PTSD is a real phenomenon that emanates from normal/abnormal human experience. In fact, I can't walk out on the streets of New York on a sunny, crystal clear, blue skyed day without flashing on the hundreds of families I counseled post 911. The collective experience of working with all those people left an indelible mark in my emotional brain. I still vividly remember the stories of these people and my crying at some of their stories. The crying was something I had never done before in working with patients but their pain was overwhelming. I will never forget their stories or walking downtown that day to help the "survivors" of the World Trade Center collapses. I do not suffer with PTSD but some of my responses are in part reflective of PTSD.
The following are the DSM IV criteria for PTSD: | Diagnostic criteria for 309.81 Posttraumatic Stress Disorder - The person has been exposed to a traumatic event in which both of the following were present:
- the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
- the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior
- The traumatic event is persistently reexperienced in one (or more) of the following ways:
- recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
- recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
- acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
- intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
- physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
- Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
- efforts to avoid thoughts, feelings, or conversations associated with the trauma
- efforts to avoid activities, places, or people that arouse recollections of the trauma
- inability to recall an important aspect of the trauma
- markedly diminished interest or participation in significant activities
- feeling of detachment or estrangement from others
- restricted range of affect (e.g., unable to have loving feelings)
- sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
- Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
- difficulty falling or staying asleep
- irritability or outbursts of anger
- difficulty concentrating
- hypervigilance
- exaggerated startle response
- Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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The estimated lifetime prevalence of PTSD ranges from 1.3% in Germany to 7.8% in the United States. In contrast, 89.6% of citizens in the United States are exposed to at least one traumatic event at some time in their lives. Thus, PTSD is a possible but not inevitable consequence of trauma exposure. Because initial evidence suggests the potential benefits of early intervention shortly after trauma, accurate identification of specific risk and protective factors is needed to provide effective treatment to those who are likely to develop long-term trauma-related psychopathology.
Aside from the most salient predictor of PTSD, which is the nature of the traumatic event itself, three other risk factors were consistently identified across studies in a meta-analysis by Brewin et al.: psychiatric history, family history of mental disorders, and childhood abuse. In addition, personality traits (e.g., hostility, neuroticism, self-efficacy) were also identified as predictors of PTSD symptoms.
In a rare prospective study of firefighters in this months AmJournal of Psychiatry Markus Heinrichs, Ph.D. et al followed 43 professional firefighters for two years to determine what pre-traumatic risk factors may exist that could predict the development of PTSD. The authors found that :
The results of the multiple regression analysis show that the combination of preexisting high levels of hostility and low levels of self-efficacy is a strong predictor of the development of PTSD symptoms in the high-risk population of firefighters. The presence of both risk factors at baseline accounted for 42% of the variance in posttraumatic stress symptoms at 2-year follow-up. Moreover, firefighters with both of these personality characteristics at baseline had a steady increase during the 2-year period in scores on measures of PTSD symptoms, depression, anxiety, general psychological morbidity, global severity of symptoms, and alexithymia.
The fact that personality traits can be potentially predictive of an increased risk of developing PTSD is critically important to the selection process for the military, police and firefighters. Additionally, the proactive identification of personnel at risk would allow resources to be allotted for prophylactic treatment of these at risk individuals.
With the veterans returning from the War on Terror we all need to be attuned to their special needs in order to help provide resources that can address their traumas and pain that have emanated from their unique experiences in Afganistan and Iraq.
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