Post traumatic stress disorder

Essential (Required) Features:

• Exposure to an event or situation (either short- or long-lasting) of an extremely threatening or horrific nature. Such events include, but are not limited to, directly experiencing natural or human-made disasters, combat, serious accidents, torture, sexual violence, terrorism, assault or acute life-threatening illness (e.g., a heart attack); witnessing the threatened or actual injury or death of others in a sudden, unexpected, or violent manner; and learning about the sudden, unexpected or violent death of a loved one.
• Following the traumatic event or situation, the development of a characteristic syndrome lasting for at least several weeks, consisting of all three core elements:
• Re-experiencing the traumatic event in the present, in which the event(s) is not just remembered but is experienced as occurring again in the here and now. This typically occurs in the form of vivid intrusive memories or images; flashbacks, which can vary from mild (there is a transient sense of the event occurring again in the present) to severe (there is a complete loss of awareness of present surroundings), or repetitive dreams or nightmares that are thematically related to the traumatic event(s). Re-experiencing is typically accompanied by strong or overwhelming emotions, such as fear or horror, and strong physical sensations. Re-experiencing in the present can also involve feelings of being overwhelmed or immersed in the same intense emotions that were experienced during the traumatic event, without a prominent cognitive aspect, and may occur in response to reminders of the event. Reflecting on or ruminating about the event(s) and remembering the feelings that one experienced at that time are not sufficient to meet the re-experiencing requirement.
• Deliberate avoidance of reminders likely to produce re-experiencing of the traumatic event(s). This may take the form either of active internal avoidance of thoughts and memories related to the event(s), or external avoidance of people, conversations, activities, or situations reminiscent of the event(s). In extreme cases the person may change their environment (e.g., move to a different city or change jobs) to avoid reminders.
• Persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises. Hypervigilant persons constantly guard themselves against danger and feel themselves or others close to them to be under immediate threat either in specific situations or more generally. They may adopt new behaviours designed to ensure safety (e.g., not sitting with ones’ back to the door, repeated checking in vehicles’ rear-view mirrors).
• The disturbance results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• Common symptomatic presentations of Post-Traumatic Stress Disorder may also include general dysphoria, dissociative symptoms, somatic complaints, suicidal ideation and behaviour, social withdrawal, excessive alcohol or drug use to avoid re-experiencing or manage emotional reactions, anxiety symptoms including panic, and obsessions or compulsions in response to memories or reminders of the trauma.
• The emotional experience of individuals with Post-Traumatic Stress Disorder commonly includes anger, shame, sadness, humiliation, or guilt, including survivor guilt.

Boundary with Normality (Threshold):

• A history of exposure to an event or situation of an extremely threatening or horrific nature does not in itself indicate the presence of Post-Traumatic Stress Disorder. Many people experience such stressors without developing a disorder. Rather, the presentation must meet all diagnostic requirements for the disorder.

Course Features:

• Onset of Post-Traumatic Stress Disorder can occur at any time during the life span following exposure to a traumatic event.
• Onset of Post-Traumatic Stress Disorder symptoms typically occurs within three months following exposure to a traumatic event. However, delays in the expression of Post-Traumatic Stress Disorder symptomology can occur even years after exposure to a traumatic event.
• The symptoms and course of Post-Traumatic Stress Disorder can vary significantly over time and individuals. Recurrence of symptoms may occur after to exposure to reminders of the traumatic event or as a result of experiencing additional life stressors or traumatic events. Some individuals diagnosed with Post-Traumatic Stress Disorder can experience persistent symptoms for months or years without reprieve.
• Nearly one half of individuals diagnosed with Post-Traumatic Stress Disorder will experience complete recovery of symptoms within 3 months of onset.

Developmental Presentations:

