Selecting a Diagnosis
By
Robbyn Wallace
Principles of Psychopathology
May 3, 2015
Selecting a Diagnosis
DSM-5 Diagnosis
PTSD is strongly associated with traumatic stress and encapsulates “the dominant clinical understanding of trauma impact” (Eagle & Kaminer, 2011, p. 25), defined as “the consequences of experiencing extreme stressors, referred to as traumas” (Nolen-Hoeksema, 2014, p. 110). The DSM 5 considers traumas to be events of exposure to “actual or threatened death, serious injury, or sexual violation” (Nolen-Hoeksema, 2014, p. 110). In the wake of a traumatic event, a PTSD risk assessment may identify risk factors such as pre-trauma—prior trauma history with childhood conduct problems, peritrauma—perceived threat, heighted arousal, as well as dissociation, and post-trauma factors— such as hardiness and social support (Wisco, Marx, & Keane, 2012). The DSM 5 Criteria require the duration of symptoms—Criteria B, C, D, and E—be beyond 1 month; causing “clinically significant distress or impairment in social, occupational, or other important areas of functioning” (Nolen-Hoeksema, 2014, p. 112); and, “not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition” (p. 112). PTSD symptoms include four primary categories; (1) re-experiencing the trauma, (2) numbing of response, (3) hyperarousal, and (4) avoidance and cognitive and emotional changes (Courtois, 2014, p. 146-151). An individual’s response to trauma is dependent upon “individualized experience, perspective, and temperament” (p. 180). Exposure to a traumatic or stressful event is usually captured through such clinical characteristics as “anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms” (APA, 2013, p. 265), which may or may not include anxiety- or fear-based symptoms (Eagle & Kaminer, 2015). Even though complex trauma was not added to the DSM V—while some disagree with that choice (Eagle & Kaminer, 2015), it is essential to explore and understand the impact when trauma is repeated and/or layered—why it is “usually more damaging, sometimes causing the victim to lose his or her sense of self altogether” (Courtois, 2014, p. 676)—and how it increases vulnerability to future trauma and microtraumas.
Symptoms characteristic of PTSD can be grouped into three categories (Courtois, 2014): (1) Re-experiencing symptoms—such as flashbacks to include physical symptoms like a racing heart or sweating, nightmares or bad dreams, and/or frightening cognitions—arises from the individual’s cognitions and emotions, and triggered by verbal, objects, or situations perceived as reminders of the traumatic event which causes problems in the individual’s daily routine; (2) Avoidance symptoms—avoiding places, events, or objects that are reminders of the experience; feeling emotionally numb, strong guilt, depression, or worry; loss of interest in activities once enjoyable; and, difficulty with remembering the dangerous event—triggered by reminders of the traumatic event and can cause personal routine change; (3) Hyperarousal symptoms—such as easily startled, feeling tense, having difficulty sleeping, irritable and/or having anger outbursts—are usually constant, causing distress and anger, and may make daily tasks, including concentration, more difficult. An individual must have all the following for at least 1 month; minimum of one re-experiencing symptom, minimum of three avoidance symptoms, minimum of two hyperarousal symptoms, and symptoms that make daily life, school, work, relationships, and/or important task more difficult. Although trauma does not always lead to a disorder, it may find expression in complex patterns. Risk factors influence the likelihood of an individual developing PTSD, whereas resilience factors can help in the reduction of the individual to develop PTSD. Some of these factors are present in the individual before the trauma, where others become essential during and post-event. Trauma exposure shatters basic assumptions and negative attributions are central to the impact of trauma, which leads to the importance of “enduring alterations to meaning systems” (Eagle & Kaminer, 2015, p. 25) in the presentation of PTSD symptoms.
Theoretical Models and Etiological Approaches
Mental health is modernly thought to be best captured by an integrated approach, the biopsychosocial approach, which recognizes that often it is “a combination of biological, psychological, and sociocultural factors” (Nolen-Hoeksema, 2014, p. 24) that is responsible for the development of psychological symptoms. Those factors are considered risk factors, which increase likelihood of psychological problems. This is considered a more holistic perspective.
