Posttraumatic Stress Disorder

A Mainstream View of PTSD

Diagnostic Criteria. The syndrome that is currently called posttraumatic stress disorder (PTSD) has been [Page 360]recognized in some form since the beginning of recorded history. However, it was not until the 1980 publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) that PTSD was officially codified in the psychiatric nomenclature. The current DSM-IV diagnostic criteria for PTSD stipulates that for more than one month following a traumatic event, a PTSD patient must report the following types of symptoms: (1) reexperiencing (e.g., intrusive memories, recurrent dreams, flashbacks, intense physiological or emotional responses when reminded of the trauma); (2) avoidance and/or numbing (e.g., 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 (e.g., insomnia, irritability, distractibility, hypervigilance, or hyperstartle).

However, DSM-IV also introduced some changes to the PTSD criteria that have implications for the diagnosis of PTSD in diverse ethnocultural groups. For example, DSM-IV changed the way that trauma is defined. In addition to the usual objective definition of trauma (i.e., experiencing, witnessing, or learning about an event involving serious injury, threat to physical integrity, and/or death), DSM-IV stipulates that the traumatic event must be accompanied by subjective emotions, such as intense fear, helplessness, and/or horror to qualify for the diagnosis of PTSD. Because there are known cultural variations in experiencing, expressing, and reporting emotions, it is conceivable that someone diagnosed with PTSD under previous criteria might not meet the current diagnostic criteria. For example, a trauma-exposed person from a culture that eschews the reporting of strong negative emotions (e.g., Chinese culture) may not meet current criteria. The DSM-IV also added a clinical significance requirement. To warrant a diagnosis of PTSD, the symptoms must cause distress or impairment in relationships, work, or other important domains of living. Because there is evidence that some cultural groups have a higher tolerance for or acceptance of psychiatric symptoms, this new criterion suggests that an individual with objectively observed PTSD symptoms that are not distressing or debilitating would not qualify for the PTSD diagnosis.

Associated Features/Comorbidities. There are also a number of symptoms and psychiatric disorders that commonly co-occur with PTSD but that are not considered part of the core diagnostic criteria. These include guilt, shame, depression, anxiety, relationship problems, social withdrawal, emotion dysregulation, impulsive behavior, dissociation, somatization, substance abuse, and personality changes. The assessment of PTSD in diverse groups is complicated by the fact that cultures vary in their sanctioning of these symptoms. For example, dissociation (i.e., disruptions in normally integrated aspects of consciousness) is a common part of religious practices among Native Americans and some Hispanic American subgroups. Thus, the presence of dissociation in these groups may or may not be related to PTSD.

General Epidemiology. The lifetime prevalence for PTSD among adults in the United States has been estimated at 8%. Prevalence rates are considerably higher for subgroups that have been exposed to particular types of trauma. For example, in individuals who have been exposed to combat, physical or sexual abuse, or refugee experiences, lifetime prevalence rates can be as high as 65%.

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