Week 9 _ Assignment: Posttraumatic Stress Disorder

Assignment: Posttraumatic Stress Disorder

 

 

It is estimated that more almost 7% of the U.S. population will experience posttraumatic stress disorder (PTSD) in their lifetime (National Institute of Mental Health, 2017). This debilitating disorder often interferes with an individual’s ability to function in daily life. Common symptoms of anxiousness and depression frequently lead to behavioral issues, adolescent substance abuse issues, and even physical ailments. For this Assignment, you examine a PTSD video case study and consider how you might assess and treat clients presenting with PTSD.

 

To prepare:

· View the media Presentation Example: Posttraumatic Stress Disorder (PTSD) and assess the client in the case study.

· https://www.youtube.com/watch?v=RkSv_zPH-M4

 

· Review the DSM-5-TR diagnostic criteria for PTSD – see attachment

The Assignment – Instructions

 

Succinctly, in 2-3 pages, address the following:

 

· Briefly explain the neurobiological basis for PTSD illness.

 

· Discuss the DSM-5-TR diagnostic criteria for PTSD (see attachment with diagnostic criteria for PTSD) and relate these criteria to the symptomology presented in the case study (case study – see link above).

Does the video case presentation provide sufficient information to derive a PTSD diagnosis? Justify your reasoning. Do you agree with the other diagnoses in the case presentation? Why or why not?

 

· Discuss one other psychotherapy treatment option for the client in this case study. Explain whether your treatment option is considered a “gold standard treatment” from a clinical practice guideline perspective, and why using gold standard, evidence-based treatments from clinical practice guidelines is important for psychiatric-mental health nurse practitioners.

 

· Support your Assignment with specific examples from this week’s media (above link) and at least three peer-reviewed, evidence-based sources. Explain why each of your supporting sources is considered scholarly.

 

· Attach the PDFs of your sources.

 

· APA 7

 

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(F43.10)

Posttraumatic Stress Disorder

Diagnostic Criteria Posttraumatic Stress Disorder in Individuals Older Than 6 Years

Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below.

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 affect 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 or closely associated with the traumatic event(s).

 

 

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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.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).

2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify if:

 

 

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With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

Posttraumatic Stress Disorder in Children 6 Years and Younger A. In children 6 years and younger, 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, especially primary caregivers.

3. Learning that the traumatic event(s) occurred to a parent or caregiving figure.

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: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

Note: It may not be possible to ascertain that the frightening content is related to the traumatic event.

3. Dissociative reactions (e.g., flashbacks) in which the child 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.) Such 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 reminders of the traumatic event(s).

C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):

Persistent Avoidance of Stimuli

1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).

2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).

Negative Alterations in Cognitions

3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).

4. Markedly diminished interest or participation in significant activities, including constriction of play.

5. Socially withdrawn behavior.

6. Persistent reduction in expression of positive emotions.

 

 

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D. 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 (including extreme temper tantrums).

2. Hypervigilance.

3. Exaggerated startle response.

4. Problems with concentration.

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

E. The duration of the disturbance is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior.

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

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following:

1.

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).

2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

Diagnostic Features The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. The clinical presentation of PTSD varies. In some individuals, fear-based reexperiencing, emotional, and behavioral symptoms may predominate. In others, anhedonic or dysphoric mood states and negative cognitions may be most prominent. In some other individuals, arousal and reactive-externalizing symptoms are prominent, while in yet others, dissociative symptoms predominate. Finally, some individuals exhibit combinations of these symptom patterns.

The following discussion of specific criteria for PTSD refers to specific criteria for adults; criteria for children 6 years or younger may differ in criterion numbering given differences in applicable criteria for this age group.

The traumatic events in Criterion A all involve actual or threatened death, serious injury, or sexual violence in some way but differ in how the individual is exposed to them, which can be through directly experiencing the traumatic event (Criterion A1), witnessing in person the event as it occurred to others (Criterion A2), learning that the event occurred to a family member or a close friend (Criterion A3), or indirect exposure in the course of occupational

 

 

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duties, through being exposed to grotesque details of an event (Criterion A4). The disorder may be especially severe or long-lasting when the stressor is interpersonal and intentional (e.g., torture, sexual violence).

The directly experienced traumatic events in Criterion A include, but are not limited to, exposure to war as a combatant or civilian, actual or threatened physical assault in which the threat is perceived as imminent and realistic (e.g., physical attack, robbery, mugging, childhood physical abuse), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human-made disasters, and severe motor vehicle accidents.

