What is PTSD?

Posttraumatic Stress Disorder (PTSD) is a prevalent anxiety disorder that may develop in individuals who have witnessed or experienced a traumatic event, as per the American Psychiatric Association (2013) guidelines. The acronym PTSD stands for Post, Traumatic, Stress, and Disorder, representing the following characteristics:

- Post: means after the traumatic event occurred.

- Traumatic: refers to the event that was frightening and/or horrific.

- Stress: indicates that the person may experience nightmares, flashbacks, and persistent feelings of fear.

- Disorder: refers to a mental health problem that may require treatment to resolve.

Symptoms of PTSD can be extremely distressing. They can interfere with your daily life and make performing even the simplest tasks difficult. Some days, just getting through the day can be a challenge. According to The British Journal of Psychiatry (2020), post-traumatic stress disorder (PTSD) was first introduced in 1980 in DSM-III as a diagnosis that differed from many DSM disorders. It described symptoms that were the result of a traumatic event like combat, rape, or vehicular accident and required the presence of a traumatic stressor as a prerequisite for the evaluation of the diagnosis.

In contrast to the diagnosis of PTSD in DSM-IV (2013), which places emphasis on the social functioning of the sufferer and limits its scope, the ICD-10 of the World Health Organization takes a different approach. According to ICD-10 (1992), the diagnosis of PTSD requires that individuals must:

A) Have been exposed to exceptional life-threatening or violent events that can cause distress to anyone, such as natural disasters, fires, assaults, wars, rapes, car accidents, etc. 

B) Persistently and involuntarily re-experience the traumatic event through intrusive and distressing ‘’flashbacks’’, vivid images and nightmares, which can occur either out of the blue or when sufferers are exposed to situations correlated with the stressful event. 

C) Present a voluntary avoidance of situations connected with the traumatic event that was not presented before. 

D) Either be incapable of recalling significant aspects of the exposure to the stressor or experience persistent symptoms of psychological sensitivity. These hyperarousal symptoms are revealed by two of the following: irritability management, difficulty in concentrating or falling asleep, hypervigilance, and startled responses. 

The eleventh revision of ICD (ICD-11) was released in 2018 (WHO, 2018). It takes a public health perspective and emphasises clinical utility, including simplicity in diagnostic structure and transparent application to treatment planning. In this revision, symptom heterogeneity among trauma survivors has been recognised and organised into two disorders - PTSD and complex PTSD (CPTSD). Each disorder consists of a relatively simplified set of symptom clusters and a conceptual organisation that clinicians can follow. Both diagnoses are classified under the parent category of 'Disorders specifically related to stress.' An individual can be diagnosed with either PTSD or CPTSD, but not both. If a person is diagnosed with CPTSD, they cannot also have PTSD.

PREVALENCE, ONSET 

Post-traumatic stress Disorder (PTSD) is a commonly occurring psychiatric disorder with a lifetime prevalence of 3.4%, as per the ICD-10 diagnostic criteria, according to Andrews et al. (1999). It has been observed that women are more susceptible to developing PTSD after a traumatic event compared to men, with a higher prevalence rate of 20.4% compared to 8.1% using DSM-III-R criteria (1980), as per Kessler et al. (1995). However, it is essential to note that the type of traumatic event plays a significant role in the development of PTSD. Deliberate acts of interpersonal violence such as rape, terrorist attacks or wars are more likely to cause PTSD than natural disasters or car accidents.

It is worth mentioning that the development of PTSD can be influenced by the sufferer's subjective perception of the traumatic experience, as stated by the National Institute for Health and Care Excellence, NICE (2005). On average, men experience more traumatic events in their lifetime than women. Still, women tend to experience major impact events that can more easily lead to PTSD, as found by Stein et al. (1997) and Creamer et al. (2001). In the majority of cases, PTSD symptoms appear within the first month after the traumatic event. However, for a minority of 15%, symptoms may still arise months or even years after the traumatic event, according to McNally (2003).

TREATMENT OF PTSD

The NICE (2005) guidelines recommend using trauma-focused CBT for treating post-traumatic stress disorder (PTSD) within three months of the traumatic event. In case the symptoms persist for more than three months after the event, trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) is recommended. 

