologic terms 1234 )%at is cumulative incidence/ umulative incidence sometimes called ris# is the %ro%ortion of %eo%le that develo% a disorder over time among only the %o%ulation at ris for that disorder$ It re%resents the occurrence of ne' cases of a disorder in a %o%ulation or grou%$
:ie %revalence, it is im%ortant to ualify cumulative incidence estimates 'ith the length of time over 'hich they are measured e$g$, over five years#$ This is &ecause a large cumulative incidence or a large amount of ne' disorder occurrence# occurring over a short %eriod of time has different intervention im%lications than a large cumulative incidence occurring over a very long %eriod of time$
)%at is a cumulative incidence ratio/ A cumulative incidence ratio sometimes called a ris ratio or a relative ris# is a relative measure of the cumulative incidence of disorder in a grou% e)%osed to a certain factor com%ared to the cumulative incidence of a disorder in a grou% that is une)%osed to that factor$
)%at is t%e incidence rate/ An incidence rate is the %ro%ortion of %eo%le 'ho develo% a disorder over a %eriod of time among the %o%ulation at ris for that disorder$ It re%resents the rate at 'hich ne' cases of a disorder are occurring in a %o%ulation or grou%$ Incidence rates are e)%ressed as the num&er of ne' cases of a disorder %er %erson!time$
)%at is an incidence rate ratio/ A rate ratio sometimes called relative ris#, is a relative measure of incidence rate of disorder in a grou% e)%osed to a certain factor com%ared to the incidence rate of a disorder in a grou% that is une)%osed to that factor$
)%at is an odds ratio/ An odds ratio sometimes called a relative ris# is a relative measure of the odds of a disorder in a grou% e)%osed to a certain factor com%ared to the odds of a disorder in a grou% une)%osed to that factor$
'eferences 1$
Hessler, /$$, 9erglund, P$, Delmer, O$, =in, /$, Meriangas, H$/$, < -alters, 8$8$ 200"#$ :ifetime %revalence and age!of!onset distri&utions of DSM!I; disorders in the (ational omor&idity Survey /e%lication$ Archives of General sychiatry, !2:!;* "G3!402$
2$
Hessler, /$$, hiu, -$T$, Demler, O$, Meriangas, H$/$, < -alters, 8$8$ 200"#$ Prevalence, severity, and comor&idity of 12!month DSM!I; disorders in the (ational omor&idity Survey /e%lication$ Archives of General sychiatry, !2:!;* 416!426$
3$
(ational omor&idity Survey$ 200"#$ (S!/ a%%endi) ta&les* Ta&le 1$ :ifetime %revalence of DSM!I;B-M7!IDI disorders &y se) and cohort$ Ta&le 2$ T'elve!month %revalence of DSM! I;B-M7!IDI disorders &y se) and cohort$ Accessed at* htt%*BB'''$hc%$med$harvard$eduBncsB%u&lications$%h%
.$
Hessler, /$$, Sonnega, A$, 9romet, 8$ 7ughes, M$, < (elson, $9$ 1GG"#$ Posttraumatic stress disorder in the (ational omor&idity Survey$ Archives of General sychiatry, 52:)2;, 10.C!1040$
"$
Ja&&ay, ;$, Oatis, M$D$, Silva, /$/$, < 7irsch, J$ 200.#$ 8%idemiological as%ects of PTSD in children and adolescents$ In /aul /$ Silva 8d$#,osttraumatic Stress Disorder in .hildren and Adolescents" 3andoo 1!16#$ (e' Nor* (orton$
4$
Hil%atric, D$J$, /uggiero, H$=$, Acierno, /$, Saunders, 9$8$, /esnic, 7$S$, < 9est, $:$ 2003#$ ;iolence and ris of PTSD, maor de%ression, su&stance a&useBde%endence, and comor&idity* results from the (ational Survey of Adolescents$ (ournal of .onsulting and .linical sychology , 61.#, 4G2!600$
6$
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Hang, 7$H$, (atelson, 9$7$, Mahan, $M$, :ee, H$N$, < Mur%hy, 5$M$ 2003#$ Post!Traumatic Stress Disorder and hronic 5atigue Syndrome!lie illness among Julf -ar ;eterans* A %o%ulation! &ased survey of 30,000 ;eterans$ American (ournal of #pidemiology , 1"62#*1.1!1.C$
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0vervie of Psyc%ot%erapy for PTSD