Sexual trauma includes, but is not limited to, actual or threatened sexual violence or coercion (e.g., forced sexual penetration; alcohol/drug-facilitated nonconsensual sexual penetration; other unwanted sexual contact; and other unwanted sexual experiences not involving contact, such as being forced to watch pornography, exposure to the display of genitals by an exhibitionist, or being the victim of unwanted photography or videotaping of a sexual nature or the unwanted dissemination of these photographs or videos) (Basile et al. 2013).

Being bullied may qualify as a Criterion A1 experience when there is a credible threat of serious harm or sexual violence. For children, sexually violent events may include developmentally inappropriate sexual experiences without physical violence or injury.

A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event. Qualifying events of this type include life-threatening medical emergencies (e.g., an acute myocardial infarction, anaphylactic shock) or a particular event in treatment that evokes catastrophic feelings of terror, pain, helplessness, or imminent death (e.g., waking during surgery, debridement of severe burn wounds, emergency cardioversion).

Witnessed events (Criterion A2) include, but are not limited to, observing threatened or serious injury, unnatural death, physical or sexual abuse of another person due to violent assault, domestic violence, accident, war, or disaster. For example, this would include parents witnessing their child in an acute life-endangering incident (e.g., a diving accident) or a medical catastrophe during the course of their child’s illness or ongoing treatment (e.g., a life- threatening hemorrhage).

Indirect exposure through learning about an event (Criterion A3) is limited to events affecting close relatives or friends that were violent or accidental (i.e., death from natural causes does not qualify). Such events include murder, violent personal assault, combat, terrorist attack, sexual violence, suicide, and serious accident or injury.

The indirect exposure of professionals to the grotesque effects of war, rape, genocide, or abusive violence inflicted on others occurring in the context of their work duties can also result in PTSD and thus is considered to be a qualifying trauma (Criterion A4). Examples include first responders exposed to serious injury or death and military personnel collecting human remains. Indirect exposure can also occur through photos, videos, verbal accounts, or written accounts (e.g., police officers reviewing crime reports or conducting interviews with crime victims, drone operators, members of the news media covering traumatic events, and psychotherapists exposed to details of their patients’ traumatic experiences).

Exposure to multiple traumatic events is common and can take many forms. Some individuals experience different types of traumatic events at different times (e.g., sexual violence during childhood and natural disaster as adults). Others experience the same type of traumatic event at different times or in a series committed by the same person/people over an extended period (e.g., child sexual or physical assault; physical or sexual assault by an intimate partner). Others may experience numerous traumatic events that are the same or different during an extended hazardous period such as deployment or living in a conflict zone. When one is assessing the PTSD criteria in individuals who have experienced multiple traumatic events across their lives, it may be useful to determine if there is a specific, discrete example that the individual considers to be the worst given that the symptomatic expressions of PTSD Criterion B and Criterion C specifically refer to the traumatic event (e.g., recurrent, involuntary, and intrusive distressing recollections of the traumatic event). However, if it is difficult for the individual to identify a worst example, it is appropriate to consider the entire exposure as meeting Criterion A. In addition, some discrete events may incorporate several traumatic event types (e.g., an individual involved in a mass casualty incident sustains a major injury, witnesses someone else being injured, and then learns that a family member was killed in the incident).

The traumatic event can be reexperienced in various ways. Commonly, the individual has recurrent, involuntary, and intrusive recollections of the event (Criterion B1). Intrusive recollections in PTSD are distinguished from depressive rumination in that they apply only to involuntary and intrusive distressing memories. The emphasis is on recurrent memories of the event that usually include intrusive, vivid, sensory, and emotional components that are distressing and not merely ruminative. A common reexperiencing symptom is distressing dreams that replay the event itself or

 

 

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that are representative or thematically related to the major threats involved in the traumatic event (Criterion B2). The individual may experience dissociative states that typically last a few seconds and rarely are of a longer duration, during which components of the event are relived and the individual behaves as if the event were occurring at that moment (Criterion B3). Such events occur on a continuum, ranging from brief visual or other sensory intrusions about part of the traumatic event without loss of reality orientation to a partial loss of awareness of present surroundings to a complete loss of awareness. These episodes, often referred to as “flashbacks,” are typically brief but can be associated with prolonged distress and heightened arousal. For young children, reenactment of events related to trauma may be expressed behaviorally in play or in dissociative states. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the individual is exposed to triggering events or somatic reactions that resemble or symbolize an aspect of the traumatic event (e.g., windy days after a hurricane, seeing someone who resembles one’s perpetrator). The triggering cue could also be a physical sensation (e.g., dizziness for survivors of head trauma, rapid heartbeat for a previously traumatized child), particularly for individuals with highly somatic presentations (Friedman et al. 2011).

