Posttraumatic stress disorder (PTSD) was included for the first time in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. It consists of symptom clusters with affective, cognitive, and behav­ioral components that some individuals de­velop in reaction to a traumatic event and that are associated with distress and impairment in functioning. According to the DSM-IV (1994), the traumatic experience must meet the following criteria: 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” and responded with “intense fear, helplessness, or horror.” This definition con­trasts with the previous conceptualization of a trauma in DSM-IIIR as a rare event “outside the range of usual human experience.” Psychological harm alone does not satisfy this definition. Rather, actual or threatened harm to one’s physical being must have been present at the time of the trauma. Although verbal, emotional, or psychological abuse often produces negative psychological effects, they may or may not satisfy this definition of trauma. In contrast, childhood sexual abuse is judged as a traumatic experience, even if the above criteria are not technically met.

 

DSM-IV groups PTSD symptoms into three clusters: re-experiencing, avoidance/numbing, and hyperarousal. The re-experiencing cluster includes: having distressing memories of the trauma, nightmares, flashbacks, emotional and physical reactivity to trauma reminders. The avoidance/numbing cluster includes: attempts to avoid trauma-related thoughts or feelings, attempts to avoid trauma-related activities and situations, inability to recall important parts of the trauma, diminished interest in activities, feelings of detachment from others, restricted range of affect, or sense of a foreshortened future. The hyperarousal cluster includes: difficulty falling or staying asleep, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response. To meet symptom criteria for PTSD, the traumatized individual must experience at least one re-experiencing symptom, three avoidance/numbing symptoms, and two hyperarousal symptoms.

 

Duration of symptoms is another aspect of the PTSD diagnosis which requires that the symptoms be present for more than one month. PTSD is specified as chronic if the symptoms persist longer than three months. Although most individuals will ex­hibit significant posttraumatic stress symptoms shortly after the trauma, the DSM does recognize that some PTSD sufferers have delayed onset when their symptoms begin six months or more after the traumatic event. As in the case of all mental disorders, PTSD symptoms must cause significant distress or impairment in social, occupational, or other areas of functioning.

 

Exposure to a traumatic event is a necessary but not sufficient condition for PTSD diagnosis, as the majority of persons ex­posed to trauma will not go on to develop clinical traumatic stress reaction. Whereas the estimated prevalence of lifetime trauma in the United States is as high as 81%, the lifetime prevalence of PTSD is much lower, about 7%. These results point to a natural recovery process that often occurs after a trauma. Most individuals experience PTSD symptoms fol­lowing a traumatic event, such as sexual assault, but the ma­jority will recover within the first three months post-trauma. The one-month duration criterion precludes diagnosing an individual with PTSD within the first month after a trauma. A primary reason for this requirement is to avoid pathologizing normal and temporary responses to traumatic experiences.

 

Recent research using the DSM-IV and its expanded trauma definition has yielded lifetime PTSD prevalence estimates of 18.3% in women and 10.2% in men. Compared to individuals without PTSD, those who developed chronic PTSD are more likely to have other current or past psychi­atric diagnoses, with lifetime comorbidity rates on the order of 80%. Individuals with PTSD show significant comorbid­ity with various mood and anxiety disorders, and lower but still significant overlap with alcohol abuse and dependence.

Other major burdens of PTSD are economic effects and associated functional impairment. The economic burden takes the form of both increased cost of care, unemploy­ment, and lost wages. Research indicates that PTSD is asso­ciated with a nearly $4,000 increase in total lifetime medical costs per patient. Studies in veterans have shown that both PTSD diagnosis and symptom severity are negatively re­lated to employment, with PTSD associated with over three times greater chance of unemployment. In a large-scale population study, PTSD diagnosis predicted greater work days lost and poorer mental and physical quality of life, even after controlling for age, sex, and comorbidity. PTSD can also have a profound effect on interpersonal function­ing, relationship distress, and parenting abilities.

 

Finally, the deleterious effects of PTSD on physical health and negative health behaviors are being increasingly recognized. There is evidence that PTSD is associated with greater risk for a number of chronic medical diseases, in­cluding chronic pain, heart disease, disturbances in cardio­vascular, gastrointestinal, neuroendocrine, immune function, and high rates of smoking, which may partly account for its negative impact on health.