7am&len, PhD, Schnurr, PhD, /osen&erg, MA, < 8ftehari, PhD Several clinical %ractice guidelines offer recommendations for the treatment of PTSD, for e)am%le see the ;ABDoD PTSD linical Practice Juideline 2010#$ These guidelines come from different federal agencies, %rofessional organi>ations, and countries 1!"#$ The Institute of Medicine IOM# also %u&lished a re%ort in 2006 evaluating the evidence on PTSD treatment 4#$ The guidelines unanimously recommend cognitive &ehavioral thera%ies as the most effective treatment for PTSD, and the maority of guidelines recommend 8ye Movement Desensiti>ation and /e%rocessing 8MD/# as 'ell$ ognitive &ehavioral treatments ty%ically include a num&er of com%onents, including %sychoeducation, an)iety management, e)%osure, and cognitive restructuring$ 8)%osure and cognitive restructuring are thought to &e the most effective com%onents$
E#posure-(ased treatments The greatest num&er of studies has &een conducted on e)%osure!&ased treatments, 'hich involve having survivors re%eatedly re!e)%erience their traumatic event$ There is strong evidence for e)%osure thera%y 6!12#, and of the various a%%roaches, Prolonged 8)%osure P8# has received the most attention$ P8 C# includes &oth imaginal e)%osure and in vivo e)%osure to safe situations that have &een avoided &ecause they elicit traumatic reminders$ In a multisite randomi>ed controlled trial of P8 in female ;eterans and active!duty %ersonnel 'ith PTSD, those 'ho received P8 e)%erienced greater reduction of PTSD sym%toms relative to 'omen 'ho received %resent!centered thera%y and 'ere less liely to meet PTSD diagnostic criteria 13#$ Moreover, P8 'as more effective than the com&ination of P8 %lus stress inoculation training SIT#, SIT alone, or a 'aitlist control in female se)ual assault survivors 10#$ In addition, P8 alone and P8 %lus cognitive restructuring reduced PTSD and de%ression relative to a 'aitlist control in intention!to!treat and com%leter sam%les 11#$
Cognitive approac%es ognitive interventions also are 'idely su%%orted in treatment guidelines 12, 1"! 16#$ ognitive Processing Thera%y PT+ 1C#, one of the most 'ell!researched cognitive a%%roaches, has a %rimary focus on challenging and modifying malada%tive &eliefs related to the trauma, &ut also includes a 'ritten e)%osure com%onent$
;eterans 'ith chronic military!related PTSD 'ho received PT sho'ed &etter im%rovements in PTSD and comor&id sym%toms than the 'aitlist control grou% 1G#$ A dismantling study of PT then e)amined the relative utility of the full %rotocol com%ared 'ith its com%onents* cognitive thera%y alone and 'ritten e)%osure alone 20#$ /esults indicated significant im%rovement in PTSD and de%ression for %artici%ants in all three treatments$ 7o'ever, the cognitive thera%y alone resulted in faster im%rovement than the 'ritten e)%osure alone, 'ith the effects of the full %rotocol of PT falling in!&et'een 20#$ 9oth PT and P8 have sho'n great success in outcome research+ thus, one logical research uestion involves 'hether one is more effective than the other$ In a head!to!head com%arison, PT and P8 'ere eually effective in treating PTSD and de%ression in female se)ual assault survivors 6#$ 8hlers and lar have also develo%ed a cognitive thera%y for PTSD that involves three goals* modifying e)cessively negative a%%raisals, correcting auto&iogra%hical memory distur&ances, and removing %ro&lematic &ehavioral and cognitive strategies 21#$ 8lements uniue to 8hlers and larKs cognitive thera%y include %erforming actions that are incom%ati&le 'ith the memory or engaging in &ehavioral e)%eriments$ T'o randomi>ed controlled trials have com%ared cognitive thera%y to a 'aitlist, &oth 'ith %ositive results 1", 14#$
Adding components Some investigators have added a novel com%onent to an effective treatment in ho%es of further o%timi>ing outcomes 22!26#$ Three grou%s of investigators com%ared an enhanced treatment to a 'aitlist control grou%* loitre and colleagues 23# seuenced sills training in affect and inter%ersonal regulation &efore P8+ 5alsetti and colleagues 2.# develo%ed Multi%le hannel 8)%osure Thera%y, a com&ination of P8, PT, and interoce%tive e)%osure techniues for %anic disorder+ and :indauer and colleagues 26# develo%ed 9rief 8clectic Thera%y, a com&ination of %sychodynamic and cognitive &ehavioral thera%y$ These studies sho'ed that the com&ined treatments 'ere effective, &ut not 'hether the additional com%onents enhanced the standard treatments$ Jlynn and colleagues 2"# com%ared e)%osure thera%y alone 'ith e)%osure thera%y follo'ed &y &ehavioral family thera%y, and Arnt> and colleagues 22# com%ared imaginal e)%osure alone 'ith imaginal e)%osure %lus imagery rescri%ting$ In &oth studies, the com&ined treatment did not result in a greater reduction of PTSD severity, 'hich suggests that the novel com%onent 'as not
