What Is PTSD? Signs, Symptoms and Diagnosis

What is PTSD? Introduction

Mankind’s earliest literature tells us that a considerable proportion of military casualties are psychological, and that witnessing horror of war can leave chronic psychological symptoms.

Post-traumatic stress disorder (PTSD) is a cluster of symptoms developed in people exposed to traumatic life-threatening events.

PTSD can develop not only people directly harmed by trauma but also those witnessing such events by other individuals, especially those emotionally closed to them.

The triggering events for PTSD could be war trauma, torture, being taken hostage, terrorist attack, serious accidents, physical or sexual assaults, natural or man-made disasters.

The term called today PTSD and its diagnostic criteria changed over the past hundred years. The diagnosis was initially referring to the combat trauma. In the past half century, the diagnosis relates not only to soldier but also to other individuals struck by a sudden trauma causing the same symptoms initially observer only by the military personnel.

In the following text we explain what PTSD is, the evolution of the diagnosis, its current criteria as well as PTSD significant signs and symptoms.

From Shel Shock to PTSD

The modern sciences became aware of the psychological combat damage caused by the traumas of World Wars I. The term “Shell Shock” was created during the WW I, describing psychological impact of the soldiers living for years in the trenches, under constant shelling and seeing the massacred bodies of their brothers in arms. At the beginning of the 20th century military doctors called the condition “shell shock”. At the same time psychiatrists coined for the combat trauma the term “Traumatic War Neurosis” following the terminology of Freud’s psychoanalysis. The psychoanalysis became also the first psychotherapy method used in PTSD treatment. Later more effective therapy methods such as Eye Movement Desensitization and Reprocessing (EMDR), Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) followed.

During WW II, the combat trauma remained but it was renamed into the less shocking term: “Battle Fatigue”. For long time the military establishment neglected the psychological impact of the combat trauma. During WW II, the American general George Patton struck two soldiers finding them at evacuation hospitals away from the front lines without visible physical injuries.

PTSD, a psychiatric disorder

The 1952 edition of the DSM-I includes the diagnosis of “Gross Stress Reaction”, which was similar to the modern definition and understanding of PTSD. “Gross Stress Reaction” was defined as a “normal personality utilizing established patterns of reaction to deal with overwhelming fear” as a response to “conditions of great stress”.

The term “Post Traumatic Stress Disorder, (PTSD)” came into use in the 1970s. The new awoken interest for PTSD raised as the consequence of the Vietnam war and high number of traumatized US military veterans. PTSD was officially recognized as a psychiatric disorder by the American Psychiatric Association in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).

Signs and symptoms of PTSD

People with PTSD experience feelings of panic or extreme fear, similar to the fear they felt being exposed to the traumatizing situation. The most common PTSD symptoms are:

• The person relives the traumatic event through intrusive and recurring memories, in particular vivid images and nightmares. Those memories are causing usual intense emotional and physical reactions, such as extreme fears, heart palpitations, sweating, and other somatic symptoms.

• The person is overly alert or wound up, suffering from insomnia, irritability, lack of concentration, becoming easily startled and constantly on the lookout for signs of danger.

• The affected individual deliberately avoids activities, places, people, thoughts or feelings associated with the traumatizing event.

• In the chronic stage of the PTSD other symptoms such as loss of interest in day-to-day activities, social detachment and feeling of numbness, appear.

The individuals affected by PTSD develop often other mental health problems most commonly depression, anxiety, and alcohol or drug abuse.

PTSD is a natural response to danger and is almost unavoidable in the short term. In long term it possesses self-correcting dynamics reducing in most of the cases the severity of the symptoms. Only about 20 percent of people exposed to trauma react with long-term (chronic) PTSD.

Diagnosis and classification

DSM-V has made a number of important changes to the criteria of post-traumatic stress disorder. The most significant difference to the previous version, DSM IV is the more specific definition of the type and nature of the exposure to a threat. While DSM-IV classified PTSD under anxiety disorders, DSM-V created a new category called “Trauma- and Stressor-Related Disorders,” in which PTSD is now classified.

DSM V is the diagnostic manual predominantly use in the USA. The World Health Organization (WHO) uses a different manual called “International Classification of Diseases” or in its abbreviation “ICD”. The current version of this manual is the ICD 10. It has become the international standard diagnostic classification for most general epidemiological purposes. The ICD-10 classification also provides guidelines for the diagnosis of PTSD. There are only minor differences between DSM V and ICD 10 regarding the PTSD criteria.

The diagnostic category for PTSD provides a psychiatric manual allowing to identify the disorder. However, quantifying the symptoms could not capture the human dimension of the individual’s suffering.

DSM V Classification

PTSD can be difficult to diagnose, because numerous factors can lead to over-reporting and under-reporting symptoms, dysfunction and distress. The statistics manuals such as ICD 10 and DSM V provide coherent and standardized diagnostic criteria. In the chapter below we present the DSM V criteria helpful by identifying a PTSD. The DSM-V Diagnostic Criteria of American Psychiatric Association categorizes the general criteria in diagnosing PTSD in adults.

Exposure

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Symptoms

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s). The symptoms beginn or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Avoidance

C. Persistent avoidance of stimuli associated with the traumatic event(s). The symptoms beginn or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings closely associated with the traumatic event(s).
2. Avoidance of external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings closely associated with the traumatic event(s).

Negative alterations

D. Negative alterations in cognitions and mood associated with the traumatic event(s). The symptoms beginn or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

Marked alterations

E. Marked alterations in arousal and reactivity associated with the traumatic event(s). The symptoms beginn or worsen after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behaviour.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
7. Duration of the disturbance is more than 1 month.

Disturbances

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

G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

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