Recent data from the National Comorbidity Survey Replication indicates lifetime PTSD prevalence rates are 3.6% and 9.7% respectively among American men and women (7). One important finding, which was not apparent when PTSD was first proposed as a diagnosis in 1980, is that it is relatively common. A very similar syndrome is classified in ICD-10 (The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines) (6). The DSM-III diagnostic criteria for PTSD were revised in DSM-III-R (1987), DSM-IV (1994), and DSM-IV-TR (2000) (2-5). Although there is currently a renewed interest in subjective aspects of traumatic exposure, it must be emphasized that events such as rape, torture, genocide, and severe war zone stress are experienced as traumatic events by nearly everyone. Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected from and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations. Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat. Such observations have prompted the recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Therefore, while most people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion," which means that he or she has been exposed to an event that is considered traumatic. PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. (By this logic, adverse psychological responses to such "ordinary stressors" would, in DSM-III terms, be characterized as Adjustment Disorders rather than PTSD.) This dichotomization between traumatic and other stressors was based on the assumption that, although most individuals have the ability to cope with ordinary stress, their adaptive capacities are likely to be overwhelmed when confronted by a traumatic stressor. They considered traumatic events to be clearly different from the very painful stressors that constitute the normal vicissitudes of life such as divorce, failure, rejection, serious illness, financial reverses, and the like. The framers of the original PTSD diagnosis had in mind events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters (such as earthquakes, hurricanes, and volcano eruptions), and human-made disasters (such as factory explosions, airplane crashes, and automobile accidents). In its initial DSM-III formulation, a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience. The key to understanding the scientific basis and clinical expression of PTSD is the concept of "trauma."ĭSM-5 Criteria for PTSD diagnosis Assessing PTSD Treatment for PTSD Recommended Readings References Importance of traumatic events From an historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). Although controversial when first introduced, the PTSD diagnosis has filled an important gap in psychiatric theory and practice. In 1980, the American Psychiatric Association (APA) added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders ( DSM-III) nosologic classification scheme (2). The history of the development of the PTSD concept is described by Trimble (1). Shakespeare's Henry IV appears to meet many, if not all, of the diagnostic criteria for Posttraumatic Stress Disorder (PTSD), as have other heroes and heroines throughout the world's literature. Attacks by saber tooth tigers or twenty-first century terrorists have probably produced similar psychological sequelae in the survivors of such violence. The risk of exposure to trauma has been a part of the human condition since we evolved as a species. Friedman, MD, PhD A Brief History of the PTSD Diagnosis VA Software Documentation Library (VDL).Clinical Trainees (Academic Affiliations). War Related Illness & Injury Study Center.
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