Posttraumatic Stress Disorder (PTSD) and Acute Stress DisorderMatthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D.PTSD is diagnosed when a specific set of symptoms appear after exposure to an intensely, traumatic stressor involving a threatened or actual, injury or death. This stressor can be a direct personal experience of trauma such as military combat, rape, robbery or mugging, terroristic attack, natural disaster, physical assault, or car accident; but it also includes indirect traumatic experiences such as witnessing a severe trauma, or learning about the violent death, injury, or threat of death or injury, of someone who is very close, such as a family member or friend. Symptoms usually begin within 3 months of the original stressor, but in some cases there may be a delay of several months, or even several years. In children, sexual trauma does not need to include violence, in order to constitute a traumatic event.
Hallmark responses to these traumatic events include intense hopelessness, fear, and horror. Survivors often describe feeling painfully guilty over the fact that they survived the trauma, while others did not; or they may agonize over what they should have done differently. Sometimes they may experience intense shame or guilt over the things they were forced to do in order to survive. Children may demonstrate agitated behavior.
PTSD is often discussed in conjunction with military combat. While soldiers were diagnosed with military, trauma-related mental illnesses in the early 1900s, it was not until World War I that combat stress reaction, or "shell shock," became evident. This reaction was often short-term but affected a soldier's ability to continue to be effective in battle, and consisted of fatigue and intense physiological arousal. However, since PTSD was not a recognized disorder during WWI and WWII, much of what was labeled as "battle fatigue" and "shell shock" would today meet the criteria for PTSD. It is unknown how many veterans of these wars lived with untreated PTSD. The difference between PTSD and combat-related stress is the duration of symptoms (with PTSD lasting longer) and combat-related stress is considered a "normal" reaction, or transition, into and out of combat situations. Because of improvements in protective armor technologies, many soldiers now witness, and live through, these battle-related traumas whereas previously these same soldiers would have died from their injuries. Therefore, while it may appear there is a sharp increase in military-related PTSD, this may merely be an illusory conclusion resulting from the improved survival rates of modern-day soldiers.
There are several characteristic symptoms associated with PTSD. To be diagnosed with PTSD, the following criteria must be met:
1) Constant re-experiencing of the event: This includes recurrent thoughts, flashbacks, bad dreams, increased physiological arousal, and reaction to similar stimuli. For instance, if someone was assaulted on a dark street, merely passing by any dark street may trigger an intensely distressing reaction, such as a panic attack. Children may react with recurrent play that is trauma specific, such as drawing pictures of what occurred during the traumatic event, and having bad dreams without understanding the relationship of these dreams to the trauma.
2) The avoidance of anything that is a reminder of the event, and an overall sense of numbness and detachment: Rigorous attempts are made to avoid thoughts, feelings, people, and places that may serve as a reminder of the trauma such as steering clear of all alley ways if someone was assaulted in a similar location. People with PTSD commonly avoid thinking about the trauma and sometimes experience amnesia for certain parts of the traumatic event. Individuals with PTSD may report feeling numb or detached, and experience a lack of interest in activities they previously enjoyed. They may find it difficult to feel emotionally close to other people, or to experience loving feelings. Another symptom is a sense of a shortened life or future, such as not expecting to live a normal life span.
3) Symptoms of constant physiological arousal including sleep difficulties (trouble falling asleep, nightmares followed by an inability to fall back to sleep, etc.), lack of concentration, anger outbursts, or an exaggerated startle response.
4) PTSD has certain specifiers for its duration. In order to meet criteria for PTSD, symptoms must be present for more than one month. When symptoms occur within one month and last between two days and four weeks, the diagnosis would be Acute Stress Disorder. If those symptoms last beyond one month in duration, then the diagnosis would be changed to PTSD. PTSD is labeled "acute" when symptoms last less than three months. When symptoms persist beyond three months, then it would be specified as "chronic." While symptoms of PTSD usually occur within the first three months of the traumatic event, there are times when it may take several months, and even years, before the symptoms become apparent. This would be referred to as PTSD with Delayed Onset. Treatment for PTSD is found in the Treatment Section.
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