Typology of post-traumatic stress disorder in children and adolescents

Results obtained from clinical and psychopathological studies of 161 patients with post-traumatic stress disorder (PTSD) aged 3-18 years with symptom durations from one month to four years are presented. Four major clinical variants of the type of PTSD were identified in children and adolescents: insomniac( 34.8%), phobic (23.6%), psychopathic-like (21.7%), and asthenic-depressive (19.9%). These variants, differing in terms of course and prognosis, occurred at different frequencies in different age and ethnic groups; there were no gender-related differences.

[Problems in medical certification of posttraumatic neuropsychiatric disorders for the purpose of criminal and civil law proceedings]

In the past several years, in the material of Forensic Medicine Department, Medical University of Silesia in Katowice, a significant increase has been noted in the number of cases associated with CNS dysfunctions, either as isolated conditions or in association with posttraumatic disorders. In the majority of cases, such dysfunctions were causally related to a head trauma. The Faculty of the Department are also requested with an increasing frequency to estimate the association between the observed neuro-psychiatric abnormalities and complaints and the undue exposure to a stress factor. In the present publication, the authors have emphasized difficulties in assessing the complaints reported by the claimants and the possibilities of objectivization of such complaints by neuro-psychiatric examinations. They also stress problems in application of obligatory ICD 10 terms denoting dysfunctions of the central nervous system in medico-legal opinions.

Assessment for crisis intervention

This article describes the triage assessment system (TAS) for crisis intervention. The TAS assesses affective, behavioral, and cognitive reactions of individuals to crisis events. This assessment model offers clinicians an understanding of the type of reactions clients are experiencing as well as the intensity of these reactions. The TAS provides a quick, accurate, and easy-to- use method that is directly usable in the intervention process. The system can also be used to monitor clients' progress during the intervention process. Two case illustrations are presented to demonstrate the use of the model. In addition, the Triage Assessment Form: Crisis Intervention is included as an Appendix.

Taxometric Investigation of PTSD: data from two nationally representative samples

Current psychiatric nosology depicts posttraumatic stress disorder (PTSD) as a discrete diagnostic category. However, only one study has examined the latent structure of PTSD, and this study suggested that PTSD may be more accurately conceptualized as an extreme reaction to traumatic life events rather than a discrete clinical syndrome. To build on the existing literature base, the present research examined the latent structure of posttraumatic stress reactions by applying three taxometric procedures (MAXEIG, MAMBAC, and L-Mode) to data collected from large nationally representative samples of women (ns=2684 and 3033) and adolescents (n=3775). Results consistently provided evidence for a dimensional PTSD solution across samples and statistical procedures. These findings have important implications for the theory, assessment, and investigation of posttraumatic stress reactions.

Relationships among childhood maltreatment, PTSD, and health in female veterans in primary care

OBJECTIVE

Women with histories of childhood maltreatment (CM) have higher rates of physical health problems and greater medical utilization compared to women without abuse histories. This study examined whether current post-traumatic stress disorder (PTSD) symptoms mediate the relationship between CM and indicators of physical health and medical utilization in female veterans.

METHOD

Respondents were 221 female veterans (56% of the potential sample), who received medical care from the San Diego VA Healthcare System during a 12-month period. Respondents provided self-report information about CM, PTSD symptoms, use of pain medication, and physical symptoms and functioning. Additional information about medical utilization was extracted from respondents' medical charts. Regression-based models were conducted to test whether PTSD symptoms mediate the relationships between CM and physical symptoms and between CM and medical utilization.

RESULTS

Emotional abuse was associated with poorer role-physical functioning, increased bodily pain and greater odds of using pain medication in the past 6 months. Physical abuse was associated with poorer general health. Contrary to prediction, emotional neglect was associated with better role-physical functioning, and CM was not associated with increased healthcare utilization. PTSD was shown to mediate the relationship between emotional and physical abuse and health outcomes.

CONCLUSIONS

PTSD, or psychopathology more generally, appears to be an important factor in the negative health impact of CM. Given that several empirically supported interventions are available for PTSD, there may be physical health benefits in early identification and treatment of psychopathology related to CM.

