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PTSD Questions & Answers
with
Joyce Boaz & Dr. Frank Ochberg, M.D.

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Definition of PTSD

Q: Dear Frank, The new criteria for PTSD are now out, since the Diagnostic and Statistical Manual (DSM) has been revised. Are the changes significant, from our point of view? Or are the changes relatively minor and of concern mainly to academics and researchers?

A: Dear Joyce, Those of us who diagnose PTSD, who teach the subject to doctors and therapists, and who testify about trauma in court will need to know the new criteria (http://www.ptsd.va.gov/professional/PTSD-overview/diagnostic_criteria_dsm-5.asp). But the answers to your questions are, in my opinion, "No" and "Yes." That is, the changes are not significant from the perspective of the trauma survivor with PTSD and the changes are mainly meant to confirm current research and to clarify some ambiguous elements of the diagnosis. Another way to put it is if you have PTSD according to the old criteria, you will, in all likelihood, have PTSD according to the new criteria. PTSD is PTSD. The basic concept is this: You were a perfectly normal person and then something dreadful happened. You didn't recover in several weeks, in fact, you now have a recognizable pattern of difficulty that lasted at least a month. That pattern includes several different, overlapping dimensions. The first is a problem with trauma memory. The memories of being traumatized are too intense, too uncontrolled, too much "in the present" rather than in the past, and too likely to cause physical and emotional consequences. This dimension was, up until May 2013, defined as having any one of the following five symptoms:

(1) 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.

(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

(3) 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 upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

This, in my opinion, is the core feature of PTSD. To have PTSD is to have a trauma memory that haunts you, that comes when you don't want it, that isn't always there, but is there too often. And it is different from a "normal" memory of a terrible thing. Many of us have lived through natural disasters, unnatural death of loved ones, abuse, humiliation, bullying and sudden, catastrophic loss. We were traumatized and we were victimized. We remember and we hurt. But we are NOT plagued by any of the 5 symptoms listed above. We have autobiographical memory. The past feels as though it is in the past. We know the bad details. The bad details do not spring out at us every month, causing palpitations, nightmares, flashbacks, terror, or a sick thud in the chest. Without this category of unwanted re-experiencing, we do not have PTSD.

The new DSM 5 "tweaks" these definitions slightly:

Criterion B: intrusion symptoms
The traumatic event is persistently re-experienced in the following way(s): (1 required)

1. Recurrent, involuntary, and intrusive memories. Note: Children older than 6 may express this symptom in repetitive play.
2. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).
3. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.
4. Intense or prolonged distress after exposure to traumatic reminders.
5. Marked physiologic reactivity after exposure to trauma-related stimuli.

From the perspective of the survivor, there is no meaningful difference here. As a teacher, the 3rd criterion helps me explain to a medical student that a flashback is a dissociative episode. It involves an altered state of consciousness, similar to a trance or a fugue. The individual has the strange sensation of being in the past, possibly hearing or smelling things from the past. This new definition isn't meant to change who qualifies for the diagnosis, but to improve a clinician's understanding of the phenomenon.

It's not just what you remember. It's how you remember. PTSD always involves a condition of "hot memories" that come like epileptic fits, sometimes triggered, sometimes out of the blue. As the PTSD condition improves, these "hot memories" occur with less intensity and less frequency. When they no longer occur at least once a month, the PTSD is "in remission." The bad memory is still there, but the way the mind remembers is no longer impaired. This dimension of PTSD was defined in DSM III, tweaked in DSM IV and has been tweaked again in DSM 5. It's academic. The new wording doesn't really matter to the survivor or the significant other.

The second published dimension of PTSD, called the "negative symptoms," have to do with numbing and avoidance. Despite being subjected to "aftershocks" of traumatic memory, there is a form of emotional anesthesia. This constriction of feeling, this walling off of responsiveness, is both automatic and intentional. The PTSD survivor avoids contacts and situations likely to cause emotional pain, and the capacity to feel anything is reduced. The recent list of symptoms was:

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) efforts to avoid activities, places, or people that arouse recollections of the trauma

(3) inability to recall an important aspect of the trauma

(4) markedly diminished interest or participation in significant activities

(5) feeling of detachment or estrangement from others

(6) restricted range of affect (e.g., unable to have loving feelings)

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

To make the diagnosis of PTSD, a clinician needed to establish that at least three of these seven symptoms were present in the last month and had persisted for more than a month. When a person fell just short of qualifying for the PTSD diagnosis, it was most often because they had only one or two of these seven, but they met the other requirements. For example, I recently examined a man who lost two fingers when his muzzleloader exploded. He has flashbacks and anxiety. He is very worried about his career as an electrician. He is embarrassed about his disfigured hand. But he has no trouble returning to the scene, he can talk about the accident, he remembers every detail, and his diminished participation in significant activities is due to physical, not emotional impairment. He just falls short of the "Paragraph C" PTSD criteria.

