Post-Traumatic Stress Disorder Research Paper

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1. Introduction

Psychological responses to the experience of traumatic events have long been recognized, although the meaning attached to and the terms used to describe such reactions have varied over the years, and continue to do so, influenced by the prevailing beliefs and interests of the time and depending on the culture studied. ‘Post-traumatic stress disorder’ (PTSD) is the term now given, at least in Western psychiatry, to a constellation of symptoms which may follow exposure to a traumatic event, and which cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The word ‘trauma’ is derived from ancient Greek surgical terminology, meaning an injury stemming from penetration of the body defense (intactness) such as skin. Exposure to major trauma does not cause psychiatric disorder in all those who experience it, possibly due, at least in part, to differences in vulnerability and resilience. The concept of PTSD has been extended from adults to include children, although it is still uncertain to what extent the developmental status of the child influences the symptoms (Scheeringa et al. 1995). The child’s perception of its family’s reaction to a disaster may also be relevant.

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Unfortunately, the recent burgeoning of interest in PTSD has perhaps given some the idea that PTSD is the only response after trauma. This is not the case (see Udwin 1993 for a discussion regarding children). It should be emphasized at the outset that PTSD is only one of a number of possible psychological sequelae of traumatic experiences, and the concept is not without its critics.

2. History

Early descriptions of the reactions of individuals and societies during the pre-Christian period, including the Sumerian, Hebrew, and Ancient Greek eras, are described by Boehnlein and Kinzie (1992). More recent examples which have been described include the response of Samuel Pepys, as described in his diary after the Great Fire of London in 1666. Pepys wrote of his ‘dreams of the fire and falling down of houses,’ and even six months later described how he was unable to sleep ‘without great terrors of fire’ (Daly 1983). Charles Dickens, the English novelist, was involved in a railway accident in June 1865, and also helped in rescuing others. He subsequently became anxious about travelling, and wrote, ‘I am not quite right within, but believe it to be an effect of the railway shaking’ (Trimble 1984). Two years after the accident, he was still experiencing ‘sudden vague rushes of terror’ (Ackroyd 1999).

The development of the railways stimulated interest in the psychological responses to traumatic events. Doctors at that time noted that there were many victims of railway accidents who appeared to suffer no physical injury and yet who complained of a variety of symptoms. Indeed, the term ‘compensation neurosis’ was introduced in 1879 following the increase in invalidism reported after railway accidents. Some argued that post-traumatic symptoms were the result of physical damage to the nervous system following relatively mild trauma. John Eric Erichsen, a professor of surgery at University College Hospital, London, used the term ‘railway spine’ to describe such injuries. A contrary view was taken by others. Herbert Page, a London surgeon, proposed in 1885 that accident victims were suffering from ‘nervous shock,’ attributable to a functional (psychological) disturbance rather than physical injury. Jean-Martin Charcot, a Parisian neurologist, supported the psychological model, arguing that the syndrome of ‘railway spine’ was a form of hysteria. He believed that, in the immediate aftermath of an accident, the victims were in a suggestible state and that their own idea of physical injuries influenced the development of symptoms. Charcot, in turn, influenced Sigmund Freud, who later suggested that the physical symptoms of hysteria were due to the repressed memories of traumatic events. The development (in many countries) of workmen’s compensation acts, which provided for financial compensation to those injured during the course of work, also led to increased interest in the psychological effects of traumatic experiences (Trimble 1984).

A major influence on the development of the concept of PTSD has been war. The belief that the psychological responses to traumatic experiences were the result of physical injury or dysfunction of the central nervous system was strongly held and represented in the concept of ‘shell-shock’ which prevailed during the First World War in Europe. During the First World War, the British Army reported that seven to ten percent of the officers and three to four percent of the other ranks suffered ‘mental breakdowns’ (Gersons and Carlier 1992). Some soldiers were treated as cowards and deserters, and punished. The number of death sentences passed was 3,500, of which approximately 282 were executed prior to 1917. However, many more were considered ill and in need of treatment (Deahl 1997). Some, such as the Scottish doctor, William Rivers, saw the problem as a psychological one, and tried psychological techniques, such as abreaction and catharsis, as well as simply letting the person talk about their traumas. Rivers held that repression explained how an individual suppressed painful and terrifying experiences, and that these later became converted into physical and mental symptoms. World War II also produced large numbers of psychiatric casualties, despite more stringent recruit selection. Mental disorder accounted for 31 percent of medical discharges from the British Army.

After wars, increased rates of mental illness have been reported in service veterans who have seen combat. For example, between 1964 and 1975, 3.14 million US servicemen and women served in the war in Vietnam. Approximately 58,000 died and 300,000 were wounded. Of combatants, 20 percent witnessed atrocities or abusive violence. It has since been estimated that, of all US Vietnam veterans, approximately 15 percent (450,000) currently suffer from PTSD, whilst an additional 11.1 percent of male and 7.8 percent of female veterans suffer at least some symptoms of traumatic stress related to the experience in Vietnam (see Deahl 1997 for a review).

