Posttraumatic Stress Disorder (PTSD)

The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to a traumatic event that arouses "intense fear, helplessness, or horror," or in children, "disorganized or agitated behavior" (American Psychiatric Association 1994, p. 428). A host of stressors, both natural and manmade, can be traumatizing. Naturally occurring stressors include, for example, natural disasters and medical illnesses. Man-made events include accidents and acts of violence. Some of these are single events with acute effects; others involve repeated or chronic exposure. Exposure can occur through direct experience with personal victimization or through witnessing or learning about a traumatic event.

Symptoms are categorized into three clusters: persistent re-experiencing of the stressor, persistent avoidance of reminders and emotional numbing, and persistent symptoms of increased arousal (American Psychiatric Association 1994). Intrusive re-experiencing may involve intrusive distressing recollections or dreams about the trauma, "acting or feeling" as if the event were recurring, and intense distress or physiological reactivity when exposed to reminders (American Psychiatric Association 1994, p. 428). In children, re-experiencing may be evident in repetitive play with themes of the traumatic experience, generalized nightmares, and trauma-specific reenactment. At least one re-experiencing symptom is required for the diagnosis.

The avoidance/numbing cluster includes both purposeful actions and unconscious mechanisms: efforts to avoid thoughts, feelings, or conversations related to the trauma; efforts to avoid activities, places, or people reminiscent of the trauma; inability to recall important aspects of the trauma; greatly decreased interest in important activities; feeling detached or estranged; restricted affect; and a "sense of a foreshortened future" (American Psychiatric Association 1994, p. 428). At least three avoidance/numbing symptoms, not present before the trauma, are required for the diagnosis.

The arousal cluster requires increased generalized arousal, including sleep disturbance, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. At least two arousal symptoms, not present before the trauma, are required.

To qualify for a diagnosis, symptoms must continue for more than one month; they may persist for months to years. Symptoms usually begin within three months after exposure, but may be delayed, and specific symptoms and their intensity or severity may vary over time (American Psychiatric Association 1994). The symptoms must cause "clinically significant distress" or impaired functioning (American Psychiatric Association 1994, p. 429), which may be evident at home, work, or school, or in other settings and in interpersonal relationships. Endorsement of some PTSD symptoms may be normal following trauma exposure, partial symptomatology may be disabling, and the full symptom complex may develop over time. Treatment may be necessary even if all criteria are not met.

Prevalence, Epidemiology, and Comorbidity

Exposure to traumatic events and situations is increasingly common, especially in some environments. The estimated lifetime prevalence of PTSD in the general U.S. population ranges from 1 percent to 14 percent (American Psychiatric Association 1994). Rose Giaconia and colleagues (1995) found that by the age of eighteen years, more than two-fifths of youths in a community sample had been exposed to trauma severe enough to qualify for diagnosis, and over 6 percent met criteria for a lifetime diagnosis of PTSD. Co-morbid conditions are common with PTSD. They include anxiety, somatization (when psychological distress is translated to physical complaints or ailments), and substance-use disorders (American Psychiatric Association 1994; Giaconia et al. 1995).

Etiology

PTSD "is defined by its cause" (Davidson 1995, p. 1230) requiring exposure to a traumatic event or stressor that results in physiological changes associated with the fight-or-flight response, a complex interplay among several systems of the body that leads to increased blood pressure, pulse, and respiratory rate; increased blood supply to the muscles; and vigilance (Guyton and Hall 1997; Perry and Pollard 1998). This response dissipates with time except in cases of severe, prolonged, or chronic stress, in which it may persist and may have potentially detrimental consequences, especially for the developing child (Perry and Pollard 1998).

Risk Indicators and Factors That Promote Resilience

The factors that contribute to posttraumatic stress may be categorized into those occurring before, during, and after exposure to the stressor. Prestressor factors include characteristics of the victim, family, and sociocultural environment. Stressor factors include aspects of the event and exposure. Poststressor factors include aspects of the recovery environment, coping, and treatment.