necessary$ 7o'ever, statistical %o'er may have &een too lo' to com%are the active treatments adeuately$
EMD' In addition to cognitive &ehavioral thera%ies, 8MD/ is recommended in most %ractice guidelines$ Patients receiving 8MD/ engage in imaginal e)%osure to a trauma 'hile simultaneously %erforming saccadic eye movements$ There is good evidence that 8MD/ is more effective than 'aitlist and nons%ecific com%arison conditions 2C!30#$ 5urther, t'o 'ell!controlled studies com%ared 8MD/ to P8$ One study found euivalent results 2G# 'hile the other found P8 to &e su%erior 30#$ Additional research has investigated the mechanism of action in 8MD/, and there is gro'ing evidence that the theori>ed eye movements are an unnecessary com%onent 31#, suggesting that %erha%s the mechanism of action is e)%osure$
0t%er approac%es Other treatments in addition to cognitive &ehavioral thera%y and 8MD/ may &e effective+ ho'ever, at this time 'e do not have enough evidence to confidently indicate that they are effective$ 5or e)am%le, des%ite the a%%eal of grou% treatments, results of the fe' randomi>ed controlled trials of grou% thera%y have &een mi)ed 32!34#$ In addition, %sychodynamic thera%y, hy%nothera%y, and trauma desensiti>ation 'ere more effective than a 'aitlist control grou% in one trial .0#$ /ogerian su%%ortive thera%y 'as less effective in treating sym%toms of PTSD and an)iety than cognitive &ehavioral thera%y in one study .1#$ Acce%tance and ommitment Thera%y AT#, 'hich is considered a third 'ave &ehavioral thera%y, focuses on reducing e)%eriential avoidance and engagement 'ith malada%tive thoughts and encourages clients to a%%roach activities consistent 'ith their %ersonal values$ Several case studies have documented su%%ort for AT in the treatment of PTSD 36, 3C#$ 7o'ever, no trials of AT for PTSD have &een %u&lished to date$ 5inally, there is also interest in alternative medicine treatments$ 5or e)am%le, acu%uncture 'as as effective as grou% cognitive &ehavioral treatment, and &oth 'ere more effective than the 'aitlist condition 3G#$
Conclusion Overall, cognitive &ehavioral thera%ies such as Prolonged 8)%osure and ognitive Processing Thera%y, as 'ell as 8ye Movement Desensiti>ation
/e%rocessing, are considered first!line treatments for PTSD and have strong evidence &ases$ om%onents of these treatments have &een com&ined 'ith other interventions, 'ith no su%%ort for im%roved &enefits over the standard treatments alone$ Other interventions, such as grou% treatment, sho' %romise+ ho'ever, more research is needed &efore dra'ing firm conclusions a&out their effectiveness$
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Clinicians !uide to Medications for PTSD Matt =effreys, MD
0vervie Posttraumatic Stress Disorder PTSD# has &iological, %sychological, and social com%onents$ Medications can &e used in treatment to address the &iological &asis for PTSD sym%toms and co!mor&id A)is I diagnoses$ Medications may
