Post Traumatic Stress Disorder (PTSD) was recognized formally in 1980 by the DSM III (The Diagnostic and Statistical Manual published by the American Psychiatric Association). Formal recognition only confirmed what had been observed for centuries. Post Traumatic Stress had long been known by many other names and seems related to other emotional problems that have followed traumatic events. There is a direct line between hysteria, the name given to those symptoms by the Psychoanalysts, nostalgia in the Civil War, shell shock in World War I, combat fatigue or battle exhaustion in World War II, stress disorder in Korea, post-Vietnam syndrome, rape trauma syndrome, post sexual abuse syndrome, battered wife syndrome, and the Post Traumatic Stress Disorder finally given official status in in 1980. As early as 1966, Samuel Pepys, the renowned diarist, described people's reaction to the great fire in London using symptoms that at the time would easily be recognized as Post traumatic Stress Disorder. Since 1980, its use as a given diagnosis has correctly exploded. Consider this statistic: In a representative sample of women in the United States over the age of eighteen (18), researchers found that 69% had been exposed to a traumatic event at some time in their lives. The remarkable array of victimization experiences (rape, sexual and physical assault, crime and noncrime traumas) that women encounter, contributes to estimates that 11.8 million adult women in the U.S. experienced PTSD at some point during their lives and 4.4 million currently have PTSD. Unfortunately, many physicians still do not recognize the trauma as the primary cause of their patient's suffering. They diagnose the symptoms as anxiety disorder, depressive disorder or even a substance abuse disorder. All too often we mistake symptoms for cause. The full blame for this confusion, however cannot rest solely with the physician. Since 1980 the DSM diagnostic criteria have been revised twice. The diagnosis of PTSD is different from most other psychiatric diagnosis categories because it includes the presumed cause in the diagnostic criteria. (Brain injury and intoxication disorders also require an explicit external etiological cause.) The DSM requires explicit specification of the probable cause, namely, the presence of explicit traumatic stressor (or what is called criterion A in the DSM system). Please note the changes in the definition of what constitutes the Criterion A stressor. In order to receive a diagnosis of PTSD the individual must experience an extreme life-threatening stressor. Such common stressors as financial loss, severe marital conflict, chronic illness, and "simple" bereavement do not meet the Criterion A "gatekeeping role" for PTSD. Yet, a reading of today's headlines reveals the all too tragic effect of any one of these stressors.
DSM-III Criterion A: Existence of a recognizable stressor that would evoke significant symptoms of distress in almost everyone.
DSM-III-R Criterion A: The person has experienced an event that is outside the range of usual human experience and almost anyone, e.g., serious threat or harm to one's children, spouse, or other 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.
DSM-IV Criterion A: The person has been exposed to a traumatic event in which the following event in which the following were 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.
(3) The disturbance causes clinically significant distress and impairment in social, occupational or other important areas of functioning.
An event that involved serious injury to others can also cause symptoms that can meet criterion A. That broadened the definition to include vicarious traumatization.
When considering the relationship between exposure to PTSD, the majority of studies that have demonstrated the primacy of the stressor (in the form of exposure characteristics) in influencing outcome were conducted on patient populations. When community samples were studied, the relationship between the severity of symptoms and exposure to the stressor does not hold up.
Further complicating the diagnosis is that these changes are certainly not the final word. There is good reason that some seek a new diagnosis, Prolonged Duress Stress Disorder (PDSD). That is, individuals who manifest Post Traumatic Stress Disorder symptoms without fulfilling the Stressor Criterion A demanded by DSM IV. This would mean that it is not just being exposed to an extreme or severe traumatic event that causes the problem, the cumulative impact of an unremitting stressor can also cause the symptomatic Post Traumatic Stress Disorder.
Estimates are that Post Traumatic Stress Disorders account for about 10% of patients seeking treatment at pain clinics. Yet, little is known about the disease. Why do the majority of people faced with experiencing even cataclysmic events not develop it? Or, do they develop it but are able to deal with it and, if so, what mechanisms do they use? All these are unanswered questions at the present. Some very dramatic issues have presented themselves to me in my experience dealing with these patients. A search of the literature has revealed only one citation of a Post Traumatic Stress Disorder following electric shock. Yet, Dr. Michael Hearns, a specialist in environmental medicine and environmental medicine and pain alleviation, and I have already been confronted by four such cases in just two years. Dr. Jeffrey Perry, a physiatrist, has referred a number of patients suffering from an interesting narrow band on the Post Traumatic Stress Disorder spectrum. These patients are able to function in other areas of their life experience but cannot return to work. They suffer PTSD specifically in their ability to return to work. Even thinking of returning can bring on severe symptoms. I have begun to call this form of PTSD; Occupational Stress Disorder. Dr. Shawn Sosnik, a chiropractor, referred a developmentally disabled young man to me. This sixteen (16) year old had experienced a traumatic event and was clearly suffering from symptoms of Post Traumatic Stress. Unfortunately, it was difficult for those treating him to see beyond his disability. Ironically, it took a chiropractor to recognize it. Obviously, more research is needed on all of the above
Sadly, Post Traumatic Stress Disorder is still a diagnosis which is all too often missed, not only by general physicians, but even by mental health professionals. A high level of awareness is vital when examining patients who may have experienced trauma. Physicians, especially primary care physicians, must be made aware of the diagnostic criteria of Post Traumatic Stress Disorder as well as the fact that ti can be brought about by a very wide and varied array of causes. Further complicating the issue, traumatized persons with other disorders often have Post Traumatic Stress Disorder as a concurrent diagnosis.
In truth, we really do not yet know enough about the myriad of events that can cause Post Traumatic Stress. A better question may be, what does not cause it? It is a challenge for future scholars. I, for one, stand in awe of a disease entity that can profoundly affect the children of concentration camp survivors. These children have, at most, experienced the retelling of those horrific events yet suffer significant symptomatology. This occurred in cases even when parents took pains not to share terrible experiences.
Sadly, because so many cases of PTSD are involved in forensic issues, there are those who are concerned that Post Traumatic Stress Disorder may become "the nineties soft tissue injury". Fearing an explosion of claims, they have too often labeled these people "malingerers". In my experience, there may be a small minority who are malingering but there are many more who are truly suffering. The malingerers should and must be exposed. The sufferers deserve recognition, understanding and treatment.