Stimuli associated with the trauma are persistently avoided. The individual commonly makes deliberate efforts to avoid thoughts, memories, or feelings (e.g., by utilizing distraction or suppression techniques, including substance use, to avoid internal reminders) (Criterion C1), and to avoid activities, conversations, objects, situations, or people who arouse recollections of it (Criterion C2).

Negative alterations in cognitions or mood associated with the traumatic event begin or worsen after exposure to the event. These negative alterations can take various forms, including an inability to remember key and emotionally painful aspects of the traumatic event. Such memory loss is typically attributable to dissociative amnesia and is not attributable to head injury or impaired encoding of the memory due to drug or alcohol use (Criterion D1). Individuals with PTSD often report that the traumatic event has irrevocably altered their lives and their view of the world (Janoff-Bulman 1992; Lifton 1979). This is characterized by persistent and exaggerated negative beliefs and expectations regarding important aspects of life applied to themselves, others, the world, or the future (Criterion D2) (e.g., “Bad things will always happen to me”; “The world is dangerous, and I can never be adequately protected”; “I can’t trust anyone ever again”; “My life is permanently ruined”; “I have lost any chance for future happiness”; “My life will be cut short”). Individuals with PTSD may have persistent erroneous cognitions about the causes of the traumatic event that lead them to blame themselves or others (e.g., “It’s all my fault that my uncle abused me”) (Criterion D3). A persistent negative mood state (e.g., fear, dysphoria, horror, anger, guilt, shame) either began or worsened after exposure to the event (Criterion D4). The individual may experience markedly diminished interest or participation in previously enjoyed activities (Criterion D5), may feel detached or estranged from other people (Criterion D6), or may experience a persistent inability to feel positive emotions (especially happiness, joy, satisfaction, or emotions associated with intimacy, tenderness, and sexuality) (Criterion D7) (Friedman et al. 2011).

Negative alterations in arousal and reactivity also begin or get worse after exposure to the event. Individuals with PTSD may exhibit irritable or angry behavior and may engage in aggressive verbal or physical behavior with little or no provocation (e.g., yelling at people, getting into fights, destroying objects) (Criterion E1). They may also engage voluntarily in reckless or self-destructive behavior that is dangerous, that shows a disregard for the physical safety of themselves or others, and that could directly result in serious physical harm or death (Criterion E2). Examples include, but are not limited to, dangerous driving (e.g., drunk driving, driving at dangerously high speeds), excessive alcohol or drug use, having risky sex (e.g., unprotected sex with a partner whose HIV status is unknown, high number of sexual partners), or self-directed violence including suicidal behaviors. Criterion E2 does not include circumstances in which individuals must engage in dangerous situations as a part of their job (e.g., armed forces members in combat situations or first responders in emergency situations) and take reasonable safety precautions to reduce their risk or when individuals engage in behaviors that may be unwise, unhealthy, or financially harmful but pose no direct risk of immediate serious physical harm or death (e.g., pathological gambling, poor financial decisions, binge eating, unhealthy lifestyles). PTSD is often characterized by a heightened vigilance for potential threats, including those that are related to the traumatic experience (e.g., following a motor vehicle accident, being especially sensitive to the threat potentially caused by cars or trucks) and those not related to the traumatic event (e.g., being fearful of suffering a heart attack) (Criterion E3) (Smith and Bryant 2000; Warda and Bryant 1998). Individuals with PTSD may be very reactive to unexpected stimuli, displaying a heightened startle response, or jumpiness, to loud noises or unexpected movements (e.g., jumping markedly in response to a telephone ringing) (Criterion E4). Startle responses are involuntary and reflexive (automatic, instantaneous), and stimuli that evoke exaggerated startle responses (Criterion E4) need not be related at all to the traumatic event. Startle responses are distinguished from the cued physiological arousal responses in Criterion B5, for which there needs to be at least some level of conscious appraisal that the stimulus producing physiological responses is related to the trauma. Concentration difficulties, including difficulty remembering daily events (e.g., forgetting one’s telephone number) or attending to focused tasks (e.g., following a conversation for a sustained period of time), are commonly reported (Criterion E5).