&enefit %sychological and social sym%toms as 'ell$ -hile studies suggest that cognitive &ehavioral thera%ies such as %rolonged e)%osure P8# and cognitive %rocessing thera%y PT# have greater effects in im%roving PTSD sym%toms than medications, some %eo%le may %refer medications or may &enefit from receiving a medication in addition to %sychothera%y$ Place&o!controlled dou&le!&lind randomi>ed controlled trials are the gold standard for %harmacothera%y$ :ess strongly su%%orted evidence includes o%en trials and case re%orts$ It is im%ortant for the clinician to uestion the level of evidence su%%orting the medications %rescri&ed in PTSD treatment$ There are a variety of factors influencing %rescri&ing, including mareting, %atient %references, and clinical custom, all of 'hich can &e inconsistent 'ith the evidence &ase$ urrently, the evidence &ase is strongest for the selective serotonin reu%tae inhi&itors SS/Is#$ The only t'o 5DA a%%roved medications for the treatment of PTSD are sertraline oloft# and %aro)etine Pa)il# 1, 2#$ All other medication uses are off la&el, though there are differing levels of evidence su%%orting their use$ In addition to sertraline and %aro)etine, there is strong evidence for the SS/I fluo)etine Pro>ac# and for the serotonin nore%ine%hrine reu%tae inhi&itor S(/I# venlafa)ine 8ffe)or# 'hich are considered first!line treatments in the ;ABDoD linical Practice Juideline for PTSD$ There are a num&er of &iological changes 'hich have &een associated 'ith PTSD, and medications can &e used to modify the resultant PTSD sym%toms$ ;eterans 'hose PTSD sym%toms have &een %resent for many years %ose a s%ecial challenge$ Studies indicate they are more refractory to the &eneficial effects of medications for PTSD sym%toms 3#$
$%at core PTSD symptoms are e trying to treat, The three main PTSD sym%tom clusters are listed &elo'* •
e*e'periencing 8)am%les include nightmares, un'anted thoughts of the traumatic events, and flash&acs$
•
Avoidance 8)am%les include avoiding triggers for traumatic memories including %laces, conversations, or other reminders$ The avoidance may generali>e to other %reviously enoya&le activities$
•
&#perarousal 8)am%les include slee% %ro&lems, concentration %ro&lems, irrita&ility, increased startle res%onse, and hy%ervigilance$
$%at are some of t%e (iological distur(ances found in PTSD, Some of the main &iological distur&ances in PTSD can &e conce%tuali>ed as dysregulation of the naturally occurring stress hormones in the &ody and increased sensitivity of the stress and an)iety circuits in the &rain$ There is dysregulation of adrenergic mechanisms that mediate the classical fight!flight or free>e res%onse$ Nehuda and others have found that %atients 'ith PTSD have hy%ersensitivity of the hy%othalamic!%ituitary!adrenal a)is 7PA# as com%ared to %atients 'ithout PTSD .#$ Patients have a much greater variation in their levels of adrenocorticoids than %atients 'ithout PTSD$ Other researchers have found differences in &oth &rain structures and &rain circuits that %rocess threatening in%ut &et'een %atients 'ith PTSD and those 'ithout$ It is not no'n for certain 'hether these changes 'ere %resent &efore the traumatic event and %redis%osed the %erson to develo%ing PTSD or 'hether these changes 'ere the result of the PTSD$ One 'ay to thin of this is the fear circuitry no longer &eing integrated 'ith the e)ecutive centers of the &rain located in the %refrontal corte) "#$ 8ven minor stresses may then set off the fight or flight res%onse in %atients 'ith PTSD, 'hich leads to increased heart rate, s'eating, ra%id &reathing, tremors, and other sym%toms of hy%erarousal listed a&ove$
"o do medications %elp regulate t%ese responses, The medications %rescri&ed for treating PTSD sym%toms act u%on neurotransmitters related to the fear and an)iety circuitry of the &rain including serotonin, nore%ine%hrine, JA9A, and do%amine among many others$ There is great interest in develo%ing ne'er, more s%ecific agents than are currently availa&le to target the PTSD sym%toms descri&ed earlier 'hile also minimi>ing %otential side effects of medications$ Studies sho' that a num&er of medications are hel%ful in minimi>ing the three sym%tom clusters of PTSD$ Most of the time, medications do n ot entirely eliminate sym%toms &ut %rovide a sym%tom reduction and are &est used in
conunction 'ith an ongoing %rogram of trauma s%ecific %sychothera%y for %atients such as P8 or PT$