Psychological sequelae in both adults and children, including PTSD, have now been reported after a wide variety of traumatic events, such as a fire in a nightclub in Boston (Lindemann 1944), and, more recently, after a variety of both human-made and natural disasters, kidnapping, torture, and road traffic accidents, as well as in rape victims, after abuse, in refugees, after domestic violence, and even after childbirth. Epidemiological studies suggest that PTSD or subthreshold PTSD may be present in a significant proportion of a population, although it may not be recognized as such. Comorbidity may be present.

3. Classification

Attempts have been made to categorize responses to traumatic experiences. Publication of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I ) (American Psychiatric Association 1952) coincided with the Korean war, and included the categories of ‘gross stress reactions’ and ‘anxiety neurosis transient situational disturbance’ with reference to ‘response to overwhelming environmental stress.’ The second edition (DSM-II ) (American Psychiatric Association 1968), which developed during a period of relative global peace, eliminated the diagnostic category of gross stress reaction.

In 1980, diagnostic criteria for PTSD were described in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III ) (American Psychiatric Association 1980). These criteria were based on information obtained from Vietnam veterans, and probably also reflected the experience of Holocaust concentration-camp survivors from World War II. The diagnostic criteria were modified in the revised edition (DSM-III-R) published in 1987. There was increasing emphasis on avoidance phenomena. It was acknowledged that children may be affected, that ‘survivor guilt’ was not a primary feature, and that symbolic reminders of the trauma may be important.

Meanwhile, in Europe, the ninth revision of the International Classification of Diseases (ICD-9) (World Health Organization [WHO] 1978) incorporated the subcategories of ‘acute reaction to stress’ and ‘adjustment reaction’ following exposure to acute stress. Acute reaction to stress described transient responses to exceptional physical or mental stress, lasting only a few hours to a few days. Adjustment reactions were longer lasting, but usually lasted only a few months.

The diagnostic criteria are presently defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ), published by the American Psychiatric Association in 1994, and The ICD-10 Classification of Mental and Behavioural Disorders, published by the World Health Organization in 1992. There is also the publication The ICD-10 Diagnostic Criteria for Research (World Health Organization 1993). According to ICD-10, PTSD is a delayed and/or protracted response to a stressful event or situation (either shortor long-lasting) of an exceptionally threatening or catastrophic nature (including serious accident). Typical symptoms include episodes of repeated reliving of the trauma in intrusive memories or dreams, a sense of numbness and emotional blunting, with feelings of detachment from other people, inability to enjoy activities, and avoidance of activities and situations reminiscent of the trauma. Other symptoms, such as hyperarousal of the autonomic nervous system, hyper vigilance, an enhanced startle reaction, difficulty sleeping, anxiety, and depression may also be present. The ICD-10 Diagnostic Criteria for Research are similar, but specify that there must be persistent remembering or ‘reliving’ of the stressor in intrusive ‘flashbacks,’ vivid memories, or recurring dreams, or in experiencing distress when exposed to circumstances resembling or associated with the stressor. In addition, for the diagnosis of PTSD to be made using these criteria, there should be an actual or preferred avoidance of circumstances which resemble or are associated with the stressor, which was not present before exposure to the stressor, and either an inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor, or persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor), as shown by any two of the following—difficulty sleeping, difficulty concentrating, irritability or outbursts of anger, hypervigilance, or an exaggerated startle reaction. These symptoms should have started within six months of the stressor.

According to DSM-IV, PTSD occurs after a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person’s response should have involved intense fear, helplessness, or horror. For the diagnosis of PTSD, the individual should be persistently re-experiencing the traumatic event, such as experiencing recurrent and intrusive distressing recollections of the event (which, in children, may be manifest in repetitive play in which themes or aspects of the trauma are expressed), having recurrent distressing dreams of the event (in children, the content of the dreams may be less recognizable), acting or feeling as if the traumatic event were recurring, experiencing intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event, or experiencing physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. There should be evidence of persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that arouse recollections of the trauma, an inability to recall an important aspect of the trauma, markedly diminished interest or participation in significant activities, a feeling of detachment or estrangement from others, a restricted range of emotions, a sense of a foreshortened future. There should also be at least two persistent symptoms of increased arousal (not present before the trauma), such as difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, an exaggerated startle response. These symptoms should have lasted more than one month and be causing clinically significant distress or impairment in social, occupational, or other important areas of functioning. ‘Delayed-onset’ PTSD may be seen where a person initially appears to have dealt with a traumatic experience but, perhaps years later, symptoms of PTSD develop, possibly after a reminder of the original trauma or after a relatively trivial incident.

While diagnostic classification systems are useful, they are not a checklist, and clinical judgment is considered essential in their use. Criteria are not ‘written in stone’ but evolve in the light of clinical experience and information from research. For example, there is ongoing discussion about the validity of the ‘stressor criterion,’ since PTSD may occur after seemingly minor accidents. It seems likely that, in the future, there will be attempts to eliminate as many differences as possible between the ICD and DSM systems of classification.