Simple versus complex PTSD: a cluster analytic investigation

A cluster analytic investigation was conducted on measures of PTSD associated features (e.g., personality pathology, dissociative tendencies) to investigate whether empirically-defined clusters correspond to Herman's [1992, Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377-391; 1997, Trauma and recovery (Rev. ed.). New York: Basic Books] distinction between simple and complex PTSD. Results from a sample of 60 PTSD patients were broadly consistent with this distinction, although some inconsistencies were observed. Treatment outcome generally did not differ between the two clusters. Implications for classifying and treating PTSD are discussed.

[Mild brain injuries: definition, classifications and prognosis]

Brain injuries may be graded into mild, moderate and severe depending on clinical and radiological criterions. Mild brain injuries (MBI) are usually defined by an initial unconsciousness limited to 30 minutes, a Glasgow score between 13 and 15, the absence of intra-cranial lesion on the CT scan, a post-traumatic amnesia period between one and 24 hours depending on the authors. The consequences of a MBI may be simple but the injured often suffer from a transitory post-concussive syndrome. Traumatic stress states are a well known pathology and consist in a psychological reaction against the trauma. The acute traumatic stress may or may not run its course to a chronic post-traumatic stress disorder, formerly called post-traumatic neurosis.

Human brain evolution and the "Neuroevolutionary Time-depth Principle:" Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder

The DSM-III, DSM-IV, DSM-IV-TR and ICD-10 have judiciously minimized discussion of etiologies to distance clinical psychiatry from Freudian psychoanalysis. With this goal mostly achieved, discussion of etiological factors should be reintroduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). A research agenda for the DSM-V advocated the "development of a pathophysiologically based classification system". The author critically reviews the neuroevolutionary literature on stress-induced and fear circuitry disorders and related amygdala-driven, species-atypical fear behaviors of clinical severity in adult humans. Over 30 empirically testable/falsifiable predictions are presented. It is noted that in DSM-IV-TR and ICD-10, the classification of stress and fear circuitry disorders is neither mode-of-acquisition-based nor brain-evolution-based. For example, snake phobia (innate) and dog phobia (overconsolidational) are clustered together. Similarly, research on blood-injection-injury-type-specific phobia clusters two fears different in their innateness: 1) an arguably ontogenetic memory-trace-overconsolidation-based fear (hospital phobia) and 2) a hardwired (innate) fear of the sight of one's blood or a sharp object penetrating one's skin. Genetic architecture-charting of fear-circuitry-related traits has been challenging. Various, non-phenotype-based architectures can serve as targets for research. In this article, the author will propose one such alternative genetic architecture. This article was inspired by the following: A) Nesse's "Smoke-Detector Principle", B) the increasing suspicion that the "smooth" rather than "lumpy" distribution of complex psychiatric phenotypes (including fear-circuitry disorders) may in some cases be accounted for by oligogenic (and not necessarily polygenic) transmission, and C) insights from the initial sequence of the chimpanzee genome and comparison with the human genome by the Chimpanzee Sequencing and Analysis Consortium published in late 2005. Neuroevolutionary insights relevant to fear circuitry symptoms that primarily emerge overconsolidationally (especially Combat related Posttraumatic Stress Disorder) are presented. Also introduced is a human-evolution-based principle for clustering innate fear traits. The "Neuroevolutionary Time-depth Principle" of innate fears proposed in this article may be useful in the development of a neuroevolution-based taxonomic re-clustering of stress-triggered and fear-circuitry disorders in DSM-V. Four broad clusters of evolved fear circuits are proposed based on their time-depths: 1) Mesozoic (mammalian-wide) circuits hardwired by wild-type alleles driven to fixation by Mesozoic selective sweeps; 2) Cenozoic (simian-wide) circuits relevant to many specific phobias; 3) mid Paleolithic and upper Paleolithic (Homo sapiens-specific) circuits (arguably resulting mostly from mate-choice-driven stabilizing selection); 4) Neolithic circuits (arguably mostly related to stabilizing selection driven by gene-culture co-evolution). More importantly, the author presents evolutionary perspectives on warzone-related PTSD, Combat-Stress Reaction, Combat-related Stress, Operational-Stress, and other deployment-stress-induced symptoms. The Neuroevolutionary Time-depth Principle presented in this article may help explain the dissimilar stress-resilience levels following different types of acute threat to survival of oneself or one's progency (aka DSM-III and DSM-V PTSD Criterion-A events). PTSD rates following exposure to lethal inter-group violence (combat, warzone exposure or intentionally caused disasters such as terrorism) are usually 5-10 times higher than rates following large-scale natural disasters such as forest fires, floods, hurricanes, volcanic eruptions, and earthquakes. The author predicts that both intentionally-caused large-scale bioevent-disasters, as well as natural bioevents such as SARS and avian flu pandemics will be an exception and are likely to be followed by PTSD rates approaching those that follow warzone exposure. During bioevents, Amygdala-driven and locus-coeruleus-driven epidemic pseudosomatic symptoms may be an order of magnitude more common than infection-caused cytokine-driven symptoms. Implications for the red cross and FEMA are discussed. It is also argued that hospital phobia as well as dog phobia, bird phobia and bat phobia require re-taxonomization in DSM-V in a new "overconsolidational disorders" category anchored around PTSD. The overconsolidational spectrum category may be conceptualized as straddling the fear circuitry spectrum disorders and the affective spectrum disorders categories, and may be a category for which Pitman's secondary prevention propranolol regimen may be specifically indicated as a "morning after pill" intervention. Predictions are presented regarding obsessive-compulsive disorder (OCD) (e.g., female-pattern hoarding vs. male-pattern hoarding) and "culture-bound" acute anxiety symptoms (taijin-kyofusho, koro, shuk yang, shook yong, suo yang, rok-joo, jinjinia-bemar, karoshi, gwarosa, Voodoo death). Also discussed are insights relevant to pseudoneurological symptoms and to the forthcoming Dissociative-Conversive disorders category in DSM-V, including what the author terms fright-triggered acute pseudo-localized symptoms (i.e., pseudoparalysis, pseudocerebellar imbalance, psychogenic blindness, pseudoseizures, and epidemic sociogenic illness). Speculations based on studies of the human abnormal-spindle-like, microcephaly-associated (ASPM) gene, the microcephaly primary autosomal recessive (MCPH) gene, and the forkhead box p2 (FOXP2) gene are made and incorporated into what is termed "The pre-FOXP2 Hypothesis of Blood-Injection-Injury Phobia." Finally, the author argues for a non-reductionistic fusion of "distal (evolutionary) neurobiology" with clinical "proximal neurobiology," utilizing neurological heuristics. It is noted that the value of re-clustering fear traits based on behavioral ethology, human-phylogenomics-derived endophenotypes and on ontogenomics (gene-environment interactions) can be confirmed or disconfirmed using epidemiological or twin studies and psychiatric genomics.

