PTSD, classification, pathogenesis

Posttraumatic Stress Disorder (PTSD), Diagnostics, Pathogenesis, Treatment

Dr Gregor Kowal

Dr Gregor Kowal
Senior Consultant
in Psychiatry and Psychotherapy,
German Board Certified,
Medical Director,
Clinic for Health and Medical Care
Phone: 00971-4-4574240

Post-traumatic stress disorder (PTSD) is a cluster of symptoms developed in people who have been exposed to traumatic life threatening events, or witnessing such events by other individuals, especially those emotionally closed to them. This could be a war trauma, torture, being taken hostage, terrorist attack, serious accidents, physical or sexual assaults, natural or man-made disasters.

People with PTSD experience feelings of panic or extreme fear, similar to the fear they felt being exposed to the traumatizing situation. The most common PTSD symptoms are:

– The person relives the traumatic event through intrusive and recurring memories, in particular vivid images and nightmares. Those memories are causing usual intense emotional and physical reactions, such as extreme fears, heart palpitations, sweating, and other somatic symptoms.

– The person is overly alert or wound up, suffering from insomnia, irritability, lack of concentration, becoming easily startled and constantly on the lookout for signs of danger.

– The affected individual deliberately avoids activities, places, people, thoughts or feelings associated with the traumatizing event.

– In the chronic stage of the PTSD other symptoms such as loss of interest in day-to-day activities, social detachment and feeling of numbness, appear.

The individuals affected by PTSD develop often other mental health problems most commonly depression, anxiety, and alcohol or drug abuse.

Because PTSD is a natural response to danger, it’s almost unavoidable in the short term and mostly self-correcting in the long term. Only about 20 percent of people exposed to trauma react with long-term (chronic) PTSD.

Mankind’s earliest literature tells us that a significant proportion of military casualties are psychological, and that witnessing horror of war can leave chronic psychological symptoms.

PTSD as a diagnostic category, along with its symptom clusters, provides a psychiatric manual which allows identifying the disorder but could not capture the human dimension of the individual’s suffering.

1. Diagnosis and classification

The modern sciences become aware of the PTSD during the World Wars where the condition was known under various terms. In the WW I and in the following years it was called: “Shell Shock” or “Traumatic War Neurosis”; during the WW II it was described as “Battle Fatigue”.

The 1952 edition of the DSM-I includes a diagnosis of “Gross Stress Reaction”, which was similar to the modern definition and understanding of PTSD. “Gross Stress Reaction” was defined as a “normal personality utilizing established patterns of reaction to deal with overwhelming fear” as a response to “conditions of great stress”.

The term “Posttraumatic Stress Disorder” came into use in the 1970s in large part due to the studies on the US military veterans of the Vietnam War.

PTSD was officially recognized as a psychiatric disorder by the American Psychiatric Association in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).

DSM-V has made a number of important changes to the criteria of post-traumatic stress disorder, the most significant being a more specific definition of the type and nature of the exposure to a threat. The DSM-IV classified PTSD under anxiety disorders, but the DSM-V created a new category called “Trauma- and Stressor-Related Disorders,” in which PTSD is now classified.

DSM V is the diagnostic manual predominantly use in the USA. The World Health Organization (WHO) uses a different manual called “International Classification of Diseases” or in its abbreviation “ICD”. The current version of this manual is the ICD 10.  It has become the international standard diagnostic classification for most general epidemiological purposes. Also the ICD-10 classification provides also guidelines for the diagnosis of PTSD. There are only minor differences between DSM V and ICD 10 regarding the PTSD criteria.

PTSD can be particularly difficult to diagnose, because numerous factors can lead to over-reporting and under-reporting symptoms, dysfunction and distress. The statistics manuals such as ICD 10 and DSM V provide coherent and standardized diagnostic criteria. In the chapter below we present the DSM V criteria helpful by identifying a PTSD.