 

Currently, cognitive behavioral therapy (CBT) is the treatment of choice for chronic PTSD. CBT is not a single technique but rather a broad approach that includes a range of techniques, the goals of which are to reduce the intensity and frequency of PTSD and related symptoms, modify er­roneous cognitions, and promote functioning. CBT programs  for PTSD include exposure therapy, stress inoculation training, and cognitive therapy. Each of these programs can be admin­istered individually or in combination. A fourth treatment for PTSD that has received empirical support is eye movement desensitization and reprocessing (EMDR), a treatment that utilizes elements of exposure and cognitive restructuring but with the addition of therapist-directed rapid eye movements or other bi-lateral stimuli. Two recent innovations in the treat­ment of PTSD are the application of imagery rehearsal therapy to PTSD-related nightmares and the use of technology, such as virtual reality technology and delivery of therapy via the Internet, but evidence for their efficacy is limited.

 

Exposure Therapy. PTSD is characterized by the re-expe­riencing of the traumatic event and attempts to ward off the intrusive symptoms or avoid the trauma-reminders, even when such trigger stimuli are not inherently dangerous. The most studied and utilized exposure therapy program is prolonged exposure, (PE) which was developed by Dr. Foa on the basis of emotional processing theory. The core components of PE are 1) imaginal exposure, which consists of revisiting the traumatic memory, recounting it aloud repeatedly, and processing the revisiting experience; and 2) in vivo exposure, which involves the repeated confrontation of trauma-related situations and objects that evoke excessive anxiety but are not inherently dangerous. The goal is to promote processing of the trauma memory, thereby modifying the erroneous cognitions associ­ated with PTSD, decreasing the re-experiencing symptoms, and reducing distress and avoidance elicited by the trauma remind­ers. Additionally, individuals with pronounced symptoms of emotional numbing and depression are encouraged to engage in pleasurable activities even if these activities do not elicit fear or anxiety but instead have dropped out the person’s repertoire due to loss of interest. Prolonged exposure received the most empirical evidence for its efficacy and effectiveness and has been disseminated throughout the United States and abroard.

 

Stress Inoculation Training. This treatment combines educa­tion about trauma-related symptoms with anxiety manage­ment techniques such as controlled breathing and relaxation training, cognitive restructuring, guided self-dialogue, asser­tiveness training, role-playing, covert modeling, and thought-stopping. Once the various techniques have been introduced, the therapist and patient work together to select and implement the techniques in a flexible manner to address patient’s current concerns. Stress inoculation programs vary, with the most no­table difference being that some programs include an exposure component whereas others do not.

 

Cognitive Therapy. This treatment is derived from Beck’s model of treatment for depression and its extension to anxiety, wherein the goal of therapy is help patients identify trauma-re­lated dysfunctional beliefs that influence emotional and behav­ioral responses to a situation. Once identified, patients are taught to evaluate the thoughts in a logical, evidence-based manner. Information that supports or refutes the belief is examined as are alternative ways of interpreting the problematic situation, and the therapist helps patients to weigh the evidence before decid­ing whether the belief accurately reflects reality. Some cognitive therapy programs include an exposure component.

 

Eye Movement Desensitization and Reprogramming (EMDR). In EMDR, the therapist asks the patient to generate images, thoughts, and feelings about the trauma, to evaluate their aversive qualities, and to make alternative cognitive ap­praisals of the trauma or their behavior during it. As the patient initially focuses on distressing images and thoughts and later focuses on alternative cognitions, the therapist elicits rapid, lat­eral alternating eye movements by instructing the patient to vi­sually track the therapist’s finger as it is moves back and forth across the patient’s visual field. Originally, these eye move­ments were regarded as essential to processing the traumatic memory, but the importance of eye movements has not gained empirical support. Some EMDR programs have replaced eye movements with other procedures (e.g., patient alternating fin­ger tapping from right to left hand); however, studies have not demonstrated that these movements affect symptom reduction, and well-designed treatment outcome research has found no advantage of EMDR over exposure therapy alone.

 

According to consensus panels such as the Institute of Medicine (IOM), the treatment of choice for chronic PTSD is exposure therapy or some other form of CBT. After reviewing the research evidence, the IOM concluded, “Based on its as­sessment of the psychotherapy approaches for which random­ized controlled trials were available . . . , the committee found the evidence for all but one psychotherapeutic approach inad­equate to reach a conclusion regarding efficacy. The evidence was sufficient to conclude the efficacy of exposure therapies in treating patients with PTSD.” The IOM also concluded that the evidence was inadequate to determine the efficacy of phar­macotherapy for PTSD.

 

Overall, the data suggest that the various forms of CBT are effective in treating chronic PTSD with no major differences in outcome between treatments; however, as noted above, exposure-based treatments have the largest amount of empiri­cal support to date.

 

References are available on request from the LACPA office, 818-905-0410 or lacpsych@aol.com.

 

 

Dr. Foa will give her keynote presentation, “Healing People with PTSD,” from 1:30 p.m. to 4:30 p.m. at the LACPA Convention, October 23, 2010, at the Radisson Los Angeles Westside in Culver City.