Posttraumatic stress disorder part II: development of the construct within the North American psychiatric taxonomy

TOPIC

The impairment associated with posttraumatic stress disorder (PTSD) carries with it staggering costs to the individual, to the family, and to society as a whole. Although there is strong evidence that gender plays a significant role in responses to stress and trauma, gender specificity is still not well incorporated into clinical or research work in the area of PTSD.

PURPOSE

This is the second of three articles examining the sufficiency of the current PTSD construct to articulate the full spectrum of human responses to trauma. This article chronicles ongoing refinements to the original PTSD criteria and the subsequent controversies.

SOURCE OF INFORMATION

Existing bodies of theoretical and research literature related to the effects of trauma.

CONCLUSION

In a third article we will review evidence supporting the existence of a more complex posttraumatic stress reaction associated with interpersonal trauma (physical/sexual abuse/assault).

[Dispute over the multiple personality disorder: theoretical or practical dilemma?]

Dissociative identity disorder (DID) could also be referred to as multiple personality disorder (MPD). Due to rare occurrence and difficulty in its' identification it is infrequently diagnosed in Poland. The indicated disorder has been portrayed by the authors throughout the historical context, referring to initial 18th century's references concerning dissociation. A typical dissociatively disordered person has been characterized along with his individual personality categories such as: original personality, altered personality, host and personality fragment. Moreover various diagnosis criterions of DID have been introduced. DID has also been differentiated with other disorders: PTSD (post-traumatic stress disorder) and BPD (borderline personality disorder). A hypothesis has been set up, stating that DID is directly correlated with the trauma experienced during childhood, while PTSD is linked with traumatic lived-through events in the later period of ones' life. The most contemporary and frequently used research tools for DID have been indicated: dissociative experience scale (DES) and somatoform dissociation questionnaire (SDQ-20). Based upon the known literature, the authors have presented treatment methods such as hypnotherapy and recorded therapy sessions. It is the view of the authors that the switching in dissociative identity disorder is of adaptive character (it occurrs depending upon adaptive needs).

