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The European Network for Traumatic Stress
Training & Practice
www.tentsproject.eu
The diagnosis of Posttraumatic
Stress Disorder (PTSD)
Ask Elklit, Denmark
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Glimpses of the history of trauma
• ‘Railway spine’ (1866) was a diagnosis given
after railway accidents to describe emotional
and personality impact
• Pierre Janet (1889) developed a dynamic
understanding of trauma that is still valid
• Various wars gave name to ‘soldiers’ heart’,
‘shell shock’, ‘combat neurosis’, ‘KZ-syndrom’,
‘Vietnam syndrom’ etc.
• This knowledge disappeared in the years
following the wars and was ‘reinvented’
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Horowitz (1976)
• In the book, ”Stress Response Syndrom”, Mardi
Horowitz described what he saw as the core
dynamics after a traumatic experience:
• A long-lasting oscilliation between intrusive
reexperiences and denial/avoidance
• As Horowitz mainly worked with bereaved
people, he paid little attention to arousal
symptoms
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Split
Perceptions
Emotions
Paralysed
Hyperstate
Cognitions
Actions
Model of the consciousness in shock
Scenes in a fixed order
Amnesia for
Intervening details
Model of the perceptual condensation
(”etching”) after trauma
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Demogra
fis
Personality
Body state
Social group
Life events
Traumatic event
(situational factors)
Original shock / defence reflexes
(dissociation)
*PLEASE ADD AN EXPLANANTION FOR TEACHERS:
Social support
(secondary
victimization)
Attributions
Defence
Primary appraisal
(cognitive-emotional)
Hypervigiilance
Coping
(action possibilities)
Intrusive recollections
Avoidance
Personality disorders /
dysfunctional traits
Psychiatric
syndromes
(ASD, PTSD etc.)
Social changes
Psycho-physiological
disorders
The DSM-III (a)
• Before DSM-III, clinicians and scientists met and
tried to find common ground in the symptoms of
veterans, rape victims, and battered women.
• In 1980, the APA published the first version of
PTSD with the three core symptom clusters
• Re-experiencing (”intrusive”)
• Avoidance
• Hypervigiliance (”arousal”)
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DSM-III (b)
• The clusters consist of items that are descriptive; so are
the clusters and there are no expectations about the
inherent dynamics as suggested by Horowitz
• The Hypervigiliance cluster is a substantial development
and addition to the work of Horowitz acknowledging the
psychosomatic aspects of experiencing an extreme and
threatening situation
• Confer the Kardiner (1941) concept of trauma as a
”psychoneurosis”
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PTSD today (DSM-IV)
• The stressor criteria (both A1 and A2):
• A1 ”a life threatening situation, injury or
threat to physical integrity”
• This can be direct exposure or indirect –
witnessing events
• The subjective experience is what counts
• A2 The person reacts with fear or helplessness
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Re-experiencing (1 symptom)
• 1) Recurrent thoughts or perceptions of
the event
• 2) Recurrent dreams of the event
• 3) Acting or feeling as if the event were
recurring (flashbacks)
• 4) Intense psychological distress and
• (5) physiological reactivity when exposed
to cues resembling the event
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Avoidance 1 (3/7 symptoms)
• 1) Avoiding trauma thoughts and feelings
• 2) Avoiding activities, places, and people
that remind of the trauma
• 3) Inability to recall important parts of
trauma
• 4) Lack of interest in significant activities
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Avoidance 2
• 5) Feeling of detachment from others
• 6) Restricted affect (no loving feelings)
• 7) Sense of a foreshortened future
• Note: The two first symptoms are conscious
efforts; 4-6 are called ’numbness’ (inability to
express feelings and plan for a future).
Symptoms not present before the trauma
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Hypervigiliance (2/5
symptoms)
1)
2)
3)
4)
5)
Difficulties falling or staying asleep
Irritability or outburst of anger
Difficulty concentrating
Hypervigiliance*
Exaggerated startle response*
Note: Symptoms not present before the trauma.
The three first may be considered less specific
than the two last symptoms*
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Duration
• Duration of symptoms more than one
month
• Acute PTSD (less than 3 months)
• Chronic (3 months or more)
• Delayed (if onset is at least 6 months after
the trauma)
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Functional impairment
• The disturbance causes clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning
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PTSD according to WHO
• In the ICD-10 diagnostic system, F 43.1
describes PTSD quite differently
• The stressor criterion is normative
• ”exposed to an unusual threatening or
catastrophe stressor that in almost
everyone would result in extensive and
very distressing reactions”
• This downplays the traumas in everyday
life
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ICD-10 (cont.)
• The re-experiencing symptoms
corresponds to DSM-IV 2,3, and 4
• Avoidance demands one symptom
• Hypervigiliance is like DSM-IV (2/5
symptoms
• Amnesia can substitute the hypervigiliance
symptoms
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ICD-10 (cont.)
• Duration: symptoms must be present
before 6 months
• No functional impairment demands.
• The diagnosis can be given after a few
days
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ICD-10 and DSM-IV
compared
• Very little research has used the ICD-10
• It is easier to get a PTSD diagnosis from
ICD-10 than from DSM-IV
• There is little (35%) concordance between
diagnoses given by the two systems due
to fewer demands in the ICD-10 avoidance
clusters and lack of impairment criterion
• Epidemiological studies using ICD-10
reveal very few cases of PTSD
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Empirical analyses of PTSD
• No study has replicated the PTSD
structure with the three symptom clusters
• Many have suggested that the avoidance
group should be divided in conscious
avoidance and numbing.
• Numbing seems to be closely associated
with hypervigiliance where conscious
avoidance is associated with reexperiencing
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Empirical analyses of PTSD - 2
• Recently, several have suggested that
numbing symptoms together the nonspecific hypervigiliance symptoms
constitute a dysphoria factor not specific to
PTSD
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Subclinical PTSD
• A large number of clients miss one
symptom to get the full diagnosis
• They typically miss one avoidance
symptom
• They are often described as having ’subsyndromal’, ’partial’, or ’subclinical’ PTSD
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Subclinical PTSD - 2
• This group often requires clinical attention
• It is important to distinguish between those
who once had PTSD and are now in
partial remission and those never
exceeded the full PTSD threshold
• For this group is important to consider the
functional impairment criterion
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PTSD remission
• PTSD symptoms often decrease in the
weeks and months following a trauma
• After three to six months a stabilisation (=
little or no change) often comes about
• One third will recover fully
• One third will have a number of symptoms
• One third will become chronic cases
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PTSD and other disorders
• Having PTSD means that 4 out of 5 will
have comorbid (= at the same time)
disorders; the most common being:
• Anxiety (and phobias)
• Depression
• Somatoform disorders
• Alcohol and drug abuse
• Some also develop a personality disorder
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