 

 

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Problems with sleep onset and maintenance are common and may be associated with nightmares and safety concerns or with generalized elevated arousal that interferes with adequate sleep (Criterion E6).

The diagnosis of PTSD requires that the duration of the symptoms in Criteria B, C, D, and E be more than 1 month (Criterion F). For a current diagnosis of PTSD, Criteria B, C, D, and E must all be met for more than 1 month, for at least the past month. For a lifetime diagnosis of PTSD, there must be a period of time lasting more than 1 month during which Criteria B, C, D, and E have all been met for the same 1-month period of time.

A significant subgroup of individuals with PTSD experience persistent dissociative symptoms of either depersonalization (detachment from their bodies) or derealization (detachment from the world around them). This can be indicated by using the “with dissociative symptoms” specifier (Friedman et al. 2011; Hansen et al. 2017; van Huijstee and Vermetten 2018).

Associated Features Developmental regression, such as loss of language in young children, may occur. Auditory pseudo-hallucinations, such as having the sensory experience of hearing one’s thoughts spoken in one or more different voices (Brewin and Patel 2010), as well as paranoid ideation, can be present. Following prolonged, repeated, and severe traumatic events (e.g., childhood abuse, torture), the individual may additionally experience difficulties in regulating emotions or maintaining stable interpersonal relationships, or dissociative symptoms. When the traumatic event involves the violent death of someone with whom the individual had a close relationship, symptoms of both prolonged grief disorder and PTSD may be present.

Prevalence The national lifetime prevalence estimate for PTSD using DSM-IV criteria is 6.8% for U.S. adults (Kessler et al. 2005a). Lifetime prevalence for U.S. adolescents using DSM-IV criteria has ranged from 5.0% (Merikangas et al. 2010) to 8.1% (Kilpatrick et al. 2003b) and a past 6-month prevalence of 4.9% for adolescents (Kilpatrick et al. 2003a). While definitive, comprehensive population-based data using DSM-5 are not available, findings are beginning to emerge. In two U.S. national epidemiological studies, lifetime DSM-5 PTSD prevalence estimates ranged from 6.1% to 8.3%, and the national 12-month DSM-5 prevalence estimate was 4.7% in both studies (Goldstein et al. 2016; Kilpatrick et al. 2013). National lifetime DSM-IV PTSD estimates from World Mental Health Surveys in 24 countries varied substantially among countries, income country groups, and WHO regions but was 3.9% overall (Koenen et al. 2017). In conflict-affected populations worldwide, the point prevalence of PTSD with functional impairment is 11% after adjustment for age differences across studies (Charlson et al. 2019).

Rates of PTSD are higher among veterans and others whose vocation increases the risk of traumatic exposure (e.g., police, firefighters, emergency medical personnel). Highest rates (ranging from one-third to more than one-half of those exposed) are found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide. The prevalence of PTSD may vary across development; children and adolescents, including preschool children, generally have displayed lower prevalence following exposure to serious traumatic events; however, this may be because previous criteria were insufficiently developmentally informed (Scheeringa et al. 2011). Racial differences, based on DSM-IV data, show higher rates of PTSD among U.S. Latinx, African Americans, and American Indians compared with Whites (Beals et al. 2002; Hinton and Lewis- Fernández 2011; Perilla et al. 2002). Potential reasons for these prevalence variations include differences in predisposing or enabling factors, such as exposure to past adversity and racism and discrimination, and in availability or quality of treatment, social support, socioeconomic status, and other social resources that facilitate recovery and are confounded with ethnic and racialized background (Chou et al. 2012; Hinton and Lewis-Fernández 2011; McClendon et al. 2019; Spoont et al. 2017).

Development and Course PTSD can occur at any age, beginning after the first year of life. Symptoms usually begin within the first 3 months after the trauma, although there may be a delay of months, or even years, before full criteria for the diagnosis are met. There is abundant evidence for what DSM-IV called “delayed onset” but is now called “delayed expression,” with the recognition that some symptoms typically appear immediately and that the delay is in meeting full criteria (Andrews et al. 2007).

Frequently, an individual’s reaction to a trauma initially meets criteria for acute stress disorder in the immediate aftermath of the trauma. The symptoms of PTSD and the relative predominance of different symptoms may vary over time. Duration of the symptoms also varies, with complete recovery within 3 months occurring in approximately one-

 

 

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half of adults, while some individuals remain symptomatic for longer than 12 months (Bryant et al. 2011) and sometimes for more than 50 years. Symptom recurrence and intensification may occur in response to reminders of the original trauma, ongoing life stressors, or newly experienced traumatic events.