Pre-event factors. Rates of PTSD are higher in women than men (Ballenger et al. 2000), though gender differences are less clear in children (Foy et al. 1996; Pfefferbaum 1997). The influence of age and ethnicity is not well established. Age and developmental differences may be evident in the symptoms of the disorder, and may reflect prior experience, coping, and the availability of support. Ethnic minorities may be at risk for trauma exposure, but this may reflect differences in socioeconomic status or family influences rather than ethnicity. Other individual factors important in trauma response are preexisting psychopathology and prior exposure to trauma (American Psychiatric Association 1994; Asarnow et al. 1999; Ballenger et al. 2000; Davidson 1995).

Prestressor family and social factors that may influence outcome include relationships within the family and social environment, family organization, and the family's long-term adaptation (Boney-McCoy and Finkelhor 1996; McFarlane 1987; Solomon 1989). Positive family relationships are generally considered protective for traumatized children. Specifically, problems in children appear to be associated with irritable, depressed, and overprotective families (Green et al. 1991; McFarlane 1987). Family adaptability—the capacity for change—and family cohesion—the flexibility of emotional bonds—are likely to affect trauma response. Both extremes of cohesion, too distant and too close, create risk for maladaptive outcome (Laor et al. 1996), although more research is needed to help clarify these family factors.

PTSD has been described in individuals from many cultures. In fact, one would expect high rates of exposure to trauma and PTSD in individuals from those parts of the world where war, crime, and poverty prevail and in refugee populations (American Psychiatric Association 1994). Race, ethnicity, and culture shape conceptualization of events, reactions to trauma, expectations, and treatment (Parson 1994). The biologic response to trauma appears to be consistent across cultures, while the psychosocial aspects of symptom expression are influenced by pre-event, stressor, and poststressor factors (Parson 1994). Of particular concern when Western concepts of trauma are applied in non-Western cultural contexts are potential differences in notions of illness and health, symptom expression, and the phenomenology of the disorder (Marsella et al. 1994).

Stressor factors. Characteristics of the stressor and one's exposure to it influence response. For example, man-made events are thought to be more traumatizing than natural ones (American Psychiatric Association 1994). Exposure can be direct or indirect. Direct exposure involves physical presence or direct victimization; indirect exposure occurs through witnessing or learning of an event experienced by a family member or close associate (American Psychiatric Association 1994). Severity, duration, and proximity are the most important aspects of exposure in predicting the likelihood of developing the disorder (American Psychiatric Association 1994). The role of interpersonal exposure through relationship to direct victims has also been established (American Psychiatric Association 1994). Television viewing as a form of indirect exposure may be associated with posttraumatic stress reactions (Pfefferbaum et al. 2001; Schuster et al. 2001), but no studies link television exposure to the diagnosis of PTSD. One's reaction at the time of the trauma is an important predictor of post-traumatic stress (Asarnow et al. 1999; Ballenger et al. 2000; Schwarz and Kowalski 1991).

Poststressor factors. Family and social factors may influence adjustment following exposure to trauma. For example, within a family, there may be an association between child and parent symptomatology (Foy et al. 1996; Green et al. 1991; Laor et al. 1996; McFarlane 1987) that in some cases may reflect similar exposure. Parental symptoms and poor parental functioning constitute important risk factors for symptom development in traumatized children (Green et al. 1991; McFarlane 1987). Consistency in reaction and mood between parents (Handford et al. 1986), and the quality of the parent-child relationship (Boney-McCoy and Finkelhor 1996) may also affect the intensity of the child's reaction.

When a traumatic event affects large numbers, social factors, such as community disruption, competition for resources, and community response, may influence adjustment (Pfefferbaum 1998; Quarantelli and Dynes 1985; Solomon 1989). Secondary adversities associated with a traumatic event such as displacement and relocation, property and economic loss, family and social problems, and loss of interpersonal support networks affect recovery (Freedy et al. 1992; Laor et al. 1996; Pfefferbaum 1998; Shaw et al. 1995). Traumatic reminders—stimulus cues that activate symptoms—may also interfere with recovery.