• Post-Traumatic Stress Disorder can occur at all ages, but responses to a traumatic event—that is, the core elements of the characteristic syndrome—manifest differently depending on age and developmental stage.
• Emerging cognitive capacities and limited verbal abilities for self-report in young children (e.g., less than 6 years of age) makes it more difficult to assess for the presence of re-experiencing, active avoidance of internal states, and perceptions of heightened current threat. Assessments of symptoms should not be based exclusively on child-reported internal symptoms, but include caregiver reports of observable behavioural symptoms emerging after traumatic experiences.
• In younger children, evidence of the core symptoms supporting a diagnosis of Post-Traumatic Stress Disorder often manifests behaviourally, such as in trauma-specific reenactments that may occur during repetitive play or in drawings, frightening dreams without clear content or night terrors, or uncharacteristic impulsivity. However, children may not necessarily appear distressed when talking about or playing out their traumatic recollections, despite substantial impact on psychosocial functioning and development. Other manifestations of Post-Traumatic Stress Disorder in pre-school children may be less trauma-specific and include both inhibited and disinhibited behaviours. For example, hypervigilance may manifest as increased frequency and intensity of temper tantrums, separation anxiety, regression in skills (e.g., verbal skills, toileting), exaggerated age-associated fears, or excessive crying. External avoidance or expressions of recollection of traumatic experiences may be evidenced by a new onset of acting out, protective or rescue strategies, limited exploration or reluctance to engage in new activities, and excessive reassurance seeking from a trusted caregiver.
• Limited capacity to reflect on and report internal states may also be characteristic of some school-age children and adolescents. Furthermore, children and adolescents may be more reluctant than adults to report their reactions to traumatic events. In such cases, greater reliance on changes in behaviour such as increased trauma-specific reenactments or overt avoidance may be necessary.
• Children or adolescents may deny feelings of distress or horror associated with re-experiencing but rather report no affect or other types of strong or overwhelming emotions as a part of re-experiencing, including those that are non-distressing.
• In adolescence, reluctance to pursue developmental opportunities (e.g., to gain autonomy from caregivers) may be a sign of psychosocial impairment. Self-injurious or risky behaviours (e.g., substance use or unprotected sex) occur at elevated rates among adolescents and adults with Post-Traumatic Stress Disorder.
• Assessment can be complicated in children and adolescents when loss of a parent or caregiver is associated with a traumatic event or an intervention. For example, a chronically abused child who is removed from the home may place greater emphasis on the loss of a primary caregiver than on aspects of the experience that might objectively be considered more threatening or horrific.
• Among older adults with Post-Traumatic Stress Disorder, symptom severity may decline over the life course, especially re-experiencing. However, avoidance of situations, people, activities, or conversations about the event(s) as well as hypervigilance typically persist. Older persons may dismiss their symptoms as a normal part of life, which may be related to shame and fear of stigma.

Culture-Related Features:

• The salience of particular Post-Traumatic Stress Disorder symptoms may vary across cultures. For example, in some groups anger may be the most prominent symptom related to traumatic exposure, and the most culturally appropriate way of expressing distress. In other cultural contexts, nightmares may have elaborate cultural significance that increases their importance in assessing for the characteristic symptoms of Post-Traumatic Stress Disorder.
• Symptoms central to Post-Traumatic Stress Disorder in some cultures may not be included in descriptions of the disorder and may therefore be missed by clinicians unfamiliar with those cultural expressions. For example, somatic symptoms such as headaches (often with visual aura), dizziness, bodily heat, shortness of breath, gastrointestinal distress, trembling, and orthostatic hypotension may be prominent.
• Cultural variation may affect Post-Traumatic Stress Disorder onset and the meaning of traumatic stressors. For example, some cultural groups attribute greater risk of Post-Traumatic Stress Disorder to traumatic events affecting family members than the person him/herself; other societies may find it particularly traumatic to observe the desecration or destruction of religious symbols or to be denied the ability to perform funeral rites for deceased relatives.
• Certain trauma-related symptoms may be associated with intense fear in particular cultural contexts, due to their connection with specific catastrophic cognitions, and may precipitate panic attacks in the context of Post-Traumatic Stress Disorder. These catastrophic interpretations may impact the trajectory of the disorder and be associated with greater severity, chronicity or poorer response to treatment. For example, some Latin American patients may consider trauma-related trembling to be the precursor of a lifelong condition of severe nervios (nerves) and some Cambodians may interpret palpitations as signs of a ‘weak heart.’
• Some Post-Traumatic Stress Disorder symptoms may not be viewed as pathological in some cultural groups. For example, intrusive thoughts may be considered normal rather than a symptom indicating illness. It is important to evaluate the presence of all required diagnostic elements including functional impairment rather than treating any one symptom as pathognomonic.