The clinical expression of reexperiencing can vary across development. Developmental variations in clinical expression inform the use of different criteria in children 6 years and younger and in individuals who are older. Young children may report new onset of frightening dreams without content specific to the traumatic event. Children age 6 and younger may develop PTSD as a result of severe emotional abuse (e.g., threat of abandonment), which can be perceived as life-threatening. During treatment for life-threatening illness (e.g., cancer, solid organ transplantation), the experience of young children of the severity and intensity of the treatment may contribute to risk of developing posttraumatic stress symptoms (Stuber et al. 1997); the self-appraisal of threat may also contribute to the risk of developing posttraumatic stress symptoms in adolescents (Mintzer et al. 2005). Before age 6 years, young children are more likely to express reexperiencing symptoms through play that refers directly or symbolically to the trauma (see PTSD criteria for children 6 years and younger). They may not manifest fearful reactions at the time of the exposure or during reexperiencing. Parents may report a wide range of emotional or behavioral changes in young children. Children may focus on imagined interventions in their play or storytelling. In addition to avoidance, children may become preoccupied with reminders. Because of young children’s limitations in expressing thoughts or labeling emotions, negative alterations in mood or cognition tend to involve primarily mood changes. Children may experience co-occurring traumas (e.g., physical abuse, witnessing domestic violence) and in chronic circumstances may not be able to identify onset of symptomatology (Scheeringa et al. 2005; Scheeringa et al. 2006). Avoidant behavior may be associated with restricted play or exploratory behavior in young children; reduced participation in new activities in school-age children; or reluctance to pursue developmental opportunities in adolescents (e.g., dating, driving). Older children and adolescents may judge themselves as cowardly. Adolescents may harbor beliefs of being changed in ways that make them socially undesirable and estrange them from peers and lose aspirations for the future. Irritable or aggressive behavior in children and adolescents can interfere with peer relationships and school behavior. Reckless behavior may lead to accidental injury to self or others, thrill-seeking, or high-risk behaviors (Pynoos et al. 2009). In older individuals, the disorder is associated with negative health perceptions, primary care utilization, and suicidal thoughts (Rauch et al. 2006). In addition, declining health, worsening cognitive functioning, and social isolation may exacerbate PTSD symptoms (Thorp et al. 2011).

Risk and Prognostic Factors Risk factors for PTSD can operate in many ways, including predisposing individuals to trauma or to extreme emotional responses when exposed to traumatic events. Risk (and protective) factors are generally divided into pretraumatic, peritraumatic, and posttraumatic factors.

Pretraumatic Factors

Temperamental

High-risk factors include childhood emotional problems by age 6 years (e.g., externalizing or anxiety problems) and prior mental disorders (e.g., panic disorder, depressive disorder, PTSD, or obsessive-compulsive disorder [OCD]). Individual differences in premorbid personality may influence the trajectory of response to trauma and treatment outcomes. Personality traits associated with negative emotional responses such as depressed mood and anxiousness represent risk factors for the development of PTSD (Jakšic et al. 2012). Such traits might be captured in measures of negative affectivity (neuroticism) on standardized personality scales. Premorbid trait impulsivity tends to be associated with externalizing manifestations of PTSD and comorbidities of the externalizing spectrum, including substance use disorder or aggressive behavior.

Environmental

As documented among U.S. civilians and veterans, these risk factors include lower socioeconomic status; lower education; exposure to prior trauma (especially during childhood) (Binder et al. 2008; Cougle et al. 2009; Smith et al. 2008); childhood adversity (e.g., economic deprivation, family dysfunction, parental separation or death); lower intelligence; ethnic discrimination and racism (Chou et al. 2012); and a family psychiatric history. Social support prior to event exposure is protective.

Genetic and physiological

 

 

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The risk of developing PTSD following traumatic exposure has been demonstrated to be modestly heritable in twin studies (Stein et al. 2002) and molecular studies (Duncan et al. 2018). Genome-wide association data from a large multiethnic cohort support the heritability of PTSD and demonstrate three robust genome-wide significant loci that vary by geographic ancestry (Nievergelt et al. 2018). Susceptibility to PTSD may also be influenced by epigenetic factors (Smith et al. 2019). Genome-wide association data from U.S. veterans identify eight significant regions in Americans of European descent associated with intrusive reexperiencing symptoms of PTSD; data from the United Kingdom also support these associations (Gelernter et al. 2019).

