Overview of Post Traumatic Stress Disorder including diagnostic criteria from ICD-10 and DSM-5, prevalence, course, differential diagnosis, co-morbidity, assessment, risk, prognostic and protective factors, etiology and management.

1. Post-Traumatic Stress Disorder
Prachi Sanghvi
M. Phil. Clinical Psychology
Gujarat Forensic Sciences University
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

2. • ‘War neurosis’ proposed by Freud
• Earlier described as ‘shell shock’ and ‘battle fatigue’
• DSM-I: Gross stress reaction
• DSM-II: Transient situational disturbance
• Psychological consequence of Vietnam war- view of traumatic stress
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

3. • Returning combatants continued to experience significant problems
long after re-entering civilian life.
• DSM-III task force inquired case studies of events like combat, rape,
concentration camps and floods giving rise to a distinctive syndrome
and prompted formal recognition of PTSD.
(McNally, 1999)
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

4. F43.1 Post-traumatic stress disorder
Diagnostic guidelines
• This disorder should not generally be diagnosed unless there is evidence that
it arose within 6 months of a traumatic event of exceptional severity.
• Response to a stressful event
• Natural/man-made disaster, combat, serious accident, witnessing the
violent death of others, or being the victim of torture, terrorism, rape
• Predisposing factors like personality traits may lower the threshold for
development of the syndrome, but not sufficient to explain its occurrence.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

5. • Diagnosis still possible if delay b/w the event and the onset was longer than
6 months, provided that the clinical manifestations are typical
• There must be a repetitive, intrusive recollection or re-enactment of the
event in memories ("flashbacks"), daytime imagery, or dreams.
• Triggered involuntarily by specific event related cues
• Dominated by vivid visual images; may include sounds & other
sensations which are unorganized and fragmentary.
• ‘Reliving’ of these memories is reflected in distortion of sense of time
seeming to happen in the present rather than the past.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

6. • Conspicuous emotional detachment, numbing of feeling, and avoidance
of stimuli might arouse recollection of trauma often present but not
essential for the diagnosis
• Autonomic disturbances, mood disorder, and behavioural abnormalities
all contribute but not of prime importance.
• Autonomic hyperarousal with hypervigilance, and insomnia
• Rarely, dramatic, acute bursts of fear, panic or aggression, triggered
by flashbacks
(World Health Organization, 1992)
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

7. Trauma and Stressor-related Disorders
Post-Traumatic Stress Disorder
Note: For adults, adolescents & children older than 6 years
A. Exposure to actual or threatened death, serious injury, or sexual
violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

8. 3. Learning that event occurred to close family member/ friend. The event(s)
must have been violent or accidental.
Being direct recipient not required, vicarious exposure is sufficient for some.
4. Experiencing repeated/extreme exposure to aversive details of the traumatic
event (e.g., first responders collecting human remains, police officers).
Being agent of trauma. e.g., involvement in atrocities, political dissidents forced
by their captors to torture other prisoners, killing in line of duty for police
officers
Note: Criterion A4 does not apply to exposure through electronic media,
television, movies, or pictures, unless this exposure is work related.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

9. B. One (or more) of the following intrusion symptoms associated with the event,
beginning after the event:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
Note: In children older than 6 years, repetitive play may occur in which themes of the
event are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are
related to the traumatic event(s).
Note: In children, there may be frightening dreams w/o recognizable content.
3. Flashbacks Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

10. 4. Intense/prolonged psychological distress at exposure to internal/external
cues that symbolize or resemble an aspect of the traumatic event.
5.Marked physiological reactions to internal/external cues that symbolize/
resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli, as evidenced by one or both:
1. Avoidance of distressing memories, thoughts, or feelings
2.Avoidance of avoid external reminders (people, places, conversations,
activities, objects, situations) that arouse distressing memories, thoughts/
feelings
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

11. D. Negative alterations in cognition & mood associated w/ event, as
evidenced by 2(or more):
1. Dissociative amnesia
2. Persistent and exaggerated negative beliefs/expectations about oneself,
others, or world
3. Persistent, distorted cognitions about the cause or consequences of the
event that lead the individual to blame himself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt/shame)
5. Markedly diminished interest or participation in significant activities.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

12. 6. Feelings of detachment or estrangement from others.
7.Persistent inability to experience positive emotions (happiness,
satisfaction/loving feelings)
E. Marked alterations in arousal and reactivity as evidenced by two (or more):
1. Irritable behavior & angry outbursts expressed as verbal/physical aggression
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

13. F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month
G. Significant distress/impairment in functioning
H. Disturbance not attributable to the physiological effects of a substance or
another medical condition.
Specify whether: With dissociative symptoms:
1. Depersonalization
2. Derealization
Specify if:
With delayed expression: If the full criteria not met until at least 6 months after
the event (although the onset & expression of some symptoms may be
immediate).
(American Psychiatric Association, 2013)
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