DSM V Classification

According to Desk Reference to the Diagnostic Criteria from DSM-5, American Psychiatric Association, the following are the general criteria in diagnosing PTSD. (The following criteria apply to adults, adolescents, and children older than 6 years.)

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).Note: In children, there may be frightening dreams without recognizable content.

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

Note In children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about o closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

4. Persistent negative emotional state (e.g., fear, horror, anger guilt, or shame).

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 

2. Pathogenesis

2.1. Risk factors

Not every person exposed to a trauma will develop the symptoms of PTSD. The people more vulnerable to trauma tend to be individuals suffering from preexistent psychological disorders. According to a study on high-risk twins and combat-related PTSD, a twin brother of a person who was not exposed to war trauma but suffers from a psychiatric disorder, is more likely to develop PTSD. According to a study published 1989 in the British Journal of Psychiatry individuals who were exposed to traumatizing events in the childhood the risk of developing PTDS rises dramatically. On the other hand also people which normal childhood development and without prior exposure to traumatizing events can develop PTSD. The probability of developing PTSD correlates to the intensity of the trauma and the time of the exposer as the studies of the survivals of the concentration camps show.

Persons considered at risk include, for example, combat military personnel, victims of violent crime or natural disasters, concentration camp survivors, and victims of violent crime. Individuals frequently experience “survivor’s guilt” for remaining alive while others died.

2.2. Trauma

PTSD is believed to be caused by the experience of a wide range of traumatic events and, in particular if the trauma is extreme and occurs suddenly. In a survey done after the first Gulf War combat veterans reported that killing an enemy soldier—or even witnessing one getting killed—was more distressing than being wounded oneself. But the very worst experience, by a significant margin, was witnessing a friend dyeing.

2.3. Pathophysiology

2.3.1. Neuroendocrinology

Dysregulation of the stress system, including the hypothalamic-pituitary-adrenal (HPA) axis and the locus caeruleus/norepinephrine-sympathetic nervous system (SNS), is involved in the pathophysiology of PTSD. The HPA axis that coordinates the hormonal response to stress, which activates the LC-noradrenergic system, is implicated in the over-consolidation of memories that occurs in the aftermath of trauma. During traumatic experiences the release of high level of stress hormones suppresses hypothalamic activity. Most people with PTSD show a low secretion of cortisol and high secretion of catecholamines in urine, with a norepinephrine/cortisol ratio consequently higher than comparable non-diagnosed individuals. This is in contrast to the normative fight-or-flight response, in which both catecholamine and cortisol levels are elevated after exposure to a stressor. Brain catecholamine levels are high, and corticotropin-releasing factor (CRF) concentrations are high. Other studies in individuals with PTSD have demonstrated elevated basal cerebrospinal fluid corticotropin-releasing hormone concentrations and contradictory results from peripheral measurements. Peripheral biomarkers of the SNS activity are more consistent, showing increased 24h urinary or plasma catecholamines in PTSD patients compared to control individuals. PTSD can be the effect of a maladaptive learning pathway to fear response through a hypersensitive and hyper-responsive HPA axis. Hyper-responsiveness in the norepinephrine system ist most probably caused by continued exposure to high stress level.

2.3.2. Neuroanatomy

In the PTSD patients the brain areas being affected are the prefrontal cortex, amygdala, and hippocampus. The prefrontal cortex is responsible for planning complex cognitive behavior, decision making, and moderating social behaviour. PTSD patients have inhibited brain activity in such areas of the prefrontal cortex as the dorsal and rostral anterior cingulate cortices and the ventromedial cortex. These brain areas are involved in the process of experiencing and regulating emotions. The other part of the brain called amygdala, which along with the hippocampus belongs to the limbic system, is involved in forming emotional memories, especially fear-related memories. The hippocampus plays important roles in the consolidation of information from short-term memory to long-term memory. During high stress, the hippocampus is suppressed which can explain the later occurrence of flashbacks. The amygdalocentric model of PTSD assumes that in the affected individuals the amygdala is overstimulated and insufficiently controlled by the medial prefrontal cortex and the hippocampus.