Assessment and Treatment

Assessment. Clinical assessment of posttraumatic stress involves the traditional methods of evaluation. The history of exposure, prior trauma, and pre-existing and co-morbid conditions must be assessed. In some situations, such as natural disasters or reported criminal victimization, exposure to trauma is obvious, and the clinician quite naturally inquires about the signs and symptoms of PTSD. In other situations, however, exposure is obscure, and the need for evaluation may be less obvious. Children may not spontaneously report their symptoms, and adults may underestimate trauma in children (Almqvist and Brandell-Forsberg 1997; Handford et al. 1986; Yule and Williams 1990), making it essential to ask children themselves about their experiences and reactions. In addition, children may have difficulty understanding concepts such as avoidance and numbing; therefore, evaluation of them should include observation and reports by parents, teachers, and/or other adults.

Treatment. Treatment involves transforming the individual's self-concept from victim to survivor as the trauma is resolved in a safe setting in which painful and overwhelming experiences can be explored (Amaya-Jackson and March 1995; Gillis 1993; Hollander et al. 1999). Avoidance, a core symptom of PTSD, may prevent the victim from seeking or continuing treatment (Ehlers 2000). The therapist, therefore, must consider omitted information and associated feelings and affects. Avoidance can be protective, decreasing suffering temporarily, but it may be interrupted by intrusive experiences and heightened arousal that occur spontaneously or with exposure to traumatic cues. Educational information is an important aspect of the treatment of PTSD, especially when anxiety and avoidance discourage the patient from seeking or continuing treatment. Prior traumatic experiences must be explored and co-morbid symptoms such as anxiety and depression must be identified and treated. A variety of modalities are used to treat PTSD, although the comparative effectiveness of various modalities has received little attention.

Psychotherapeutic and cognitive-behavioral approaches. The literature suggests that crisis intervention, individual and group therapy, play therapy for children, therapeutic exposure, desensitization, relaxation, other cognitive-behavioral techniques, and pharmacotherapy are beneficial in treating PTSD (Davidson 1995; Terr 1989). Exposure therapy that involves repeated review of the traumatic experience is a component of many approaches. Use of projective techniques such as play in children and art may provide access to traumatic themes without threatening the victim's defensive structure. Relaxation techniques may decrease arousal, tension, physical symptoms, anxiety, and sleep disturbance (Hollander et al. 1999). Hypnosis can also be effective (Davidson 1995; Ehlers 2000; Hollander et al. 1999; Terr 1989).

Pharmacotherapy. Pharmacotherapy is an adjunctive treatment that may be needed if symptoms are disabling (Amaya-Jackson and March 1995; Hollander et al. 1999; Marmar et al. 1994). A variety of drugs are potentially effective, most notably anxiolytics (agents that dispel anxiety) and antidepressants. Specific symptoms and the stage of the illness determine whether to use a drug, what drug to use, and the duration of use. Positive symptoms of re-experiencing and arousal may be more responsive to medication than negative symptoms of avoidance (Marmar et al. 1994). Co-morbid conditions should be considered in selecting an agent.

Family therapy. Family work is an excellent means of providing education about trauma and what to expect over time. Parents of traumatized children may benefit from psychoeducation about their children's symptoms and how to effectively manage them. Often, more than one family member will be traumatized though individual exposure and the course of the illness and recovery may differ. Parental trauma may be so great that the needs of a young child may be overlooked. Helping parents resolve their own emotional distress can increase their perceptiveness and responsiveness to their children. The focus of family work includes validating the experiences and emotional reactions of each family member, helping family members regain a sense of security, anticipating situations in which additional support will be needed, and exploring ways to decrease traumatic reminders and secondary stresses.

Group treatment. Group work is ideal for educating victims about symptoms and the posttraumatic course. Sharing with others who have experienced the same or similar trauma can be reassuring, but some are uncomfortable sharing in a group. Group discussions may be re-traumatizing through re-exposure to one's own experiences or through exposure to the experiences of others. Group work also provides an expedient means of reaching individuals in need of more intensive individual assistance.