Peritraumatic Factors

Environmental

These include severity (dose) of the trauma, perceived life threat, personal injury, interpersonal violence (particularly trauma perpetrated by a caregiver or involving a witnessed threat to a caregiver in children) (Scheeringa et al. 2006), and, for military personnel, being a perpetrator, witnessing atrocities, or killing the enemy. Finally, dissociation, fear, panic, and other peritraumatic responses that occur during the trauma and persist afterward are risk factors.

Posttraumatic Factors

Temperamental

These include negative appraisals, inappropriate coping strategies, and development of acute stress disorder.

Environmental

These include subsequent exposure to repeated upsetting reminders, subsequent adverse life events, and financial or other trauma-related losses. Posttraumatic experiences such as forced migration and high levels of daily stressors may contribute to different conditional risks of PTSD across cultural contexts (Bustamante et al. 2017; Miller and Rasmussen 2010; Rasmussen et al. 2010). Exposure to racial and ethnic discrimination has been associated with a more chronic course among African American and Latinx adults (Sibrava et al. 2019). Social support (including family stability, for children) is a protective factor that moderates outcome after trauma (Breslau 2009; Vogt et al. 2007).

Culture-Related Diagnostic Issues Different demographic, cultural, and occupational groups have different levels of exposure to traumatic events (Blanco 2011), and the relative risk of developing PTSD following a similar level of exposure (e.g., religious persecution) may also vary across cultural, ethnic, and racialized groups (Alcántara et al. 2013; Hinton and Lewis- Fernández 2011). Variation in the type of traumatic exposure (e.g., genocide), the impact on disorder severity of the meaning attributed to the traumatic event (e.g., inability to perform funerary rites after a mass killing), the ongoing sociocultural context (e.g., residing among unpunished perpetrators in postconflict settings), exposure to racial and ethnic discrimination (Chou et al. 2012; Sibrava et al. 2019), and other cultural factors (e.g., acculturative stress in migrants) may influence the risk of onset and severity of PTSD across cultural groups (Hinton and Lewis-Fernández 2011; Kohrt and Hruschka 2010; Shala et al. 2020). Some communities are exposed to pervasive and ongoing traumatic environments, rather than isolated Criterion A events (Bensimon et al. 2013; Rasmussen et al. 2014); in these communities, the predictive power of individual traumatic events for the development of PTSD may diminish (Bensimon et al. 2013). In cultures where social image (e.g., maintaining a family’s “face”) is emphasized, public defamation or shaming may magnify the impact of Criterion A events (Bockers et al. 2016; Budden 2009; Hinton and Lewis-Fernández 2011). Some cultures may attribute PTSD syndromes to negative supernatural experiences (Rasmussen et al. 2014).

The clinical expression of the symptoms or symptom clusters of PTSD can vary culturally in both adults and children. In many non-Western groups, avoidance is less commonly observed, whereas somatic symptoms (e.g., dizziness, shortness of breath, heat sensations) are more common; other symptoms that vary cross-culturally are distressing dreams, amnesia not related to head injury, and reckless but nonsuicidal behavior (Doric et al. 2019; Hinton and Lewis-Fernández 2011; Rasmussen et al. 2014). Negative moods, especially anger, are common cross-culturally in individuals with PTSD (Caspi et al. 2015; Rasmussen et al. 2014), as are distressing dreams and sleep paralysis (Hinton and Good 2016). Across cultures, somatic symptoms are frequent, occurring in both children and adults (Gupta 2013; Rasmussen et al. 2014), especially after sexual trauma (Kugler et al. 2012). Symptoms that vary cross-culturally in relation to PTSD among children include intrusive thoughts, diminished participation in activities,

 

 

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inability to experience positive emotions, irritability, aggression, and hypervigilance. Distressing dreams, flashbacks, psychological distress upon exposure to trauma cues, and efforts to avoid memories and thoughts are common in children with PTSD across cultures (Doric et al. 2019).

In certain cultural contexts, it may be normative to respond to traumatic events with negative beliefs about oneself or with spiritual attributions that may appear exaggerated to others. For example, blaming oneself may be consistent with ideas of karma in South and East Asia, destiny or “spoiled medicine law” in West Africa, and cultural differences in locus of control and conceptions of self (Adams 1998; Chung et al. 2006; Davidson et al. 2005; Jobson 2009, Kenny 1996; Kohrt and Hruschka 2010).