3. Treatment

The first psychological treatment of the PTSD in the WW I was the Freudian psychoanalysis. Psychoanalysts did much of the early work in treating trauma, from shell shock of WW I and “Battle Fatigue” of WW II. Treatment of PTSD still contains elements that harken back to psychoanalysis.

The traumas of World Wars affected many of the founding figures of psychodynamic psychology.

For Sigmund Freud the WW I was a traumatizing but also a formative experience. He was anxious about his three serving sons and deeply affected by the loss of his bellowed daughter Sophie, who was one of the two and a half million European victims of the influenza epidemic of 1918-19. The disruption, deprivation and losses of the war raised his skepticism about human nature, as he realized how thin the veneer of civilization in advanced European societies was. The appearance of shell-shock among trench soldiers challenged Freud’s thinking. On the one hand it seemed to demonstrate that hysterical symptoms, like the stuttering, tics and paralyses of traumatized soldiers, were psychological in origin. On the other hand, it led to question his dogma about the sexual etiology as the only cause of neuroses. In his 1920 essay “Beyond the Pleasure Principle” Freud put forward the theory of the “death instinct”. “The aim of all life is death,” he wrote.

Freud’s daughter, Anna Freud was working during the WW I in a nursery for children. During and after the WW II she worked with the war orphans, becoming one of the founders of the psychoanalytic child psychology alongside Melanie Klein. During WW II she observed the effect of deprivation of parental care on children. She set up a centre for young war victims, called “The Hampstead War Nursery”. The underlying idea was to give children the opportunity to form attachments by providing continuity of relationships.

Melanie Klein’s first attempts at child analysis coincided with the violent revolution in Hungary in 1919, her son Erich’s play and day-dreams being filled with murdering soldiers and fathers returning from the front. The disruption, deprivation and losses of the war contributed to Freud’s pessimism about human nature, as he realized how thin was the veneer of civilisation in advanced European societies. The appearance of shell-shock among trench soldiers challenged his thinking. On the one hand it seemed to demonstrate that hysterical symptoms, like the stuttering, tics and paralyses of traumatised soldiers, were psychological in origin. On the other, it led him to question his dogma about the sexual aetiology of neuroses. In his 1920 essay ‘Beyond the Pleasure Principle’ Freud put forward the theory of the “death instinct”. ‘The aim of all life is death,’ he wrote,

Donald Winnicott (born 1896) was a paediatrician and psychoanalyst influential in the field of object relations theory. He was trained at a military hospital in Cambridge and served in the Navy, described the knowledge of death as a defining feature of his generation.

The war not only touched those who were adults at the time, but children like John Bowlby (born 1907), who was sent away to boarding school at the outbreak of War II and between the ages of seven and eleven barely saw his father. Bowlby’s childhood experiences influenced his future studies on the child development and the development of the “attachment theory”.

Many other analysts had experience the “shell-shock” trauma treating the victims, among them Matthew Eder who ran a hospital for shell-shocked soldiers in Malta, Sándor Ferenczi in Budapest, and Max Eitingon and Karl Abraham in Berlin.

At the end of the war a debate between Freud’s followers and the military psychiatrists engaged. The first were downplaying the emphasis on the external stimuli causing the “shell shock” defending its infantile origins. This discussion continues until today.

Today the fact that psychoanalysis helped to bring about the close and complex relation of physical maladies to states of mind is largely forgotten.

After the WW II the interest and the research on PTSD stagnated. In fact, much of the available published research regarding PTSD is based on studies done on veterans of the war in Vietnam.

The main treatment method of PTSD involves psychotherapy. Also medication can be prescribed in some cases. Within four weeks of symptoms appearing drug treatment is not recommended unless the severity of symptoms cannot be managed by psychological means alone.