Sex- and/or Gender-Related Features:

• Post-Traumatic Stress Disorder is more common among females.
• Females diagnosed with Post-Traumatic Stress Disorder are more likely to experience a longer duration of impairment and higher levels of negative emotionality and somatic symptoms as a part of their clinical presentation.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Complex Post-Traumatic Stress Disorder: Whereas the diagnostic requirements for Complex Post-Traumatic Stress Disorder include all Essential Features of Post-Traumatic Stress Disorder, the diagnosis of Complex Post-Traumatic Stress Disorder also requires the additional Essential Features of severe problems in affect regulation, persistent negative beliefs about oneself, and persistent difficulties in sustaining relationships.
• Boundary with Prolonged Grief Disorder: Similar to Post-Traumatic Stress Disorder, Prolonged Grief Disorder may occur in individuals who experience bereavement as a result of the death of a loved one occurring in traumatic circumstances. In Post-Traumatic Stress Disorder, where the individual re-experiences the event or situation associated with the death, in Prolonged Grief Disorder the person may be preoccupied with memories of the circumstances surrounding the death but, unlike in Post-Traumatic Stress Disorder, does not re-experience them as occurring again in the here and now.
• Boundary with Adjustment Disorder: In Adjustment Disorder, the stressor can be of any severity or any type, and is not necessarily of an extremely threatening or horrific nature. A response to a less serious event or situation that otherwise meets the symptom requirements for Post-Traumatic Stress Disorder but that is beyond the duration appropriate for Acute Stress Reaction should be diagnosed as Adjustment Disorder. Moreover, many people who experience an extremely threatening or horrific event develop symptoms that do not meet the full diagnostic requirements for Post-Traumatic Stress Disorder; these reactions are generally better diagnosed as Adjustment Disorder.
• Boundary with Acute Stress Reaction: Normal acute reactions to traumatic events can include all the symptoms of Post-Traumatic Stress Disorder including re-experiencing, but these begin to subside fairly quickly (e.g., within 1 week after the event terminates or removal from the threatening situation, or 1 month in the case of ongoing stressors). If clinical intervention is warranted in these situations, a diagnosis of Acute Stress Reaction from the chapter on ‘Factors Influencing Health Status or Contact with Health Services’ (i.e., a non-disorder category) is generally most appropriate.
• Boundary with Schizophrenia or Other Primary Psychotic Disorders: Some individuals with Post-Traumatic Stress Disorder re-experience traumatic events in the form of severe flashbacks that may have a hallucinatory quality, or are hypervigilant to threat to the extent that they may appear to be paranoid. Auditory pseudo-hallucinations, recognized as being the person’s own thoughts and of internal origin, can occur in Post-Traumatic Stress Disorder. Such symptoms should not be considered evidence of a psychotic disorder.
• Boundary with Depressive Episode: In a Depressive Episode, intrusive memories are not experienced as occurring again in the present, but as belonging to the past, and they are often accompanied by rumination. However, Depressive Episodes commonly co-occur with Post-Traumatic Stress Disorder, and an additional Mood Disorder diagnosis should be assigned if warranted.
• Boundary with Panic Disorder: In Post-Traumatic Stress Disorder, panic attacks can be triggered by reminders of the traumatic event(s) or in the context of re-experiencing. Panic attacks that occur entirely in these contexts do not warrant an additional, separate diagnosis of Panic Disorder. Instead, the ‘with panic attacks’ specifier (MB23.H) may be applied. However, if unexpected panic attacks (i.e., those that come on ‘out of the blue’) are also present and the other diagnostic requirements are met, an additional diagnosis of Panic Disorder is appropriate.
• Boundary with Specific Phobia: In some cases, a situational or conditioned Specific Phobia can arise after exposure to a traumatic event (e.g., being attacked by a dog). Specific Phobia can generally be differentiated from Post-Traumatic Stress Disorder by the absence of re-experiencing of the event in the present. Although phobic responses may include powerful memories of the event, in response to which the individual experiences anxiety, the memories are experienced as belonging to the past.
• Boundary with Dissociative Disorders: Following an experience of a traumatic event(s), a variety of dissociative symptoms can occur, including somatic symptoms, memory disturbances, flashbacks or other trance-like states, alterations in identity and sense of agency, and experiences of depersonalization, especially during the episodes of re-experiencing. If the dissociative symptoms are confined to episodes of re-experiencing in an individual with Post-Traumatic Stress Disorder or Complex Post-Traumatic Stress Disorder, an additional diagnosis of a Dissociative Disorder should not be assigned. If significant dissociative symptoms are present outside of episodes of re-experiencing and the full diagnostic requirements are met, an additional Dissociative Disorder diagnosis may be assigned.
• Boundary with other mental disorders: It is common for other mental disorders other than or in addition to Post-Traumatic Stress Disorder to develop in the aftermath of an event or situation (either short- or long-lasting) of an extremely threatening or horrific nature. Thus, a history of exposure to a potentially traumatic event does not in itself indicate the presence of Post-Traumatic Stress Disorder. Depressive Disorders, Anxiety or Fear-Related Disorders, Disorders Due to Substance Use, and Dissociative Disorders can all occur in the aftermath of potentially traumatic experiences, often in the absence of Post-Traumatic Stress Disorder.