"o do e measure t%e effects of treatment, There are a num&er of self!rating scales and structured clinical intervie's to monitor the effects of treatment$ T'o e)am%les include the Post!Traumatic Stress Disorder heclist P:# and the linician!Administered PTSD Scale APS#$ The P: military or civilian version is an e)am%le of a %atient self!rating form 'ithout stressor information, 'hile the APS is an e)am%le of a structured clinical intervie' including stressor information$ There is literature su%%ortive of a strong correlation &et'een the t'o measures, and the P: has the advantage of &eing uic and easy to administer$ 9oth the P: and the APS %rovide a uantitative measure of the %atientKs PTSD sym%toms and res%onse to treatment over time$ This information enhances the clinical assessment and intervie' 'ith the %atient$
$%at is t%e evidence (ase for t%e specific groups of medications used for PTSD treatment, Selective Serotonin Reupta0e In%ibitors 1SSRIs2 These medications are the only 5DA a%%roved medications for PTSD$ SS/Is %rimarily affect the neurotransmitter serotonin 'hich is im%ortant in regulating mood, an)iety, a%%etite, and slee% and other &odily functions$ This class of medication has the strongest em%irical evidence 'ith 'ell designed randomi>ed controlled trials /Ts# and is the %referred initial class of medications used in PTSD treatment 1, 2#$ 8)ce%tions may occur for %atients &ased u%on their individual histories of side effects, res%onse, and comor&idities$ •
An e)am%le of an e)ce%tion 'ould &e a PTSD %atient 'ith comor&id 9i%olar Disorder$ In this %atient, there is a ris of %reci%itating a manic e%isode 'ith the SS/Is$ 8ach %atient varies in their res%onse and a&ility to tolerate a s%ecific medication and dosage, so medications must &e tailored to individual needs$
/esearch has suggested that ma)imum &enefit from SS/I treatment de%ends u%on adeuate dosages and duration of treatment$ Treatment adherence is ey to successful %harmacothera%y treatment for PTSD$ 8)am%les of the SS/Is and some ty%ical dosage ranges are listed &elo'* •
Sertraline oloft# "0 mg to 200 mg daily
•
Paro)etine Pa)il# 20 to 40 mg daily
•
5luo)etine Pro>ac# 20 mg to 40 mg daily
* Only sertraline and %aro)etine have &een a%%roved for PTSD treatment &y the 5DA$ All other medications descri&ed in this guide are &eing used off la&el and may have em%irical su%%ort &ut have not &een through the 5DA a%%roval %rocess for PTSD$ Note:
*t%er ne3er antidepressants for PTSD Antide%ressants that 'or through other neurotransmitter com&inations or through different mechanisms for altering serotonin neurotransmission are also hel%ful in PTSD$ ;enlafa)ine acts %rimarily as a serotonin reu%tae inhi&itor at lo'er dosages and as a com&ined serotonin and nore%ine%hrine reu%tae inhi&itor at higher dosages$ It is no' a recommended first!line treatment for PTSD in the revised ;ABDoD linical Practice Juideline for PTSD &ased u%on large multi!site /Ts 4#$ There have &een smaller /Ts 'ith mirta>a%ine as 'ell as o%en trials 6#$ Mirta>a%ine may &e %articularly hel%ful for treatment of insomnia in PTSD$ Tra>odone is also commonly used for insomnia in PTSD even though there is little em%irical evidence availa&le for its use$ (efa>odone is still availa&le in a generic form &ut carries a &lac &o) 'arning regarding liver failure, so liver function tests need to &e monitored and %recautions taen as recommended in the medicationKs %rescri&ing information C, G#$ 8)am%les of the ne'er antide%ressants for PTSD and some ty%ical dosage ranges are listed &elo'* •
Mirta>a%ine /emeron# 6$" mg to ." mg daily
•
;enlafa)ine 8ffe)or# 6" mg to 300 mg daily
•
(efa>odone Ser>one# 200 mg to 400 mg daily
All of the antide%ressants descri&ed a&ove are also effective in treating comor&id Maor De%ressive Disorder MDD# 'hich often accom%anies PTSD$ -hile &u%ro%ion is useful in treating comor&id MDD, it has not &een sho'n effective for PTSD in controlled trials 10#$ A recent trial sho'ed su%erior outcomes on MDD 'hen mirta>a%ine 'as com&ined initially 'ith antide%ressants versus %atients &eing randomi>ed to monothera%y 'ith fluo)etine 11#$ This raises im%ortant uestions regarding costs, side effects, and %atient %references 'hich merit further study$