In many populations around the world, there are cultural concepts of distress that resemble PTSD and are characterized by diverse manifestations of psychological distress attributed to frightening or traumatic experiences (Hinton and Lewis-Fernández 2011; Kohrt et al. 2014; Lewis-Fernández and Kirmayer 2019; Rasmussen et al. 2014). Thus, cultural concepts of distress influence the expression of PTSD and the range of its comorbid disorders (see “Culture and Psychiatric Diagnosis” in Section III).

Sex- and Gender-Related Diagnostic Issues PTSD is more prevalent among women than among men across the life span. Lifetime prevalence of PTSD ranges from 8.0% to 11.0% for women and 4.1% to 5.4% for men based on two large U.S. population-based studies using DSM-5 criteria (Goldstein et al. 2016; Kilpatrick et al. 2013). Some of the increased risk for PTSD in women appears to be attributable to a greater likelihood of exposure to childhood sexual abuse, sexual assault, and other forms of interpersonal violence, which carry the highest risk for development of PTSD (Kessler et al. 1995). Women in the general population also experience PTSD for a longer duration than do men (Kessler et al. 2005b). However, other factors likely contributing to the higher prevalence in women include gender differences in the emotional and cognitive processing of trauma (Street and Dardis 2018), as well as effects of reproductive hormones (Ramikie and Ressler 2018). When responses of men and women to specific stressors are compared, gender differences in risk for PTSD persist (Blanco et al. 2018). On the other hand, PTSD symptom profiles and factor structures are similar between men and women (Rivollier et al. 2015).

Association With Suicidal Thoughts or Behavior Traumatic events such as childhood abuse or sexual trauma increase an individual’s suicide risk in both civilians (Affi et al. 2008; Dworkin et al., 2017; Gradus et al. 2012; Klomek et al. 2015; Ranney et al. 2016) and veterans (Kimerling et al. 2016). PTSD is associated with suicidal thoughts, suicide attempts, and death from suicide (Gradus et al. 2015; Sareen et al. 2005; Sareen et al. 2007). The presence of PTSD has been associated with an increased likelihood of transitioning from suicidal thoughts to a suicide plan or attempt (Nock et al. 2010), and this effect of PTSD occurs independently of the increased risk of mood disorders on the likelihood of suicidal behaviors (Bentley et al. 2016; Naifeh et al. 2019). Among adolescents there is also a significant relationship between PTSD and suicidal thoughts or behavior even after adjustment for the effects of comorbidity (Panagioti et al. 2015).

Functional Consequences of Posttraumatic Stress Disorder PTSD is associated with high impairment in social, occupational, and physical functioning; reduced quality of life; and physical health problems (Goldstein et al. 2016; Kessler et al. 2005a; Olatunji et al. 2007; Ryder et al. 2018; Sayer et al. 2011; Schnurr et al. 2009). Impaired functioning is exhibited across social, interpersonal, developmental, educational, physical health, and occupational domains. In community and veteran samples, PTSD is associated with poor social and family relationships, absenteeism from work, lower income, and lower educational and occupational success (Olatunji et al. 2007; Sayer et al. 2011; Schnurr et al. 2009).

Differential Diagnosis

Adjustment disorders

In adjustment disorders, the stressor can be of any severity or type rather than a stressor involving exposure to actual or threatened death, serious injury, or sexual violence as required by PTSD Criterion A. The diagnosis of an adjustment disorder is used when the response to a stressor that meets PTSD Criterion A does not meet all other PTSD criteria (or criteria for another mental disorder). An adjustment disorder is also diagnosed when the symptom pattern of PTSD occurs in response to a stressor that does not meet PTSD Criterion A (e.g., spouse leaving, being fired) (Strain and Friedman 2011).

 

 

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Other posttraumatic disorders and conditions

Not all psychopathology that occurs in individuals exposed to an extreme stressor should necessarily be attributed to PTSD. The PTSD diagnosis requires that trauma exposure precede the onset or exacerbation of pertinent symptoms. If the symptom response pattern to the extreme stressor meets criteria for another mental disorder, these diagnoses should be given instead of, or in addition to, PTSD. Other diagnoses and conditions are excluded if they are better explained by PTSD (e.g., symptoms of panic disorder that occur only after exposure to traumatic reminders). If severe, symptom response patterns to the extreme stressor that meet criteria for another mental disorder may warrant a separate diagnosis (e.g., dissociative amnesia) in addition to PTSD.

Acute stress disorder

Acute stress disorder is distinguished from PTSD because the symptom pattern in acute stress disorder is restricted to a duration of 3 days to 1 month following exposure to the traumatic event.

