The syndrome currently called posttraumatic stress disorder (PTSD) has long been recognized in survivors of interpersonal violence such as military combat and sexual assault. However, it was not until the 1980 publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) that PTSD was officially codified in the psychiatric nomenclature. The current DSM-IV criteria stipulate the following for a PTSD diagnosis: (a) exposure to a traumatic event accompanied by (b) intense feelings of helplessness, horror, or fear, and followed by (c) more than one month of (d) clinically significant distress arising from three categories of symptoms: (1) re-experiencing symptoms (intrusive memories, nightmares, flashbacks, intense physiological or emotional responses when reminded of the trauma), (2) avoidance and/or numbing symptoms (effortful evasion of thoughts, feelings, people, or places that are reminiscent of the trauma; amnesia about the trauma; reduced interest in previously enjoyed activities; emotional detachment from others; reduced capacity for pleasure; or expectations of a truncated future), and (3) elevated arousal or arousability symptoms (insomnia, irritability, distractibility, hyper vigilance, or exaggerated startle reactions).
Associated Features
There are also a number of psychiatric disorders, symptoms, and characteristics that commonly co-occur with PTSD but that are not part of the core diagnostic criteria. For example, PTSD patients frequently meet criteria for depression, substance abuse, or other anxiety disorders (e.g., panic disorder). PTSD patients also typically report social withdrawal, relationship problems, guilt, shame, difficulty managing emotions, risky or impulsive behavior, personality changes, disruptions in normally integrated aspects of consciousness (also known as dissociation), and medically unsubstantiated physical complaints (also known as somatization). Finally, PTSD patients generally suffer from cognitive distortions such as exaggerated perceptions of danger, vulnerability, and powerlessness that are inappropriately generalized from their trauma experience to many post trauma situations.
Other Factors Associated With PTSD
A large body of research has been devoted to identifying predictors of PTSD. However, because most of these variables have only been assessed retrospectively after trauma exposure rather than before or during trauma, it is unclear whether they are actually predictive of or merely associated with PTSD. Two meta-analyses have identified the following variables listed in descending order of their strength of association with PTSD: lower social support, greater peritraumatic dissociation (i.e., experiencing time distortion, disrupted sense of reality, or other major disturbances of cognition or perception during a traumatic event), greater exposure to nontraumatic life stress, more intense peritraumatic emotions (i.e., intense emotions occurring during the traumatic event), greater perceived life threat during the trauma, greater trauma severity, lower intelligence, lower socioeconomic status, childhood abuse, family history of psychiatric disorder, previous adulthood trauma, history of pretrauma psychiatric difficulties, lower education, and younger age. Other factors associated with PTSD but not included in these meta-analyses include more neurotic traits, less controllability, and less predictability during the trauma, and less active coping or more passive coping after the trauma.
In addition, there is now a substantial literature identifying biological differences between people with and without PTSD. These studies indicate that people with PTSD show higher resting physiological activity in domains such as heart rate, blood pressure, and sweat gland activity; greater physiological reactivity to startling sounds and trauma reminders; increased activity in the fear center of their brains (i.e., amygdala) and decreased activity in regions of their brains involved in inhibiting emotion (e.g., anterior cingulate); abnormalities in regions of their brains involved in memory (e.g., hippocampus); and lower levels of a stress hormone involved in attenuating the stress response (i.e., cortisol).
General Epidemiology
PTSD is one of the top five most common psychiatric disorders in the United States. Between 15% and 24% of trauma-exposed adults and 7% to 10% of the general adult population will likely have PTSD in their lifetime. Several studies have reported that ethnic minorities (especially Latino Americans) have higher rates of PTSD than Caucasian Americans. With regard to gender, females typically have twice the rate of PTSD of their male counterparts. Studies report lifetime rates of PTSD between 10% and 14% for women and between 5% and 6% for men.
Interpersonal Violence Trauma Versus Other Trauma Types
The types of trauma that qualify for the PTSD diagnosis include experiencing, witnessing, or learning about an event involving serious injury, threat to physical integrity, and/or death. Risk for PTSD rises with increased frequency, magnitude of severity, and type of trauma exposure. Traumatic events involving interpersonal violence are particularly likely to lead to PTSD. For instance, in individuals who have been exposed to combat, physical or sexual abuse, violent crimes, or refugee experiences, PTSD prevalence rates can be as high as 65% as compared to rates of under 8% in those exposed to disasters, accidents, or who learned of traumatic events happening to others. Furthermore, prior exposure to interpersonal violence increases the likelihood that an individual will develop PTSD upon subsequent trauma exposure. The increased risk is nearly fivefold if an adult was repeatedly exposed to interpersonal violence in childhood and approximately tenfold if the subsequent trauma exposure involves further interpersonal violence.
Exposure to interpersonal violence appears to partially account for gender differences in PTSD in complex ways. For both males and females, exposure to interpersonal violence confers the highest risk for PTSD. In males, this risk is linked to exposure to combat and for females the risk is linked to sexual assault. Though males and females report approximately equal exposure to other types of trauma (e.g., accidents, natural disasters), males report higher rates of exposure to most types of interpersonal violence, with the notable exception of sexual assault to which females report more exposure. Paradoxically, with the exception of sexual assault that triggers more PTSD in men (65%) than women (46%), other forms of interpersonal violence are more likely to trigger PTSD in women than in men. Specifically, one study found that over half of PTSD cases in women were due to interpersonal violence compared with approximately 15% in men. Another study found that, whether or not sexual assault was included in the analysis, about one third of women exposed to interpersonal violence developed PTSD as compared with 6% of men. These findings appeared to be unique to interpersonal trauma. No other category of trauma exposure yielded gender differences in risk for PTSD. Some have argued that the gender difference in susceptibility to PTSD following interpersonal violence is due to women’s greater tendency to respond to interpersonal violence with avoidance and numbing symptoms, which are thought to prolong other categories of PTSD symptoms. Another possibility is that contexts in which interpersonal violence occurs for men and women may be very different. Women may be more likely to encounter interpersonal violence at the hands of their domestic partner, a difference that increases their vulnerability and likelihood for repeated violence.
Treatment
PTSD is commonly treated with either medication or psychotherapy. Among psychopharmacologic treatments, selective serotonin-reuptake inhibitors (such as Paxil or Zoloft) are commonly prescribed. All psychotherapies potentially offer a supportive and collaborative relationship, which has been shown to be in part related to recovery. However, different brands of psychotherapy also offer specific techniques that target particular problems associated with PTSD. Behavioral therapies (e.g., prolonged exposure, eye movement desensitization, and reprocessing) focus on reducing the anxiety associated with re-experiencing symptoms by eliminating avoidant behaviors. Cognitive therapies (e.g., stress inoculation training) focus on education about PTSD, correcting distorted attributions, challenging negative or irrational thoughts, and teaching new coping skills. Psychodynamic therapies (e.g., time limited dynamic therapy) focus on regulating defenses, fostering insight, providing a safe context for remembering trauma, and helping the patient to integrate a sense of meaning regarding the trauma. Transpersonal therapies (e.g., holotropic breathwork, shamanic counseling) focus on the role that spiritual factors play in healing trauma. Some of these approaches (particularly the cognitive and behavioral) are supported by controlled studies. However, many other types of therapy have not been adequately tested, so their efficacy remains unknown.
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