Evidence for a dissociative subtype of post-traumatic stress disorder among help-seeking childhood sexual abuse survivors

This study examined evidence for a dissociative subtype of post-traumatic stress disorder (PTSD) among women seeking psychotherapy for childhood sexual abuse (CSA). One hundred and twenty-two women seeking treatment for CSA completed a battery of questionnaires assessing PTSD, dissociative symptoms, and child maltreatment. Using signal detection analysis, we identified high and low dissociation PTSD subgroups. A constellation of three PTSD symptoms-hypervigilance, sense of foreshortened future, and sleep difficulties-discriminated between these two subgroups (OR = 8.15). Further evidence was provided by the finding of a nonlinear relationship between severity of childhood maltreatment and dissociation in the women with PTSD. These results provide support for a dissociative subtype of PTSD that may stem from more severe childhood experiences of neglect and abuse.

[Fetal and early trauma syndrome-FETS]

This is a new clinical description for cases of children whose parents are among those who have disappeared and were given birth by women held prisoners and subjected to torture, humiliation and abuses. This description is considered a special case of early, and in many cases fetal distress. These children felt horror when they were violently separated from their parents immediately after being born in captivity or in early infancy during the last military dictatorship (1976-1983). Afterwards they were sold by their captors and raised as adoptive or as their own children by the purchasers. The fact that these cases be included in the existing WHO categories contained in CIE-10: Posttraumatic stress disorder, F43.1, is discussed as they show late responses on the part of the victims to situations of torture, terrorism and rape. However, it is clarified that cases in which the aftereffects of severe stress become evident after decades will have to be classified as Persistent personality disorders, after catastrophic experience, F62.0. It is concluded that it is necessary to consider FETS as a new combination of manifestations of the Persistent Personality Disorders due to its specific idiosyncratic characteristics that go beyond the available clinical descriptions, to its own etiophatic equation and to its recognizable pathognomonic identification. Its pathognomonic identification in some cases was useful to detect children with these alienated identity problems (understood as legally neglected and clinically alienated). Propedeutic and treatment aspects are mentioned in conjunction with the peculiarities of a therapy that restores the illegally deprived personality of these children, who nowadays are adults of approximately 25 to 29 years of age. Finally, a metapsychologic discussion is presented, which is about the resilience of the truth and the fact that when it is rejected it returns, thus constituting ethics of the truth.

The structure of posttraumatic stress disorder: latent class analysis in 2 community samples

CONTEXT

Latent structure analysis of DSM-IV posttraumatic stress disorder (PTSD) can help clarify how persons who experience traumatic events might be sorted into clusters with respect to their symptom profiles. Classification of persons exposed to traumatic events into clinically homogeneous groups would facilitate further etiologic and treatment research, as well as research on the relationship of trauma and PTSD with other disorders.

OBJECTIVES

To examine empirically the structure underlying PTSD criterion symptoms and identify discrete classes with similar symptom profiles.

DESIGN

Data on PTSD symptoms from trauma-exposed subsets of 2 community samples were subjected to latent class analysis. The resultant classes were studied in associations with trauma type and indicators of impairment.

SETTING

The first sample is from the Detroit Area Survey of Trauma (1899 trauma-exposed respondents with complete data) and the second is from a mid-Atlantic study of young adults conducted by The Johns Hopkins University Prevention Research Center, Baltimore, Md (1377 trauma-exposed respondents with complete data).

PARTICIPANTS

Respondents in the 2 community samples who experienced 1 or more qualifying PTSD-level traumatic events.

MAIN OUTCOME MEASURES

Number, size, and symptom profiles of latent classes.

RESULTS

In both samples, analysis yielded 3 classes: no disturbance, intermediate disturbance, and pervasive disturbance. The classes also varied qualitatively, with emotional numbing distinguishing the class of pervasive disturbance, a class that approximates the subset with DSM-IV PTSD. Members of the pervasive disturbance class were far more likely to report use of medical care and disruptions in life or activities.

CONCLUSIONS

The 3-class structure separates trauma-exposed persons with pervasive disturbance (a class that approximates DSM-IV PTSD) from no disturbance and intermediate disturbance, a distinction that also helps identify population subgroups with low risk for any posttrauma disturbance. The results suggest that the structure of PTSD is ordinal and configurational and that emotional numbing differentiates the class with pervasive disturbance. These results should motivate prospective research of persons who have experienced trauma to trace the emergence of posttrauma symptoms and the timing of emotional numbing relative to other symptoms.