3.1 Psychotherapy

3.1.1 Cognitive-Behavioral Therapy

CBT has been proven to be an effective treatment for PTSD and is currently considered the standard of care for PTSD

The main approach of Cognitive Behavioral Therapy for PTSD is based on the idea that problems arise as a result of the way people internally interpret situations, thoughts and feelings and the problems arising out of this interpretation causing them to act, for example, through avoidance. Cognitive behavioral therapy (CBT) tries to change the way a trauma victim feels and acts by influencing the patterns of thinking and behavior, responsible for negative emotions, helping the individual to identify thoughts that make them feel afraid.

Examples of cognitive-behavioral therapies for PTSD are exposure therapy, stress-inoculation training, cognitive processing therapybehavioral activation and acceptance and commitment therapy. Many of these therapy methods have demonstrated success in treating the primary problems of PTSD and co-occurring depressive symptoms.

Exposure therapy is a type of cognitive behavioral therapy that involves assisting trauma survivors to re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation with the traumatic memories and real-life exposure to trauma reminders; this therapy modality is well supported by clinical evidence.

Short-term therapy—which is typical of CBT—is often the only option in military settings. In such setting common for the military, there is frequently the situation where a patient or therapist is leaving soon and it limits the length of the treatment time.

3.1.2 Psychodynamic psychotherapy

Psychodynamic psychotherapy for PTSD has not been studied as extensively as cognitive-behavioral therapy for PTSD. Of the studies that have been conducted, though, it has been shown that psychodynamic psychotherapy can have a number of benefits. While cognitive-behavioral therapy remains the most well-researched treatment for post-traumatic stress disorder, it doesn’t help all patients. The psychodynamic psychotherapy is more effective for the individuals who have been perpetrators as well as victims of violence.

Unlike cognitive-behavioral therapy, psychodynamic psychotherapy places a large emphasis on the unconscious, where upsetting feelings, urges and thoughts painful or shameful for the individual are stored. Even though these painful feelings, urges and thoughts are not accessible to our conscious perception, they influence our behavior.

Despite the different approach, just as with cognitive-behavioral therapy, psychodynamic therapy also wants to bring about changes in behavior. Psychodynamic approaches to PTSD focus on a number of different factors such as early childhood experiences (particularly the attachment level to the parents), current relationships and the defense mechanism (things an individual do without being aware of it to protect himself).

Trauma patients need to develop an awareness of their suffering, which helps them gradually incorporate the traumatic experience. Reducing the intensity of the underlying tension leads to symptom reduction. Making the unbearable feelings conscious trough the mediation of another human being, and employing the ego (the conscious part of the psyche) in understanding cause and effect, also the CBT techniques owe their roots to psychoanalysis.

3.1.3 Eye Movement Desensitization and Reprocessing (EMDR)

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed and studied by Francine Shapiro. This is a technique which uses eye movements to help the brain to process flashbacks and to make sense of the traumatic experience. The eye movement can be used to facilitate emotional processing of memories, changing the person’s memory to attend to more adaptive information.

3.1.4 Interpersonal Psychotherapy

Interpersonal Psychotherapy involves meeting with a group of other people who have been through the same, or a similar traumatic event. It can be easier to talk about what happened if you are with other people who have been through a similar experience. An open trial of interpersonal psychotherapy reported high rates of remission from PTSD symptoms without using exposure.

3.2 Medication

While many medications do not have enough evidence to support their use, three (fluoxetine, paroxetine, and venlafaxine) have been shown to have a small benefit over placebo. This study concluded that “the drugs included were well tolerated overall.” With many medications, residual PTSD symptoms following treatment are the rule rather than the exception. SSRI antidepressant and relieve any depression that is also present. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) may help to reduce the strength of PTSD symptoms . Evidence provides support for a small or modest improvement using such antidepressants as sertraline, fluoxetine, paroxetine, and venlafaxine.

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