Etiology

The major etiological event leading to PTSD is the stressor. Because not all persons who experience a major stressor develop the disorder, other variables such as underlying personality and biological vulnerability are undoubtedly important. Stressors of all types may contribute to the development of PTSD, but they must be severe enough to be outside the range of normal human experience. Certain experiences are highly linked to the development of PTSD: witnessing a friend being killed in action, witnessing wartime atrocities, and, especially, participating in atrocities.

Individual differences that can predispose to the development of PTSD include age, history of emotional disturbance, social support, and proximity to the stressor. Eighty percent of young children who sustain a burn injury, for example, show symptoms of posttraumatic stress 1-2 years after the initial injury, but only 30% of adults who sustain this injury have symptoms after 1 year. Persons with a prior history of psychiatric treatment have a greater likelihood of developing the syndrome, presumable because the previous illness reflects a greater sensitivity to stress; and persons with adequate social support are less likely to develop the disorder than persons with poor support.

Table 1. DSM-IV Criteria for Posttraumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

1. The person experienced, witnessed, or was confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

2. The person's response involved intense fear, helplessness, or horror. In children, it may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

3. Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions. In young children, there may be frightening dreams without recognizable content.

4. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

5. Acting or feeling as if the traumatic event were recurring (including a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including these that occur on awakening or when intoxicated). In young children, traumatic specific reenactment may occur.

6. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

7. Physiological reactivity on exposure to internal or external cues that symbolize or resemble as aspect of the traumatic event.

C. 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:

8. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.

9. Efforts to avoid activities, places, or people that arouse recollections of the trauma.

10. Inability to recall an important aspect of the trauma.

11. Markedly diminished interest or participation in significant activities.

12. Feeling of detachment or estrangement from others.

13. Restricted range of affect (e.g., unable to have loving feelings).

14. Sense of foreshortened future (e.g., does not expect to have a career, marriage, or children, or a normal life span).

D. Persistent symptoms of increased arousal (no present before the trauma), as indicated by two (or more of the following:

15. Difficulty falling or staying asleep.

16. Irritability or outbursts of anger.

17. Difficulty concentrating.

18. Hypervigilance.

19. Exaggerated startle response.

E. Duration of the disturbance symptoms in criteria B, C, and D is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more

Specify if:

With delayed onset: if onset of symptoms is at least 6 months after the stressor.

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