Childhood trauma exposure and maltreatment are considered significant in the development of neurological pathways that determine vulnerability to external stress, especially with no caregiver mediation of the experience(s) (Eagle & Kaminer, 2015). Therefore, those exposed to trauma during childhood, especially chronic or complex trauma, are much more vulnerable to developing PTSD (Nolen-Hoeksema, 2014, p. 115). Abnormally low levels of cortisol, as is suggested (Nolen-Hoeksema, 2014), “may be one heritable risk factor for PTSD” (p. 117). Epigenetics—gene expression is affected by environmental conditions—may provide an understanding of how PTSD might invoke genetic and environmental factors. A social cognitive and affective neuroscience approach (Lanius, Bluhm, & Frewen, 2011) can be used to understand and explain the psychology as well as neurobiology of complex history of post-traumatic stress, the difference it has on the presentation of PTSD, and effective treatment.
Cognitions—thoughts or beliefs—shape our experience by means of behavior and emotive expression. Traumatic experience can cause dysfunction in the individual’s ability to make meaning due to hyperarousal of the stress-response. This can sometimes lead to a negative thinking style, which can exacerbate symptoms such as anti-social behaviors. A cognitive approach allows an opportunity to “identify and challenge…negative thoughts and dysfunctional belief system” (Nolen-Hoeksema, 2014, p. 40).
The availability of social support is also a predictor of vulnerability to the development of PTSD and can have an effect on the length of the recovery process. Prior to a traumatic event, individuals who experience psychological distress and poor interpersonal relationships (Nolen-Hoeksema, 2014) may be more vulnerable or susceptible to developing PTSD. The effects of PTSD may play out in an intergenerational cycle, where, usually, trauma is either passed down indirectly or directly. Many beliefs are socially constructed and are subjective, these beliefs can either serve as a protective factor or as a risk factor for PTSD development.
Forces Shaping the Development of Post-Traumatic Stress Disorder
During World War II, PTSD was first called war neurosis (Millon, 2004) and was treated for the most part with drug therapy, which was mainly unsuccessful “in helping these anxiety-ridden patients overcome their painful memories” (p. 360). From a historical perspective, traumatized people seeking treatment “were likely to be viewed with suspicion and even stigmatized for both their trauma history and their symptoms” (Courtois, 2014, p. 115). Instead of treatment focusing on trauma, or even consider it, therapists concentrated on symptoms, problematic behavior—to include addictions, genetics, and possibly personality structure (Courtois, 2014).
Risk factors for PTSD include: living through dangerous events and traumas; having a history of mental illness; getting hurt, seeing people hurt or killed; feeling horror, helplessness or extreme fear; having little or no social support after the event; and, dealing with extra stress after the event, such as losing a loved one, pain and injury, or loss of a job or home (Eagle & Kaminer, 2011). Resilience factors that may reduce the risk of PTSD include: seeking out support from other people, such as friends and family; finding a support group after a traumatic event; feeling good about one’s own actions in the face of danger; having a coping strategy, or a way of getting through the bad event and learning from it; and, being able to act and respond effectively despite feeling fear (Eagle & Kaminer, 2011).
References
Courtois, C. A. (2014). It’s not you, it’s what happened to you: Complex trauma and treatment. Washington, DC: Telemachus Press, LLC.
Eagle, G. T., & Kaminer, D. (2011). Traumatic stress: Established knowledge, current debates and new horizons. South African Journal of Psychology, 45(1), 22-35. DOI: 10.1177/0081246314547124.
Lanius, R. A., Bluhm, R. L., & Frewen, P. A. (2011). How understanding the neurobiology of complex post-traumatic stress disorder can inform clinical practice: A social cognitive and affective neuroscience approach. Acta Psychiatrica Scandinavica, 124(5), 331-348. doi:10.1111/j.1600-0447.2011.01755.x
Meltzer, E. C., Averbuch, T., Samet, J. H., Saitz, R., Jabbar, K., Lloyd-Travaglini, C., & Liebschutz, J. M. (2011). Discrepancy in diagnosis and treatment of PTSD treatment for the wrong reason. Journal of Behavioral Health Services & Research, 39(2), 190-201.
Millon, T. (2004). Masters of the mind: Exploring the story of mental illness from ancient times to the new millennium. Hoboken, NJ: John Wiley & Sons, Inc.
Nolen-Hoeksema, S. (2014). Abnormal psychology (6th ed.). New York, NY: McGraw-Hill.
Resick, P. A., Bovin, M. J., Calloway, A. L., Dick, A. M., King, M. W., Mitchell, K. S., & ... Wolf, E. J. (2012). A critical evaluation of the complex PTSD literature: Implications for DSM-5. Journal of Traumatic Stress, 25(3), 241-251. doi:10.1002/jts.21699
Wisco, B. E., Marx, B. P., & Keane, T. M. (2012). Screening, Diagnosis, and Treatment of Post-Traumatic Stress Disorder. Military Medicine, 7-13.