14. Prevalence
• Lifetime prevalence- 8.7%
• Women affected more than twice as likely as men
• Higher among veterans and others whose vocation increases the risk of
traumatic exposure (e.g., police, firefighters, emergency medical
personnel).
• Highest rates are found among survivors of rape, military combat and
captivity, prisoners of war and genocide.
(American Psychiatric Association, 2013)
(Kessler et. al, 1995)
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

15. Course
• Soon after the event, survivors meet the criteria but most improve
gradually
• Fluctuating but recovery expected in the majority of cases
• Depends if it’s a single-impact event or chronic trauma where there is
lasting impairment
• In a small proportion, the condition may show a chronic course over
many years and a transition to an enduring personality change.
(van Dyke et. al, 1985 &World Health Organization, 1992)
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

16. • ASD
• ATPD
• Adjustment disorders
• OCD
• Dissociative disorders
• Anxiety disorders
• Depression
• TBI
Co-morbidity
• Alcohol abuse
• Depression
• GAD
• Anxiety disorders
D/D Assessment
• Clinician Administered
PTSD Scale (CAPS)
• MMPI-2
• World Health Organization
World Mental Health
Composite International
Diagnostic Interview (WHO
WMH-CIDI)
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

17. Risk and Prognostic Factors
Pre-traumatic factors
• Temperamental: Childhood emotional problems, history of MI
• Environmental: LSES; lower education; exposure to prior trauma; economic
deprivation, family dysfunction/separation/death; minority status; and family
psychiatric history.
• Genetic and physiological. Female, younger age at the time of trauma
exposure. Certain genotypes (sharing specific genetic constitution) may be
protective or increase risk.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

18. Peri-traumatic factors
• Environmental: Severity of trauma, perceived life threat, injury, interpersonal
violence (trauma perpetrated by caregiver/witnessed threat to caregiver in
children), for military personnel, being a perpetrator, witnessing atrocities, or
killing the enemy; dissociation occurring during trauma that persists later.
Post-traumatic factors
• Temperamental: Negative appraisals, inappropriate coping strategies,
development of ASD.
• Environmental: Subsequent exposure to repeated upsetting reminders,
subsequent adverse life events, trauma-related losses.
(American Psychiatric Association, 2013)Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

19. Protective factors
A study showed that less susceptible activists were
• Highly educated
• Politically committed militants who fully expected to be tortured should
they be arrested
• Social & emotional support from relatives & friends
• Heroes upon their release
• Positive elements such as perception of emotional support
• Negative aspects of support such as indifference or criticism
(Başoğlu et. al, 1994)
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

20. Biological aspects
A study conducted on male twins who served in military during Vietnam
war found that the prevalence was 16.8 %
MRI studies indicate diminished hippocampal volume in trauma-exposed
patients
PTSD sufferers exposed to chronic uncontrollable stressors suffer from
hypersensitivity of the noradrenergic system
Etiology
(Bremner et. al, 1997; Stein et. al, 1997)
(Southwick et. al, 1994)
(Goldberg et. al, 1990)
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

21. Inescapable shock (Maier and Seligman, 1976)
The uncontrollability of an aversive event makes it traumatic
Two-Factor Conditioning Model (Mowrer, 1939)
• Visual, auditory and olfactory cues present during trauma acquire the
ability to elicit responses similar to those during trauma.
• These aversive emotional states motivate avoidance of conditioned
cues and reduction in distress negatively reinforces instrumental
avoidance responses
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

22. Cognitive Aspects
• Re-experiencing trauma in the form of intrusive recollections,
nightmares & flashbacks imply that automatic cognitive processes
underlie traumatic intrusions
• Trauma memories remembered too easily
• They have enhanced implicit memory related to event
• Cognitive coping strategies:
• Suppress unwanted thoughts which return even more strongly
• Rumination and increased use of safety behaviors
(McNally, 1995a)
(Brewin & Holmes, 2003)
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

23. Stress response theory: Horowitz (1976, 1986)
• Initial response in trauma is outcry at the realization.
• Second response: to assimilate new trauma information with prior knowledge.
• Period of information overload during which people are unable to match
thoughts & memories of trauma with the way they represented meaning
before the trauma.
• In response to this tension, psychological defense mechanisms are brought into
play to avoid memories of the trauma.
• Fundamental psychological need to reconcile new and old information
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