Anxiety disorders and obsessive-compulsive disorder

In OCD, there are recurrent intrusive thoughts, but these meet the definition of an obsession. In addition, the intrusive thoughts are not related to an experienced traumatic event, compulsions are usually present, and other symptoms of PTSD or acute stress disorder are typically absent. Neither the arousal and dissociative symptoms of panic disorder nor the avoidance, irritability, and anxiety of generalized anxiety disorder are associated with a specific traumatic event. The symptoms of separation anxiety disorder are clearly related to separation from home or family, rather than to a traumatic event.

Major depressive disorder

Major depression may or may not be preceded by a traumatic event and should be diagnosed if full criteria have been met. Specifically, major depressive disorder does not include any PTSD Criterion B or C symptoms. Nor does it include a number of symptoms from PTSD Criterion D or E. However, if full criteria for PTSD are also met, both diagnoses may be given.

Attention-deficit/hyperactivity disorder

Both ADHD and PTSD may include problems in attention, concentration, and learning. In contrast to ADHD, where the problems in attention, concentration, and learning must have their onset prior to age 12, in PTSD the symptoms have their onset following exposure to a Criterion A traumatic event. In PTSD, disruptions in the individual’s attention and concentration can be attributable to alertness to danger and exaggerated startle responses to reminders of the trauma.

Personality disorders

Interpersonal difficulties that had their onset, or were greatly exacerbated, after exposure to a traumatic event may be an indication of PTSD, rather than a personality disorder, in which such difficulties would be expected independently of any traumatic exposure.

Dissociative disorders

Dissociative amnesia, dissociative identity disorder, and depersonalization-derealization disorder may or may not be preceded by exposure to a traumatic event or may or may not have co-occurring PTSD symptoms. When full PTSD criteria are also met, however, the PTSD “with dissociative symptoms” subtype should be considered.

Functional neurological symptom disorder (conversion disorder)

New onset of somatic symptoms within the context of posttraumatic distress might be an indication of PTSD rather than functional neurological symptom disorder.

Psychotic disorders

Flashbacks in PTSD must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in schizophrenia, brief psychotic disorder, and other psychotic disorders; depressive and bipolar disorders with

 

 

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psychotic features; delirium; substance/medication-induced disorders; and psychotic disorders due to another medical condition. PTSD flashbacks are distinguished from these other perceptual disturbances by being directly related to the traumatic experience and by occurring in the absence of other psychotic or substance-induced features.

Traumatic brain injury

Some types of traumatic events increase risk of both PTSD and traumatic brain injury (TBI) because they can produce head injuries (e.g., military combat, bomb blasts, child physical abuse, intimate partner violence, violent crime, motor vehicle or other accidents). In such cases, individuals presenting with PTSD may also have TBI, and those presenting with TBI may also have PTSD. Individuals with PTSD who also have TBI may have persistent postconcussive symptoms (e.g., headaches, dizziness, sensitivity to light or sound, irritability, concentration deficits) (Ackland et al. 2019; Bryant 2011; Iverson et al. 2017). However, such symptoms may also occur in non-brain-

injured populations, including individuals with PTSD (Meares et al. 2008). Because symptoms of PTSD and TBI- related neurocognitive symptoms can overlap, a differential diagnosis between PTSD and neurocognitive disorder symptoms attributable to TBI may be possible based on the presence of symptoms that are distinctive to each presentation. Whereas reexperiencing and avoidance are characteristic of PTSD and not the effects of TBI, persistent disorientation and confusion are more specific to TBI (neurocognitive effects) than to PTSD. TBI-related memory problems concerning the traumatic event are typically attributable to injury-related inability to encode the information, whereas PTSD-related memory problems typically reflect dissociative amnesia. Sleep difficulties are common to both disorders.

Comorbidity Individuals with PTSD are more likely than those without PTSD to have symptoms that meet diagnostic criteria for at least one other mental disorder, such as depressive, bipolar, anxiety, or substance use disorders (Bryant et al. 2011; Goldstein et al. 2016; Greer et al. 2020; Smith et al. 2016). PTSD is also associated with increased risk of major neurocognitive disorder (Yaffe et al. 2010). In a U.S.-based study, women were more likely to develop PTSD following a mild TBI (Yue et al. 2019). Although most young children with PTSD also have at least one other diagnosis, the patterns of comorbidity are different than in adults, with oppositional defiant disorder and separation anxiety disorder predominating (Scheeringa et al. 2005; Scheeringa et al. 2006).

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