"ood stabili4ers for PTSD These medications, also no'n as anticonvulsants or anti!e%ile%tic drugs, either &loc glutamate or %otentiate JA9A or do &oth$ To%iramate has demonstrated %romising results in randomi>ed controlled trials 'ith civilians and ;eterans 'ith PTSD, &ut currently is listed as having no demonstrated &enefit in the ;ABDoD linical Practice Juideline for PTSD$ There are t'o dou&le!&lind, %lace&o!controlled trials evaluating to%iramate as monothera%y in civilians 'ith PTSD 12,13#$ The trial %u&lished in 2006 included 3C %artici%ants and found no significant difference in total APS scores &et'een to%iramate and %lace&o$ The 2010 trial included 3C %artici%ants and demonstrated a significant decrease in total APS scores$ There are also t'o %u&lished dou&le!&lind, %lace&o!controlled trials evaluating to%iramate as adunctive treatment for PTSD in ;eterans 1.,1"#$ The trial %u&lished in 200. included 46 %artici%ants and found a significant decrease in the total APS score$ The 2006 trial included .0 %artici%ants and sho'ed no significant decrease in total APS scores$ 9ased u%on the current studies, to%iramate could %rovide a useful o%tion for clinicians in treatment of PTSD sym%toms in %atients 'ho fail first line %harmacothera%y$ 5urther studies and meta!analyses are needed regarding the %lace of to%iramate in PTSD treatment 14#$ Other'ise, des%ite some %romising o%en la&el studies, other /Ts have &een negative for this grou% of medications in treating PTSD 16#$ As a grou%, this
class of medications is hel%ful in the treatment of comor&id 9i%olar Disorder and PTSD$ Patients 'ho have 9i%olar Disorder and PTSD often &enefit from these medications since SS/Is and other antide%ressants sometimes %reci%itate a manic e%isode$ Most reuire some regular la& 'or to monitor side effects$ (either lamotrigine nor to%iramate reuire la& 'or &ut must &e titrated slo'ly according to %acage insert directions to avoid %otentially serious side effects$ 8)am%les are given &elo'* •
ar.a!azepine (/egretol) /euires monitoring of 'hite &lood cell counts due to ris of agranulocytosis$ -ill self!induce its o'n meta&olism and increase the meta&olism of other medications including oral contrace%tives$
•
Divalproe' (Depa0ote) /euires monitoring of liver function tests due to ris of he%atoto)icity and %latelet levels due to ris of throm&ocyto%enia$ Target dosage is 10 times the %atientKs 'eight in %ounds$
•
1a!otrigine (1a!ictal) /euires slo' titration according to the %acage insert due to ris of serious rash$
•
/opira!ate (/opi!a') /euires clinical monitoring for glaucoma, sedation, di>>iness and ata)ia$
Atypical antipsyc%otics for PTSD -hile originally develo%ed for %atients 'ith a %sychotic disorder, this class of medications is &eing a%%lied to %atients 'ith many other %sychiatric disorders including PTSD$ They act %rimarily on the do%aminergic and serotonergic systems$ They can &e used 'hen a %erson 'ith PTSD has a %sychotic disorder$ There is some evidence that they are useful in ameliorating %sychotic sym%toms in PTSD %atients$ The real uestion is 'hether these medications are useful in PTSD 'hen %sychotic disorder or sym%toms are not %resent$ Previously, a num&er of small single!site studies suggested that aty%ical anti%sychotic agents 'ere effective adunctive treatment for PTSD %atients 'ho had %oor res%onses to first!line SS/Is or S(/Is 1C#$ A recent large!scale multi! site trial of ris%eridone as an adunctive agent for SS/I %oorB%artial res%onders sho'ed that there 'as no &enefit in com%arison 'ith a %lace&o grou%# for adunctive use of this agent$ As a result the recent ;ABDoD PTSD linical Practice Juideline has &een revised as follo's*
•
•
Aty%ical anti%sychotics are not recommended as monothera%y for PTSD$ /is%eridone /is%erdal# is contraindicated for use as an adunctive agent ! %otential harm side effects# e)ceeds &enefits$
•