Testing the latent structure of posttraumatic stress disorder: a taxometric study of combat veterans

Since the diagnosis of posttraumatic stress disorder (PTSD) first appeared in the psychiatric nomenclature in 1980, considerable debate has revolved around the nature of the condition. Specifically, is PTSD best conceptualized as one end of a continuum of human response to traumatic stress or does it represent a discontinuous latent category? Two taxometric procedures were used to investigate this issue in a random community sample of 692 Australian combat veterans, using structured interview and self-report instruments to assess PTSD symptomatology. Findings favored a dimensional model of PTSD, consistent with previous taxometric work on treatment-seeking samples (A. Ruscio, Ruscio, & Keane, 2002). Implications are drawn for the conceptualization, etiology, and assessment of PTSD.

Multisample cross-validation of a model of childhood posttraumatic stress disorder symptomatology

This study is the latest advancement of our research aimed at best characterizing children's posttraumatic stress reactions. In a previous study, we compared existing nosologic and empirical models of PTSD dimensionality and determined the superior model was a hierarchical one with three symptom clusters (Intrusion/Active Avoidance, Numbing/Passive Avoidance, and Arousal; Anthony, Lonigan, & Hecht, 1999). In this study, we cross-validate this model in two populations. Participants were 396 fifth graders who were exposed to either Hurricane Andrew or Hurricane Hugo. Multisample confirmatory factor analysis demonstrated the model's factorial invariance across populations who experienced traumatic events that differed in severity. These results show the model's robustness to characterize children's posttraumatic stress reactions. Implications for diagnosis, classification criteria, and an empirically supported theory of PTSD are discussed.

Confirmatory factor analysis of posttraumatic stress symptoms in sexually harassed women

Posttraumatic stress disorder (PTSD) factor analytic research to date has not provided a clear consensus on the structure of posttraumatic stress symptoms. Seven hypothesized factor structures were evaluated using confirmatory factor analysis of the Posttraumatic Stress Disorder Checklist, a paper-and-pencil measure of posttraumatic stress symptom severity, in a sample of 1,218 women who experienced a broad range of workplace sexual harassment. The model specifying correlated re-experiencing, effortful avoidance, emotional numbing, and hyperarousal factors provided the best fit to the data. Virtually no support was obtained for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994) three-factor model of re-experiencing, avoidance, and hyperarousal factors. Different patterns of correlations with external variables were found for the avoidance and emotional numbing factors, providing further validation of the supported model.

Factor structure of posttraumatic stress among Western New York undergraduates following the September 11th terrorist attack on the World Trade Center

The structure of posttraumatic stress is of both theoretical and clinical interest. In the present study, seven models of posttraumatic stress were compared using confirmatory factor analysis. A sample of 528 Western New York undergraduate students was assessed 1 and 3 months after the September 11th, 2001 terrorist attacks. At the Month 1 assessment, the current three-factor Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) model, which consists of Intrusions, Avoidance/Numbing, and Hyperarousal, did not provide a good fit to the data; however, a four-factor model consisting of factors labeled Intrusions, Avoidance, Dysphoria, and Hyperarousal did fit the data well and provided better fit than the three-factor model and other competing models. Importantly, Dysphoria spans symptoms from the traditional DSM Numbing and Hyperarousal clusters. The four-factor model continued to fit the data well at Month 3. These findings parallel the results of earlier studies which suggest that a four-factor model better reflects the nature of posttraumatic stress than do simpler models, including the DSM. The present work is consistent with a dimensional model of stress responses and calls for further longitudinal work in this area.

[Less severe sexual child abuse and its sequelae: are there different psychic and psychosomatic symptoms in relation to various forms of sexual interaction?]

A typology of less severe sexual encounters was used to analyze short and long term sequelae of sexual abuse via intimate skin contact. Well known theoretical approaches on the harmful effects of sexual abuse were tested. Do we find different peri- and posttraumatic reactions dependent upon varied forms of sexual interactions with children? A cluster analysis was calculated with symptom variables that were described in 141 child statements taken out of written expert opinions. Afterwards variance analyses of these symptom clusters were conducted in reference to six different abuse constellations. Different symptom profiles were found for these six abuse constellations. Panic symptoms, shame related feelings, avoidant behavior and physical reactions showed significant results. The sequelae to different forms of less severe sexual child abuse differ and depend more upon the situational dynamic than upon the kind of relationship between adult and child.

