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Posttraumatic Stress Disorder (PTSD)

Prevalence, Epidemiology, And Comorbidity, Etiology, Risk Indicators And Factors That Promote Resilience, Assessment And TreatmentConclusion

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.

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.


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