There is insufficient evidence to recommend any other aty%ical anti%sychotic as an adunctive agent for PTSD$
*t%er medications for PTSD There are a num&er of other medications that can &e hel%ful for s%ecific PTSD sym%toms or that have &een used as second line agents including the follo'ing* •
Pra>osin Mini%ress#
•
Tricyclic Antide%ressants such as Imi%ramine#
•
Monoamine O)idase Inhi&itors MAOIs# such as Phenel>ine#
Pra>osin has &een found to &e effective in /Ts in decreasing nightmares in PTSD$ It &locs the noradrenergic stimulation of the al%ha 1 rece%tor$ Its effectiveness for PTSD sym%toms other than nightmares has not &een determined at this time 1G, 20#$ The tricyclic antide%ressants and MAOIs act on a num&er of neurotransmitters$ -hile there are /Ts su%%orting their use, these medications are not used as first line agents due to their safety and side effect %rofiles 21, 22#$ The tricyclics have uinidine lie effects on the heart and can cause ventricular arrhythmias es%ecially in overdose$ The MAOI %hene>ine has &een sho'n to &e effective in PTSD$ areful management of the MAOIs and strict dietary controls are im%ortant &ecause they can cause %otentially fatal hy%ertensive reactions 'hen taen 'ith other medications or certain foods rich in tyramine$ MAOIs can also %rovoe the %otentially fatal serotonin syndrome 'hen used concurrently 'ith SS/Is$ 9us%irone and &eta &locers are sometimes used adunctively in treatment of hy%erarousal sym%toms, though there is little em%irical evidence in su%%ort of this$ 9us%irone acts on serotonin and might reduce an)iety in PTSD 'ithout sedation or addiction$ There are some case re%orts su%%orting its use$ 9eta &locers &loc the effects of adrenalin e%ine%hrine# on organs such as the heart, s'eat glands, and muscles$ There is interest in using &eta &locers to %revent
PTSD, though the evidence at the current time does not su%%ort this$ 9eta &locers reduce the %eri%heral manifestations of hy%erarousal and may reduce aggression as 'ell$ They may &e used for comor&id conditions such as %erformance an)iety in the conte)t of social %ho&ia for e)am%le$
5en4odia4epines and PTSD 9en>odia>e%ines act directly on the JA9A system 'hich %roduces a calming effect on the nervous system$ /his is the onl# potentiall# addictive group of !edications discussed Studies have not sho'n them to &e useful in PTSD treatment as they do not 'or on the core PTSD sym%toms 23, 2.#$ There are several other concerns 'ith the &en>odia>e%ines including %otential disinhi&ition, difficulty integrating the traumatic e)%erience, interfering 'ith the mental %rocesses needed to &enefit from %sychothera%y, and addiction$ 9ecause of their %otential for addiction and disinhi&ition, they must &e used 'ith great caution in PTSD$ 8)am%les are listed &elo'* •
:ora>e%am Ativan#
•
lona>e%am Hlono%in#
•
Al%ra>olam ana)#
Developing ne medications for PTSD The %atho%hysiological mechanism of PTSD in the nervous system is unno'n, &ut there are several interesting areas that could lead to ne' drug develo%ment for the treatment or the %revention of PTSD$ There are com%eting hy%otheses a&out the role of glucocorticoids follo'ing trauma and their effects on the &rain$ It might &e %ossi&le to intervene at some level in the hy%othalamic!%ituitary!adrenal a)is or at the level of the glucocorticoid rece%tors in the &rain to modulate the effects of stress and the develo%ment of PTSD$ (euro%e%tides such as Su&stance P and (euro%e%tide N (PN# have &een im%licated in PTSD as 'ell 2"#$ om&at troo%s e)%osed to stress have &een found to have lo'er levels of (PN$ Perha%s altering this neuromodulator could im%rove the resiliency of the &rain to the effects of trauma$ One challenge 'ith this ne' focus research is dealing 'ith the &lood!&rain &arrier for introducing neuro%e%tides into the &rain$
