PTSD

Trauma- and Stressor-Related Disorders

  • Acute Stress Disorder

  • Adjustment Disorders

  • Posttraumatic Stress Disorder (PTSD)

Posttraumatic Stress Disorder (PTSD)

Definition

  • Exposure to actual or threatened death, serious injury, or sexual violence that threatens personal safety:

    • Directly experiencing the traumatic event(s)

    • Witnessing the events as they occur to others

    • Learning that the traumatic events occurred to a person close to them

    • Experiencing repeated or extreme exposure to aversive details of trauma

Symptoms

Presence of Intrusive Symptoms

  • One or more intrusive symptoms after the event, which may include:

    • Recurrent, involuntary, and intrusive memories of the event

    • Recurrent trauma-related nightmares

    • Dissociative reactions (flashbacks)

    • Intense physiologic distress at cue exposure

    • Marked physiological reactivity at cue exposure

Persistent Avoidance

  • Persistent avoidance of both:

    • Distressing memories, thoughts, or feelings about the event(s)

    • External reminders that arouse memories of the event(s) (e.g., people, places, activities)

Changes in Cognitions and Mood

  • Symptoms may include:

    • Inability to remember an important aspect of the traumatic event(s)

    • Persistent distorted cognitions about the cause or consequence of the event that lead to self-blame or blaming others

    • Persistent negative emotional state

    • Marked diminished interest in activities

    • Feelings of detachment from others

    • Persistent inability to experience positive emotions

Changes in Arousal and Reactivity

  • Symptoms may include:

    • Irritable behavior and angry outbursts

    • Reckless or self-destructive behavior

    • Hypervigilance

    • Exaggerated startle response

    • Problems with concentration

    • Sleep disturbances

Epidemiology

  • Prevalence rates indicate:

    • 7-9% of the general population

    • 60-80% of trauma victims

    • 30% of combat veterans

    • 50-80% of sexual assault victims

    • Increased risk in women and younger individuals

    • Risk increases with "dose" of trauma, lack of social support, and pre-existing psychiatric disorders

Comorbidities

  • Common disorders co-occurring with PTSD:

    • Depression

    • Other anxiety disorders

    • Substance use disorders

    • Somatization

    • Dissociative disorders

Acute Stress Disorder

Definition

  • Similar exposure to traumatic events as in PTSD, with symptoms manifesting as:

    • Presence of more than 9 symptoms from 5 categories: intrusion, negative mood, dissociation, avoidance, and arousal

    • Duration of disturbance: 3 days to 1 month following trauma

    • Causes significant impairment in functioning

Critique of PTSD Definition

  • PTSD seen as a homogeneous response to trauma.

    • Not all individuals exposed to trauma will develop PTSD.

    • Focus on the incident rather than the individual's response.

PTSD Risk Factors

Pre-Trauma Factors

  • Genetic Predisposition

  • Neurological Vulnerabilities

  • Developmental Factors

  • Psychological Vulnerabilities

  • Cognitive Vulnerabilities

During Trauma Factors

  • Peritraumatic Dissociation

  • Cognitive Appraisal

  • Biological Reaction

Post-Trauma Factors

  • Coping Strategies

  • Social Support

Genetic Predisposition

  • Genetic factors influence susceptibility:

    • Twin study of Vietnam veterans showed heritability at approximately 0.40 (True et al., 1999, 1993)

Neurological Vulnerabilities

  • Factors associated with PTSD include:

    • Low cortisol levels

    • Increased blood flow in the left hippocampus (Shin et al., 2004)

    • Amygdala activation relating to PTSD

    • Smaller hippocampal volume as a vulnerability factor for developing PTSD (Gilbertson et al., 2002)

Developmental Risk Factors

  • Factors include:

    • Stress sensitization

    • Childhood adversity

    • Attachment styles: Secure vs. Insecure

    • History of psychiatric illness

    • Family and personal histories

Personality Factors

  • Traits influencing PTSD risk:

    • Neuroticism: More intense reactions to stress

    • Impulsivity: Likelihood of experiencing trauma

    • Psychopathology: History of mental health conditions

    • Resilience: Characterized by self-efficacy, problem-solving abilities, and coping skills

    • Optimism: Positively correlated with resilience

Psychological Vulnerabilities

  • Important psychological factors include:

    • Lack of social support: perception of availability and satisfaction

    • External locus of control leads to feeling less able to manage stressful events