One of the most widely used and accepted models of Cognitive Behavioral Therapy (CBT) for treating Post-Traumatic Stress Disorder (PTSD) is the Ehlers and Clark model, developed in 2000. This model proposes that PTSD symptoms persist when patients process and consider their trauma in a way that leads to a sense of current threat. This can occur due to three reasons: 

A) Negative and problematic appraisals that patients attribute to the traumatic event or its consequences.

B) Disruption to the patient's brain's autobiographical memory, which is characterised by limited elaboration-contextualization, associative solid memory, and perceptual priming.

C) The problematic safety-seeking behaviours and cognitive strategies of the sufferers contribute to the maintenance of the trauma memory, its appraisals, and symptoms of PTSD.

The  Ehlers and Clark model (2000) has three primary objectives. Firstly, it aims to identify the negative personal meanings that patients associate with their traumatic experiences. Secondly, it aims to reduce re-experiencing symptoms by processing the traumatic memory. Finally, it aims to address any negative beliefs and behaviours that may be associated with the trauma by: 

A) Identifying and shifting dysfunctional cognitive processes that increase re-experiencing through the 'Updating of the trauma memories' process by Ehlers and Clark (2008). This process involves:

1) Identifying and elaborating the worst moments of the trauma (hotspots), which create a sense of newness or guiltiness through imaginal reliving by Foa and Rothbaum (1998).

2) Collecting information that can reasonably update the outcome as well as the meaning that the sufferer attributes to the trauma through cognitive restructuring, Mueser et al. (2005).

3) Verbal and imagery inserting the updated information into memory through another imaginal reliving.

B) Identifying and discriminating the sensory triggers of re-experiencing, allowing patients to break the connection between them and the trauma memory. In this way, they will be able to distinguish the past from the present when re-experiencing occurs. Additionally, revisiting the site of the traumatic event can also help them differentiate between then and now, according to Murray et al. (2016).

C) Dropping safety behaviours and cognitively helpful strategies by addressing and discussing their problematic consequences to the patient's problem.

REFERENCES

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. American Psychiatric Association; Washington D.C.: 1980.

Andrews G, Slade T, Peters L. Classification in psychiatry: ICD–10 versus DSM–IV. British Journal of Psychiatry. 1999; 174:3–5

Association, A. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®). Washington, D.C.: American Psychiatric Publishing.  

Creamer M, Burgess P, McFarlane AC. Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being. Psychological Medicine. 2001; 31:1237–1247

Ehlers A., & Clark D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319–345

Ehlers, A., & Clark, D. M. (2008). Post-traumatic stress disorder: the development of effective psychological treatments. Nordic journal of psychiatry, 62 Suppl 47(Suppl 47), 11–18. 

Foa E. B., & Rothbaum B. O. (1998). Treating the trauma of rape. Cognitive-behavior therapy for PTSD. New York: Guilford.

Kessler RC, Sonnega A, Bromet E, et al. posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry. 1995; 52:1048–1060.

Mueser, K., Gottlieb, J., Xie, H., Lu, W., Yanos, P., Rosenberg, S., Silverstein, S., Duva, S., Minsky, S., Wolfe, R. and McHugo, G., 2015. Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness. British Journal of Psychiatry, 206(6), pp.501-508.

National Institute of Clinical Excellence Clinical guideline 26: Posttraumatic stress disorder: The management of PTSD in adults and children in primary and secondary care. 2005

McNally R. J. (2003). Remembering trauma. Cambridge, MA: The Belknap Press/Harvard University Press.

Stein MB, Walker JR, Hazen AL, et al. Full and partial posttraumatic stress disorder: findings from a community survey. American Journal of Psychiatry. 1997; 154:1114–1119.

The British Journal of Psychiatry, Volume 216 , Issue 3: Themed Issue: Disasters and Trauma , March 2020, pp. 129 - 131

World Health Organization. The ICD–10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: WHO; 1992

World Health Organization. International Statistical Classification of Diseases and Related Health Problems (11th Revision). WHO, 2018.