D!cycloserine DS# has &een used in %anic disorder, s%ecifically %ho&ia and social %ho&ia, to enhance the effects of e)%osure thera%y 24#$ It is a %artial agonist of the glutamatergic (!methyl!D!as%artate (MDA# rece%tor$ 9ased u%on animal research su%%orting the use of DS to facilitate e)tinction of conditioned fear, it is hy%othesi>ed that use of DS in conunction 'ith e)%osure thera%y may reduce the num&er of %sychothera%y sessions reuired 26#$ This line of research recogni>es a %aradigm shift in the use of %harmacothera%y to assist learning during %sychothera%y as o%%osed to directly affecting PTSD sym%toms 2C#$ Memantine (amenda# is a drug of much interest in %reventing neurodegeneration &y %rotecting against glutamatergic destruction of neurons$ It has &een a%%roved for use in certain neurodegenerative conditions such as Al>heimerKs disease$ This drug could &e %otentially useful in %reventing hy%othesi>ed neurodegneration in the hy%othalamus and memory loss in PTSD$ urrent research is looing to'ards the %ossi&ility of one day intervening early in the course of PTSD 'ith a com&ination of %sychothera%y and %harmacothera%y that 'ould %revent the develo%ment of the %atho%hysiology of PTSD in the &rain$
Common (arriers to effective medication treatment in PTSD There are several common &arriers to effective medication treatment for PTSD 'hich are listed &elo'$ These need to &e addressed 'ith %atients in an ongoing dialogue 'ith their %rescri&ing clinician$ Side effects need to &e e)amined and discussed, 'eighing the riss and the &enefits of continued medication treatment$ Patient education a&out the side effects, necessary dosages, duration of treatment, and taing the medications consistently can im%rove adherence$ A sim%le intervention of setting u% a %ill organi>er 'eely can go a long 'ay to im%rove adherence$ •
5ear of %ossi&le medication side effects including se)ual side effects
•
5eeling medication is a crutch and that taing it is a 'eaness
•
5ear of &ecoming addicted to medications
•
Taing the medication only occasionally 'hen sym%toms get severe
•
(ot &eing sure ho' to tae the medication
•
Hee%ing several %ill &ottles and not remem&ering 'hen the last dosage 'as taen
•
Fsing self medication 'ith alcohol or drugs 'ith %rescri&ed medications
A final ord regarding medications and treatment for PTSD A more com%rehensive discussion of %harmacothera%y can &e found online in the ;ABDoD PTSD linical Practice Juidelines $ 9ased u%on current no'ledge, most %rescri&ing clinicians vie' %harmacothera%y as an im%ortant adunct to the evidenced &ased %sychothera%ies for PTSD$ -hile there are fe' direct com%arisons of %harmacothera%y and %sychothera%y, the greatest &enefits of treatment a%%ear to come from evidenced &ased thera%ies such as PT, P8, and %atients need to &e informed of the riss and &enefits of the differing treatment o%tions$ -hen using a com&ined a%%roach of medication and thera%y, it is im%ortant to ee% several %ractices in mind$ If treatment is &eing %rovided &y a thera%ist and a %rescri&er, it is im%ortant for the clinicians to discuss treatment res%onse and to coordinate efforts$ It is im%ortant for the %rescri&ing clinician to have an ongoing dialogue 'ith the %atient a&out their medications and side effects$ It is im%ortant for the %atient to tae an active role in his or her treatment rather than feeling they are a %assive reci%ient of medications to alleviate their sym%toms$ There is emerging evidence that 'hen given a choice, most %atients 'ill select %sychothera%y treatment for their PTSD sym%toms rather than medications$
6mportant Considerations •
Patients 'ith PTSD or an)iety disorders may &e very a'are of their somatic reactions, and it is im%ortant to start lo' and go slo' often on dosage adustments to im%rove %atient adherence$
•
9e sure to as female %atients of child&earing age a&out contrace%tion 'hen %rescri&ing medication$
•
9e sure to as all %atients a&out su&stance a&use as 'ell$
•
Once mediations are started, it is crucial that the %rovider remem&er to discontinue medications 'hich are not %roving efficacious and to sim%lify the num&er and ty%es of medications used 'henever %ossi&le$
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