    • Attribution of responsibility can involve self-blame

Cognitive Vulnerabilities

  • Includes tendencies such as:

    • Negative attributional style

    • Problem-focused vs. emotion-focused coping

    • Rumination

    • Looming cognitive style: overestimation of threat intensity

    • Cognitive schemas regarding self, world, and future

Risk Factors During Trauma

Peritraumatic Dissociation

  • May alter one’s sense of self during the event, with unclear causality

Cognitive Appraisal

  • Evaluation of the traumatic situation influences outcome:

    • "The world is a safe place"—a fundamental assumption shattered

    • Generate new assumptions and integrate the traumatic event, impacting PTSD severity

Biological Reaction

  • Involves HPA axis deregulation

HPA Axis Deregulation

Cortisol Levels

  • Low cortisol levels observed in PTSD patients with findings from DST tests (Yehuda et al., 1995).

  • Comparison between Vietnam combat veterans with PTSD (N = 14) and those without (N = 14) demonstrated evidence toward cortisol hypersuppression.

Post-Trauma Risk Factors

  • Include:

    • Lack of social support

    • Maladaptive coping strategies

Coping With the Event

Negative Emotions

  • Common negative emotions include anger and shame, leading to:

    • Negative appraisals of the event, self, others, and the world

    • Avoidance behaviors or attempts to suppress thoughts

    • Rumination: ongoing focus on the trauma

    • Attention bias toward trauma-related stimuli

    • Experiential avoidance: avoidance of experiences related to trauma

Examples of Experiential Avoidance

Trauma-Related Behavior

  • Behavioral response: Using public transportation (Metro)

    • Individuals involved recount experiences and cognitive associations with the trauma (e.g., smells, sights)

  • Cognitive response: Thinking about the explosion offers temporary relief but exacerbates danger perception

  • Affective response: Feelings of sadness and mourning due to loss

  • Physiological response: Responses such as feeling warm or experiencing distressing sensations, e.g., burning smells, as a result of re-experiencing incidents

Conclusions

Understandings of PTSD

  • Exposure to trauma is a necessary but insufficient condition for developing PTSD.

  • Distinction needs to be made between retrospective (after the fact) and prospective (before the fact) benefits when studying PTSD.

Consistent Risk Factors

  • Identified consistent risk factors include:

    • Neuroticism

    • History of psychiatric illness

    • Perceived threat during the traumatic incident

    • Quality of social support

Implications for Treatment

  • Effective treatment of PTSD requires a multimodal approach:

    • Consideration of biological predispositions

    • Addressing personality and psychological factors

    • Incorporating social factors into treatment planning

Bibliography

  • American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th – Text Revision ed.) Washington, DC.

  • Shin, L.M. et al. (2004). Hippocampal Function in Posttraumatic Stress Disorder. Hippocampus, 14(3), 292-300.

  • Meewisse, M. et al. (2007). Cortisol and Post-Traumatic Stress Disorder in Adults. British Journal of Psychiatry, 191, 387-392.

  • Yehuda, R., & Flory, J.D. (2007). Differentiating Biological Correlates of Risk, PTSD, and Resilience Following Trauma Exposure. Journal of Traumatic Stress, 20(4), 435-447.

  • Elswood, L.S. et al. (2009). Cognitive Vulnerabilities to the Development of PTSD: A Review of Four Vulnerabilities and the Proposal of an Integrative Vulnerability Model. Clinical Psychology Review, 29, 87-100.

  • Solomon, Z., & Mikulincer, M. (1990). Life Events and Combat-Related Posttraumatic Stress Disorder: The Intervening Role of Locus of Control and Social Support. Military Psychology, 2(4), 241-256.

  • O’Connor, M. & Elklit, A. (2008). Attachment Styles, Traumatic Events, and PTSD: A Cross-Sectional Investigation of Adult Attachment and Trauma. Attachment and Human Development, 10(1), 59-71.

  • Declercq, F., & Palmans, V. (2006). Two Subjective Factors as Moderators between Critical Incidents and the Occurrence of Post-Traumatic Stress Disorders: ‘Adult Attachment’ and ‘Perception of Social Support’. Psychology and Psychotherapy: Theory, Research and Practice, 79, 323-337.

  • Voges, M., & Romney, D.M. (2003). Risk and Resiliency Factors in Posttraumatic Stress Disorder. Annals of General Hospital Psychiatry, 2(2), 1-9.