[Typology of posttraumatic stress disorder in children and adolescents]

The results of clinical and psychopathological study of 161 patients with posttraumatic stress disorder (PTSD), aged 318 years, illness duration from 1 month to 4 years, are presented. Four main clinical PTSD variants (types) have been singled out in children and adolescents: insomniac (34.8%), phobic (23.6%), psychopathic-like (21.7%) and asthenic-depressive (19.9%). These variants differed in the course and prognosis and their frequency depended on age and ethnicity of patients. No sex-dependent differences have been found.

Startle responses in motor vehicle accident survivors: a pilot study

The aim of the present study was to investigate startle responses in motor vehicle accident (MVA) survivors to trauma-related, startle, and neutral sounds. Participants were 17 MVA survivors, 11 of whom participated in a controlled treatment study comparing cognitive-behavioral treatment (CBT) and supportive therapy (ST) versus a waitlist condition. Though participants differed significantly in their pretreatment clinical status and symptom severity, these differences were not reflected by group differences in EMG (at orbicularis oculi) to the stimuli at the initial assessment. Some cue-specificity was found, as all participants showed larger startle responses to trauma-related sounds, compared to startle and neutral sounds. At posttreatment, a significant reduction in EMG reactivity to all stimuli was observed in participants who received active treatment (either CBT or ST), compared to waitlist controls. The use of startle responses as a PTSD treatment outcome index is discussed.

Posttraumatische Belastungsstörungen bei somatischen Erkrankungen

This review describes the incidence of posttraumatic stress disorder (PTSD) in physically ill patients. At the beginning, research in the field of PTSD was primarily focused on war veterans and victims of bodily assault or rape. Starting in the early 90 s, PTSD after civilian traumas such as motor vehicle accidents was diagnosed increasingly more often. Recent publications showed that PTSD can also follow serious somatic diseases. Hence, awareness during anaesthesia, prolonged ICU treatment (ARDS, septic shock), burns, successful resuscitation after cardiac arrest, coronary artery bypass surgery, organ transplantation and cancer were all linked to the development of PTSD. Prevalence of PTSD in these medical conditions lies around 5 - 10 %, and it is therefore considered an important comorbidity. Unfortunately, the diagnosis and treatment of PTSD are not well enough established yet and thus do receive too little attention in the treatment regime of somatic illness. Generally, PTSD can occur with every life-threatening disease, but possibly also with less severe diseases if the patient experiences intense fear. PTSD symptoms, especially intrusive recollections, avoidance and hyper-arousal can impair the patients' quality of life more than the primary disease. This seems to be also true for sub-syndromal PTSD. To adequately diagnose and treat patients at risk of developing PTSD, close collaboration between physicians of all subspecialties and psychiatrists will be necessary.

Comparison of the posttraumatic stress disorder scale versus the clinician-administered posttraumatic stress disorder scale in domestic violence survivors

The posttraumatic diagnostic scale (PDS) is a self-report instrument for PTSD that is simple to administer and has demonstrated good psychometric properties. We compared the PDS with the gold standard clinician administered PTSD scale (CAPS) diagnostic interview for PTSD. We assessed 138 women who were victims of domestic violence using both the PDS and the CAPS. Findings confirmed that PTSD develops at a high base rate in this sample. The PDS generally performed well in relation to the CAPS although with a tendency to overdiagnose PTSD. The findings lend further support to the use of the PDS as a diagnostic tool for PTSD but indicate that it is better at identifying survivors with PTSD than those without the disorder.

Are avoidance and numbing distinct PTSD symptom clusters?

We present the conceptual basis and empirical evidence for considering avoidance and numbing as distinct posttraumatic stress disorder (PTSD) symptom clusters. The majority of data from factor analytic studies supports the position that avoidance and numbing are distinct symptom clusters. As well, the available data suggest that (a) different treatment modalities have differential effects on reducing avoidance but not numbing, (b) patients with more severe pretreatment numbing have poorer treatment outcomes, (c) avoidance and numbing have different patterns of correlation with depression, and (d) they have different correlations with physiological indices of attention. We conclude that avoidance and numbing are distinct PTSD symptom clusters. This distinction has implications for revising current diagnostic criteria. The recognition of this distinction may lead to advances in understanding and treating PTSD.