4. Theoretical Models

The concept of PTSD has been accompanied by a variety of theoretical models (neuropsychiatric, psychoanalytical, cognitive-behavioral) to explain its origins and maintenance in the traumatized individual. For example, a number of psychobiological findings in PTSD, such as altered autonomic function and alterations in the hypothalamic–pituitary–adrenal axis, and studies of endogenous opioids (such as encephalins) may be relevant. Psychoanalytic models include those which regard the re-experiencing phenomena as primary, leading to defensive functioning, and those which regard the reaction to the stressor as a failure of adaptation. Common to all dynamic models is a concern with the meaning a person gives to a traumatic event and/or its aftermath. Behavioral models of PTSD have used the principles of conditioning theory to explain the development and maintenance of PTSD, while cognitive models of PTSD have included the concepts of learned helplessness, the attributional style of individuals, cognitive appraisal, and, more recently cognitive-processing theory. However, no single model offers a comprehensive view of PTSD. It has also been suggested that an understanding of memory may assist in the understanding of the phenomenology of responses seen after traumatic events. It is to be hoped that a clearer understanding of the origins of PTSD will help in the development of effective therapeutic techniques.

5. Assessment

There are a number of questionnaires or scales which may be used to help assess the psychological responses of traumatic events. Davidson et al. (1997) describe a 17-item self-rating scale for PTSD, which measures each DSM-IV symptom on five-point frequency and severity scales. Costello et al. (1998) have described a new measure of life events and PTSD for children and adolescents aged nine to seventeen years, for use in both epidemiological and clinical studies. One of the most widely used questionnaires in either research into, or clinical work on, the psychological sequelae of traumatic events, is the Horowitz Impact of Event Scale (Horowitz et al. 1979). This is a 15-item self-rating scale with two subscales: intrusion and avoidance. It is normally used to assess the response after a single traumatic event, rather than after exposure to a chronic stressful situation. It gives a subjective estimate of the frequency of intrusive recall of the traumatic event and of attempts to avoid such recall, and thus a measure of psychological disturbance when compared to normative data. It does not include questions about physiological reactivity and cannot, therefore, be used to make any diagnosis. It was not originally designed for use with children but has been shown to be useful in those aged eight years and over. A score of 20 or above is often considered to be a cause for concern for civilians in peacetime, although others have used a score of 30 or above to indicate significant post-traumatic stress.

6. Treatment

A variety of approaches are presently used, both in adults and in children. In adults, behavioral and cognitive approaches have been increasingly used over the past 15 years or so, usually involving exposure (either real-life or imagined), cognitive therapy, or anxiety management training. Clinically, exposure and cognitive restructuring are often included in an anxiety management program. Psychotherapy may be individual, group, or with a family. A further technique, ‘eye movement desensitization and reprocessing’ (EMDR), may be a useful therapeutic technique, but its value and the mechanism of any effects that it has require further elucidation. There is little evidence that drug treatments have a central role in the treatment of PTSD.

The emphasis when treating children has been on cognitive behavioral approaches that aim to help survivors of a traumatic event make sense of what has happened and to master their feelings of anxiety and helplessness. Sometimes support may be appropriately offered in groups. Since children live with adults, whose reactions to events are part of the context of that event for the child, most treatment plans for children should involve both families and schools. This may be especially relevant when the adults have themselves experienced the traumatic event. Distress in the adults may mean that they are less able to recognize distress in the children for whom they have responsibility, or that they are relatively unavailable to respond to the children’s needs.

Further research is needed to evaluate the effectiveness of the differing therapies and also to determine the effectiveness of screening populations at high risk of PTSD (for example, after a major disaster) to find out whether any interventions may prevent the development of PTSD or other psychiatric morbidity in those identified as being especially at risk. However, there is no clear evidence that offering counseling routinely to all survivors of traumatic events is helpful—indeed, there is some suggestion that it may be harmful (Wessely et al. 2000).

7. Areas Of Controversy

PTSD is an evolving concept. There has been continuing debate on whether individual, as opposed to stressor characteristics, are decisive in the development of PTSD. It may be inappropriate to use a single medical concept to describe the responses seen after different traumatic experiences. Distress after the experience of traumatic events has been variously interpreted in the past. The current emphasis on the ‘medicalization of distress’ in Western cultures may, perhaps, reflect the prevailing expectations of that society and culture. It is still unclear whether it is appropriate to use a concept which has developed in Western psychiatry to other cultures, and how appropriate it is to extend the concept to describe the responses seen after a wide range of traumatic events. The present classifications assume a dichotomous rule—disorder is either present or absent, with no opportunity to consider severity.

An important consequence of the diagnostic category of PTSD is that it has facilitated, and perhaps encouraged, claims for compensation after traumatic events. Clinicians undertaking forensic assessments are advised that diagnostic criteria are clinical guidelines, and that there may be an imperfect fit between questions of ultimate concern to the law and information contained in a clinical diagnosis.

8. Conclusions

The concept of PTSD is an evolving one, of uncertain value, and it seems likely that there will be further developments and refinements in our understanding of individual responses to traumatic events, and how best to describe and classify them. The importance of developmental influences, the significance of symptoms in differing cultures, and the risk and protective mechanisms involved require further attention.


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