School-based efforts. School-based interventions are effective for traumatized children or children at risk for trauma. They provide access in developmentally appropriate settings that encourage normality and minimize stigma.

Long-term treatment and pulsed interventions. Long-term treatment may be necessary for those with intense or enduring exposure and symptoms, pre-existing or co-morbid conditions, prior or subsequent trauma, or family problems. Treatment during the acute phase of trauma may be followed by planned interventions at strategic points. These may be especially important following mass casualty events when many have been exposed and can be reached for follow-up in groups. Periodic, brief interventions are useful during developmental transitions and at anniversaries.

Conclusion

The diagnosis of PTSD requires exposure to a traumatic stressor and can be challenging to make if exposure is not obvious or if the victim does not reveal it. Symptoms fall into three clusters—intrusive re-experiencing, avoidance/numbing, and arousal. An array of treatment modalities is used to treat the disorder, although the comparative effectiveness of these modalities has not been well examined.

See also:Anxiety Disorders; Attachment: Parent-Child Relationships; Child Abuse: Physical Abuse and Neglect; Child Abuse: Sexual Abuse; Codependency; Developmental Psychopathology; Incest; Interparental Violence—Effects on Children; Rape; Spouse Abuse: Prevalence; Spouse Abuse: Theoretical Explanations; War/Political Violence

Bibliography

almqvist, k., and brandell-forsberg, m. (1997). "refugee children in sweden: posttraumatic stress disorder in iranian preschool children exposed to organized violence." child abuse and neglect 21(4):351–366.

amaya-jackson, l., and march, j. s. (1995). "posttraumatic stress disorder." in anxiety disorders in children and adolescents, ed. j. s. march. new york: guilford press.

american psychiatric association. (1994). diagnostic andstatistical manual-iv, 4th edition. washington, dc: american psychiatric association.

asarnow, j.; glynn, s.; pynoos, r. s.; et al. (1999). "when the earth stops shaking: earthquake sequelae among children diagnosed for pre-earthquake psychopathology." journal of the american academy of child and adolescent psychiatry 38(8):1016–1023.

ballenger, j. c.; davidson, j. r. t.; and lecrubier, y.; et al. (2000). "consensus statement on posttraumatic stress disorder from the international consensus group on depression and anxiety." journal of clinical psychiatry 61(suppl 5):60–66.

boney-mccoy, s., and finkelhor, d. (1996). "is youth victimization related to trauma symptoms and depression after controlling for prior symptoms and family relationships? a longitudinal, prospective study." journal of consulting and clinical psychology 64(6):1406–1416.

davidson, j. r. t. (1995). "posttraumatic stress disorder and acute stress disorder." in comprehensive textbook of psychiatry, vol. 1, 6th edition, ed. h. i. kaplan and b. j. sadock. baltimore: williams & wilkins.

ehlers, a. (2000). "post-traumatic stress disorder." in new oxford textbook of psychiatry, vol. 1, ed. m. g. gelder, j. j. lópez-ibor, and n. andreasen. new york: oxford.

foy d.w.; madvig, b.t.; and pynoos, r.s.; et al. (1996). "etiologic factors in the development of posttraumatic stress disorder in children and adolescents." journal of school psychology 34(2):133–145.

freedy, j. r.; shaw, d. l.; and jarrell m. p. et al. (1992). "towards an understanding of the psychological impact of natural disasters: an application of the conservation resources stress model." journal of traumatic stress 5(3):441–454.

giaconia, r. m.; reinherz, h. z.; and silverman, a. b.; et al. (1995). "traumas and posttraumatic stress disorder in a community population of older adolescents." journal of the american academy of child and adolescent psychiatry 34(10):1369–1380.

gillis, h. m. (1993) "individual and small-group psychotherapy for children involved in trauma and disaster." in children and disasters, ed. c. f. saylor. new york: plenum press.

