Making the Diagnosis of PTSD

PTSD is unique in that one cannot make the diagnosis unless the patient has experienced a traumatic stressor. The framers of the initial formulation of PTSD conceptualized traumatic stressors as those that were outside the range of normal human experience (e.g., war, torture, rape, and natural disasters). The dichotomization between traumatic and other stressors was based on the assumption that most individuals have the ability to cope with ordinary stressors (e.g., divorce, major financial losses). It was assumed that the adaptive capacities of almost anyone are likely to become overwhelmed when confronted by a traumatic stressor.

When faced with life-threatening stressors such as rape or combat, it is normal to feel terrified or shocked. It also is normal, after exposure to such traumatic events, to experience unwanted memories, to have difficulties with anger, to feel a continuing sense of danger, or to feel emotionally distant and "cut-off" from other people. PTSD occurs when these normal reactions become chronic and fail to improve with time. Symptoms of PTSD may be experienced for many weeks, months, or years.

Current conceptualization of PTSD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) recognizes that traumatic stressors are, in fact, common experiences in many societies today. Considering the widespread nature of traumatic stressors, the DSM-IV specifies that four diagnostic requirements be met before a diagnosis of PTSD can be made. First, the individual must have experienced, witnessed, or been 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," and the individual's response must have involved "intense fear, helplessness, or horror." Such events include rape, war combat, and childhood abuse. The other three diagnostic criteria address the major types of PTSD symptoms:

1. Intrusive reexperiencing of traumatic memories;
2. Avoidance; and
3. Increased arousal.

Each described futher below.

Intrusions/Reexperiencing

Individuals with PTSD often describe repeated, intrusive imagery of their traumatic event(s). These intrusive memories may be sudden and unexpected multi-sensory experiences, such as "flashbacks," during which the individual may feel that the trauma is reoccurring. In addition, intrusive reexperiencing in the form of unwanted memories and feelings from the trauma experience(s) can occur during sleep (i.e., nightmares). Thus, the trauma survivor is unable to stop "reliving" the trauma and experiencing associated thoughts and feelings.

"...there's noises that bring on [memories] ... even the summer heat, so, I think it's a situation that stays with me constantly. There's not a single day that goes by without some recurring memory or even feelings that come out of it. [I have] dreams where were running through the jungle. I can actually feel the bark stinging my face, my arms, as we're running through the jungle. I can hear the gunfire behind us. And the talking, sometimes laughter of the VC or NVA or whoever's out there. And they're chasing us and we're running and stumbling."

Avoidance

In order to try to minimize intrusive reexperiencing, the individual avoids many trauma-based cues--interpersonal situations, people, places, thoughts, and emotions. Unfortunately efforts at avoidance often dominate--and can destroy--a person's life and relationships.

"I always remember that feeling. I'll never forget it. It's the one of helplessness ... It's a feeling that I don't care for very much. And to this day, I avoid situations that would bring that feeling back up again."

Physical tension and over-arousal

A person with PTSD is physically tense. This hyperarousal may manifest itself in problems with sleep, irritability and anger, concentration, and "hypervigilance." Hypervigilance is the feeling that it is never safe to relax because something terrible is just about to happen. However, it is impossible to stay "on alert" constantly without becoming mentally and physically exhausted, irritable, and unable to concentrate on tasks or activities.

"My household is a miniature base camp. I've got lights everywhere ... locking windows and, even though I know that all of these things are in place, I still tend to--for no reason--I'll stand up and I'll go over and I'll look out and look around. And I'll go to the back door and do the same thing, you know. And then, I'm up and around, you know. I'm moving and I'm looking."