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DSM-III-R diagnostic criteria for post-traumatic stress disorder
A. The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one's life or physical integrity; serious threat or harm to one's children, spouse, or close relatives and friends; sudden destruction of one's home or community; or seeing another person who has recently been, or is being, seriously injured or killed as the result of an accident or physical violence.
B. The traumatic event is persistently reexperienced in at least one of the following ways:
(1) recurrent and intrusive distressing recollections of the event
(2) recurrent distressing dreams of the event
(3) sudden acting or feeling as if the traumatic event were recurring
(4) intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma
C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before trauma), as indicated by at least three of the following:
(1) efforts to avoid thoughts or feelings associated with the trauma
(2) efforts to avoid activities or situations that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect
(7) sense of a foreshortened future
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response
(6) physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event
E. Duration of the disturbance (symptoms in B, C, and D) of at least 1 month.
Proposed definitions of Criterion A (above):
--DSM-IV (Proposal 1) The person has experienced, witnessed, or been confronted with an event or events that involve
actual or threatened death or injury, or a threat to the physical integrity of oneself or others.
--DSM-IV (Proposal 2) The person's response involved intense fear, helplessness, or horror.
Clinical Symptomology of PTSD:It is noted that many sufferers of PTSD continue to live in the emotional environment of the traumatic event, with "enduring vigilance for and sensitivity to environmental threat." He described the five principal features of the human response to trauma as 1) a persistence of startle response and irritability, 2) proclivity to explosive outbursts of aggression, 3) fixation on the trauma, 4) constriction of the general level of personality functioning, and 5) atypical dream life. In mild cases the trauma is eventually successfully resolved with an integration of the traumatic events into the totality of a person's life experiences. But in many other cases, some or all of the symptoms persist, or recur during periods of later stress.
Integration or Dissociation:"Walling off" of awareness or memory of the traumatic event is a valuable defense as long as the threat persists. However, most clinicians believe that the trauma must eventually be brought into awareness and put into perspective, lest the repressed material return in the form of intrusive thoughts or disruptions in emotional functioning. "[The patient] is obliged to repeat the repressed material as a contemporary experience, instead of remembering it as something belonging to the past."
Anger and aggression: Because they respond with hyperarousal to emotional or sensory stimuli, many traumatized individuals have difficulty controlling their anxious and aggressive feelings. Thus, warding off anxiety and aggression becomes a focal issue for many trauma victims. Clinicians saw irritability and the loss of capacity to modulate anger as central to the trauma response.
Factors in duration and severity of trauma response: The severity of the stressor is a major factor. Severity is also determined by the developmental phase at which the trauma ocurs; for example, an adult with a firm sense of identity and good social support is infinitely better protected against psychological trauma than a child. Children are thought to be extraordinarily sensitive to the long-term effects of uncontrollably traumatic events. Disruption or loss of social support is intimately associated with inability to overcome the effects of psychological trauma. Lack of support during traumatic experiences may leave enduring marks on subsequent adjustment and functioning. Conversely, many people remain fairly intact after psychological trauma as long as their environment restores a sense of trust and safety. Traumatized children left alone to suffer often possess a lost sense of basic safety, which often leads to a life-long inability to trust and a chronic rage that is turned against others around them. In both children and adults, lack of social support following trauma heightens the sense of lost security.
Psychosomatic symptoms: In patients exposed to situations similar to the trauma event, researchers noted persistent "generalized signs such as nervousness, tension and trembling...[and] panic attacks, feelings of terror, feelings of apprehension and dread, and some of the somatic correlates of anxiety and...a persistent fear response to a specific place, object, or situation which is characterized as being irrational and disproportionate to stimulus, which leads to avoidance or escape behavior."
Trauma response: Trauma occurs when one loses the sense of having a safe place to retreat within or outside oneself to deal with frightening emotions or experiences. In many traumatized individuals, the trauma is reexperienced in the form of nightmares and flashbacks, which are often an exact reliving of actual traumatic experiences. Immediately after the trauma they usually occur frequently. After a while they subside, but they often recur sometimes after decades of latency, in response to psychologically or biologically important events.
Role of the group in resolution of trauma response: Following trauma, the victim suffers from "a giving up of hope for satisfactory human contact, which is the result of the destruction of basic trust." Either way, trauma results in a disorder of hope: the capacity of others to provide emotional gratification and security is undermined or destroyed. Victims withdraw from social support and become moody and depressed. To protect oneself from further psychological injury, the victim "walls off" any intimate contact with others.
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