green, b. l.; korol, m.; and grace, m. c.; et al. (1991). "children and disaster: age, gender, and parental effects on ptsd symptoms." journal of the american academy of child and adolescent psychiatry 30(6):945–951.

guyton, a. c., and hall, j. e. (1997). "the autonomic nervous system; cerebral blood flow; and cerebrospinal fluid." in human physiology and mechanisms of disease, 6th edition, ed. a. c. guyton and j. e. hall. philadelphia: w.b. saunders company.

handford, h. a.; mayes, s. d.; and mattison, r. e.; et al. (1986). "child and parent reaction to the three mile island nuclear accident." journal of the american academy of child psychiatry 25(3):346–356.

hollander, e.; simeon, d.; and gorman, j. m. (1999). "anxiety disorders." in the american psychiatric press textbook of psychiatry, 3rd edition, ed. r. e. hales, s. c. yudofsky, and j. a. talbott. washington, dc: american psychiatric press.

laor, n.; wolmer, l.; and mayes, l. c.; et al. (1996). "israeli preschoolers under scud missile attacks." archives of general psychiatry 53:416–423.

marmar, c. r.; foy, d.; and kagan, b.; et al. (1994). "an integrated approach for treating posttraumatic stress." in posttraumatic stress disorder: a clinical review, ed. r. s. pynoos. lutherville, md: sidran press.

marsella, a. j.; friedman, m. j.; and spain, e. h. (1994). "ethnocultural aspects of posttraumatic stress disorder." in posttraumatic stress disorder: a clinical review, ed. r. s. pynoos, j. d. bremner, d. s. charney, et al. lutherville, md: the sidran press.

mcfarlane, a. c. (1987). "family functioning and over-protection following a natural disaster: the longitudinal effects of post-traumatic morbidity." australian and new zealand journal of psychiatry 21:210–218.

parson, e. r. (1994). "post-traumatic ethnotherapy (ptet): processes in assessment and intervention in aspects of global psychic trauma." in handbook of post-traumatic therapy, ed. m. b. williams and j. f. sommer jr. westport, ct: greenwood press.

perry, b. d., and pollard, r. (1998). "homeostasis, stress, trauma, and adaptation: a neurodevelopmental view of childhood trauma." child and adolescent psychiatric clinics of north america 7(1):33–51.

pfefferbaum, b. (1997). "posttraumatic stress disorder in children: a review of the past 10 years." journal of the american academy of child and adolescent psychiatry 36(11):1503–1511.

pfefferbaum, b. (1998). "caring for children affected by disaster." child and adolescent psychiatric clinics of north america 7(3):579–597.

pfefferbaum, b.; nixon, s. j.; and tivis, r. d.; et al. (2001). "television exposure in children after a terrorist incident." psychiatry 64(3):202–211.

quarantelli, e.l., and dynes, r. a. (1985). "community responses to disasters." in disasters and mental health: selected contemporary perspectives, ed. b. j. sowder. (dhhs publication no. (adm) 85–1421). rockville, md: national institute of mental health.

schuster, m. a.; stein, b. d.; and jaycox, l. h.; et al. (2001). "a national survey of stress reactions after the september 11, 2001, terrorist attacks." new england journal of medicine 345(20):1507–1512.

schwarz, e. d., and kowalski, j.m. (1991). "malignant memories: ptsd in children and adults after a school shooting." journal of the american academy of child and adolescent psychiatry 30(6):936–944.

shaw, j. a.; applegate, b.; and tanner, s.; et al. (1995). "psychological effects of hurricane andrew on an elementary school population." journal of the american academy of child and adolescent psychiatry 34(9):1185–1192.

solomon, s. d. (1989). "research issues in assessing disaster's effects." in psychosocial aspects of disaster, ed. r. gist and b. lubin. new york: john wiley and sons.

terr, l. c. (1989). "treating psychic trauma in children: a preliminary discussion." journal of traumatic stress 2(1):3–20.

yule, w. and r. m. williams. (1990). post-traumatic stress reactions in children. journal of traumatic stress 3(2):279–295.

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