24. • Trauma memories actively break into consciousness in the form of intrusions,
flashbacks & nightmares which provide an opportunity to reconcile them with
pre-trauma representations
• 2 opposing processes at work: One to defend by suppression of trauma
information & one to promote working through of traumatic material by
bringing it to mind
• Individual oscillates between avoidance and intrusion of trauma
• This oscillation allows the traumatic information to be worked through, and
the intensity decreases
• Failure to process the trauma information leads to persistent post-traumatic
reactions as the information remains in active memory and continues to
intrude and be avoided
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

25. Theory of shattered assumptions: Janoff-Bulman (1992)
• Internal assumptions help us to sustain our everyday lives, motivate to
overcome difficulties & plan for future
• 3 common assumptions significant in influencing response to trauma
are that the world is benevolent, the world is meaningful, and the self is
worthy
• Being attacked by a stranger/being involved in RTA when we have been
obeying the rules are situations that shatter deeply held & probably
unexamined assumptions about how we believe the world & ourselves
to be.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

26. Emotional processing theory: Foa and colleagues (1993, 1998)
• Relationship b/w PTSD and knowledge available prior to the trauma, during
the trauma, and after the trauma.
• Individuals with more rigid pre-trauma views more vulnerable to PTSD
• Rigid positive views about self as being extremely competent and world as
extremely safe, which would be contradicted by event, or rigid negative
views about self as being extremely incompetent and world as being
extremely dangerous, which would be confirmed by event
• Beliefs that were present before, during, and after the trauma could interact
to reinforce negative schemas involving incompetence and danger that they
hypothesized underlie chronic PTSD.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

27. Ehlers’ and Clark’s cognitive model (2000)
• Intense fear, helplessness or horror at the time of trauma
• ‘Mental defeat,’ defined as ‘the perceived loss of all autonomy, a state of
giving up in one’s own mind all efforts to retain one’s identity as a human
being with a will of one’s own’
• It is a profound state that, like helplessness, defies categorization as either
an emotion or a belief, having some characteristics of both.
• Victims who experience mental defeat may describe themselves like an
object or being destroyed, or not caring whether they lived or died.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

28. • Mental defeat goes beyond mere helplessness in attacking the person’s
very identity.
• Some emotions depend on elements of cognitive appraisal.
• Traumatic events vary considerably in the time that is available to the
victim to appraise what is happening and to generate corresponding
emotions.
• After the event, cognitive appraisal for the cause and future implication
of the trauma provides numerous opportunities to generate negative
emotions
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

29. Management
• Psychodynamic therapy to work through and resolve an unconscious
conflict which the traumatic event is thought to have provoked
• Behaviour therapy (exposure)
• CBT (self-monitoring and re-structuring)
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

30. Eye Movement Desensitization And Reprocessing (Shapiro, 1987)
• Combination of cognitive and behavioral techniques- 8 phases
• Baseline data- Select a memory and assign SUD (10-highest distress,
0-lowest)
• Desensitization phase- Think of the traumatic image & notice the
feelings attached to it as the therapist moves her hand.
• Concentrate on the image & feelings as the therapist moves her hand
back and forth as rapidly as possible.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

31. • Two fingers up with her palm facing the client about 12 inches from the client’s
face. About 15 to 30 bilateral eye movements make a set.
• After the set, the therapist tells the client to let go and take a breath. Then the
client describes his feelings, images, sensations, or thoughts.
• Desensitization process continues until near the end of the session or when the
SUD rating drops to 0 or 1
• General belief- symptoms can be relieved as patients work through the
traumatic event while in a state of deep relaxation.
• The mechanism of treatment is not yet understood.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

32. Pharmacological treatments
• Selective serotonin-reuptake inhibitors (SSRIs)
• Monoamine oxidase inhibitors (MAOIs)
• Benzodiazepines
• Antiadrenergic agents
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

33. Further Reading
• American Psychiatric Association. (2013). Diagnostic and Statistical Manual
of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric
Association.
• Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of
posttraumatic stress disorder. Clinical Psychology Review 23. 339–376.
• Ehlers, A. (2000). Post-traumatic stress disorder. In Gelder, M. G., Lopez-
Ibor Jr. J. J, & Andreasen N. (Eds.). New Oxford Textbook of Psychiatry.
Oxford: Oxford University Press.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU

34. • McNally, R. J. (1999). Posttraumatic Stress Disorder. In Millon, T., Blaney, P.
H. and Davis, R.D. (Eds.). Oxford Textbook of Psychopathology. (pp. 144-
159). New York: Oxford University Press.
• Sharf, R. S. (1996). Theories of Psychotherapy and Counseling: Concepts
and Cases (5th ed.) (pp. 310-311). Pacific Grove: Brooks/Cole Pub.
• World Health Organization. (1992). The ICD-10 Classification of Mental and
Behavioural Disorders: Clinical descriptions and diagnostic guidelines.
Geneva: World Health Organisation.
Prachi Sanghvi, M.Phil.Clinical Psychology, GFSU