The new criteria reformulate this dimension into two sections:

C.
Persistent effortful avoidance of distressing trauma-related stimuli after the event: (1 required)
1.Trauma-related thoughts or feelings.
2.Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

D. Negative alterations in cognitions and mood that began or worsened after the traumatic event: (2 required)

1.Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs).
2.Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous.").
3.Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4.Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt or shame).
5.Markedly diminished interest in (pre-traumatic) significant activities.
6.Feeling alienated from others (e.g., detachment or estrangement).
7.Constricted affect: persistent inability to experience positive emotions.


My patient would still fail to qualify, since he does not meet C.1 or C.2 and he falls short of the D criteria as well. I believe that in raising the bar for these "negative symptoms" some people who met the diagnosis as written in DSM 3 and 4 will fail to qualify in DSM 5. These definitions do include and clarify many symptoms suffered by survivors, such as "Persistent distorted blame of self or others for causing the traumatic event...," but this criterion is not always seen, particularly after natural disasters. Again, the changes are useful for the academics who do research on the subject, and the changes help with inter-rater reliability. But they do not change the essential quality of PTSD.


The last dimension of PTSD is a lowered threshold for anxious arousal, formerly requiring two out of five symptoms:

(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response


This is now modified to require two out of six criteria:

Criterion E: alterations in arousal and reactivity
Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (2 required)

1.Irritable or aggressive behavior.
2.Self-destructive or reckless behavior.
3.Hypervigilance.
4.Exaggerated startle response.
5.Problems in concentration.
6.Sleep disturbance.


The new criterion is "Reckless or self-destructive behavior." We have seen this often in the past so including it may add some survivors to the diagnosis. It is not a big change. It isn't designed to make it more or less difficult for traumatized people to receive the diagnosis.

Finally, and most significantly, the definition of a traumatic event has been edited. This will have an impact on court cases and on reimbursement arguments. It will affect veteran's benefits. It is meant to reduce ambiguity and clarify the intent of those who define PTSD.
The definition in DSM IV was:

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

(1) 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 (
2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.



The new definition of exposure to a traumatic event is:

Criterion A: stressor

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (1 required)
1.Direct exposure.
2.Witnessing, in person.
3.Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
4.Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

I do believe this is an improvement and will eliminate certain non-qualifying traumas such as being taunted or receiving threats, and it will make it easier to include those who learn their loved ones have been badly injured, assaulted or raped. Also, by removing criterion A.2, the need to experience extreme fear, horror or helplessness at the time of trauma, more professional people will qualify for the diagnosis; soldiers, police, medical personnel, reporters who are trained to react without feeling horror or terror at the time, but who have those emotions after their dangerous work is done. The fourth criterion helps tort claims against employers who send medics, social workers and reporters into harms way without adequate training or recovery time.

So, in sum, the current definition of PTSD will benefit the academics who do research, the clinicians who make diagnoses, and the advocates who seek remedies for traumatized clients. It will not change the fundamental definition of PTSD. It may make it harder for some survivors to meet the threshold for diagnosis, but it will make it easier for others, particularly the loved ones and the trauma workers.

PTSD remains PTSD. It is an injury to the function of the brain and nervous system, caused by one or more terrible, real, life-altering events. It affects otherwise normal people, but it also affects those with pre-existing disabilities. PTSD is a significant injury. Not every traumatized person develops PTSD. Labels do not define people, but they help science move forward and they help deserving people receive benefits.

I support the work of those who have refined the criteria, particularly the chair of the committee, Dr. Matt Friedman. He is an advocate for all of us who deal with PTSD, whether we have the diagnosis or give the diagnosis or care for those affected. I would like to see the name changed from PTSD to PTSI for Injury rather than Disorder. But that is another issue!

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