PTSD: a problematic diagnostic category

Analysis of implementation drivers of secondary traumatic stress (STS)-informed organizational change and experiences of STS and burnout in child welfare

BACKGROUND

STS and burnout (BO) are significant problems for child welfare professionals (Bride, 2007; Craig & Sprang, 2010). A challenge for at-risk professions is to understand how both individuals and organizations can address the potential impact of these conditions.

OBJECTIVE

This study explores the influence of organizational factors on individual experiences of STS and BO in child welfare settings.

PARTICIPANTS AND SETTING

Study participants were 382 child welfare professionals in the United States who were participating in an organizational assessment of STS and related activities.

METHOD

The Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA) tool (Sprang et al., 2014) was administered to evaluate the use of policies, practices and training activities that address STS and BO (Sprang et al., 2014). The National Implementation Research Network's (NIRN) implementation framework was applied to the STSI-OA and domain activities loaded onto the three implementation drivers of competency, organization and leadership (Sprang, Ross, & Miller, 2018). Regression analyses were conducted to determine the strength of associations between the implementation drivers of STS informed organizational activity and individual ratings of STS and BO.

RESULT

Increased use of STS-informed activities affiliated with all three implementation drivers was significantly associated with lower individual STS and BO scores. STS-informed activities associated with the organization driver seemed particularly effective for addressing STS.

CONCLUSION

This study supports the utility of the integrated framework for enacting STS-informed change in child welfare contexts. Recommendations for organizations and future research are provided.

Unity or Anarchy? A Historical Search for the Psychological Consequences of Psychotrauma

The field of traumatic stress is often referred to as being in a state of controversy and lack of continuity. Throughout history, disputes repeatedly centered on defining the psychological consequences of severe adverse events and on their causes. Even to this day this is current. To understand these controversies, an extensive historical literature review is presented of how mental consequences of trauma have been described in history, of the circumstances in which this took place, and of the disputes that have influenced the conceptualization of these mental responses. We found psychotrauma always being surrounded by controversy. Significant heterogeneity in symptom expression has been described over the centuries to this day. Some symptoms appeared steadily over many decades, but often each time period showed its own core symptoms. At syndrome level, we found an acute condition, one with longer duration, and a complex condition. Also here, definitions varied over the decades. Finally, causes have always been debated, such as biological, psychological, socio-economic, cultural, political, or legal. To better reflect the described ongoing variation in symptomatology, a more flexible diagnostic approach is proposed with a combination of both staging and subtyping that offers room for a more flexible, symptom-oriented, and personalized perspective.

Prevalence and determinants of mental health related to climate change in Australia

AIMS

The climate emergency will likely prove this century's greatest threat to public health within which mental health effects need consideration. While studies consistently show the majority of Australians are very concerned about the impacts of climate change, there is limited evidence from nation-wide research linking climate change with mental health burden in sub-populations. This study aimed to understand the impact of climate change on mental health in the Australian population and identify populations who are most at risk of climate-related mental health burden.

METHODS

A nation-wide Australian survey conducted between August and November 2020 of adults was approximately representative across sex, age, location, state and area disadvantage. Two-stage recruitment involved unrestricted self-selected community sample through mainstream and social media (N = 4428) and purposeful sampling using an online panel (N = 1055).

RESULTS

Most Australians report having a direct experience of a climate change-related event. Young people are experiencing significant rates of eco-anxiety. One in four people with direct experience of a climate change-related event met post-traumatic stress disorder screening criteria. People who have not had a direct experience are showing symptoms of pre-trauma, particularly in younger age groups and women. There were 9.37% (503/5370) of respondents with responses indicating significant eco-anxiety, 15.68% (370/2359) with pre-traumatic stress and 25.60% (727/2840) with post-traumatic stress disorder. Multivariable regressions confirmed that younger people are more affected by eco-anxiety and post-traumatic stress disorder (pre- or post-trauma); women are more affected by post-traumatic stress disorder (pre- or post-trauma) and those from more disadvantaged regions are more affected by eco-anxiety.

CONCLUSION

Australia is facing a potential mental health crisis. Individuals with and without direct experience of climate change are reporting significant mental health impacts, with younger age groups being disproportionately affected. There are key roles for clinicians and other health professionals in responding to and preventing climate-related mental health burden.

Genetic evidence suggests posttraumatic stress disorder as a subtype of major depressive disorder

BACKGROUND

Major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) are highly comorbid and exhibit strong correlations with one another. We aimed to investigate mechanisms of underlying relationships between PTSD and three kinds of depressive phenotypes, namely, MDD, depressed affect (DAF), and depression (DEP, including both MDD and the broad definition of depression).

METHODS

Genetic correlations between PTSD and the depressive phenotypes were tested using linkage disequilibrium score regression. Polygenic overlap analysis was used to estimate shared and trait-specific causal variants across a pair of traits. Causal relationships between PTSD and the depressive phenotypes were investigated using Mendelian randomization. Shared genomic loci between PTSD and MDD were identified using cross-trait meta-analysis.

RESULTS

Genetic correlations of PTSD with the depressive phenotypes were in the range of 0.71~0.80. The estimated numbers of causal variants were 14,565, 12,965, 10,565, and 4,986 for MDD, DEP, DAF, and PTSD, respectively. In each case, causal variants contributing to PTSD were completely or largely covered by causal variants defining each of the depressive phenotypes. Mendelian randomization analysis indicates that the genetically determined depressive phenotypes confer a causal effect on PTSD (b = 0.21~0.31). Notably, genetically determined PTSD confers a causal effect on DEP (b = 0.14) and DAF (b = 0.15), but not MDD. Cross-trait meta-analysis of MDD and PTSD identifies 47 genomic loci, including 29 loci shared between PTSD and MDD.

CONCLUSION

Evidence from shared genetics suggests that PTSD is a subtype of MDD. This study provides support to the efforts in reducing diagnostic heterogeneity in psychiatric nosology.

FUNDING

The National Key Research and Development Program of China (2018YFC1314300) and the National Natural Science Foundation of China (81471364 and 81971255).

Challenges of post-traumatic stress disorder (PTSD) in Iraq: biochemical network and methodologies. A brief review

Post-traumatic stress disorder (PTSD) is a multifaceted syndrome due to its complex pathophysiology. Signals of illness include alterations in genes, proteins, cells, tissues, and organism-level physiological modifications. Specificity of sensitivity to PTSD suggests that response to trauma depend on gender and type of adverse event being experienced. Individuals diagnosed with PTSD represent a heterogeneous group, as evidenced by differences in symptoms, course, and response to treatment. It is clear that the biochemical mechanisms involved in PTSD need to be elucidated to identify specific biomarkers. A brief review of the recent literature in Pubmed was made to explore the major biochemical mechanisms involved in PTSD and the methodologies applied in the assessment of the disease. PTSD shows pre-exposure vulnerability factors in addition to trauma-induced alterations. The disease was found to be associated with dysfunctions of the hypothalamic-pituitary-adrenal axis (HPA) and hypothalamus-pituitary-thyroid axis. Sympathetic nervous system (SNS) activity play a role in PTSD by releasing norepinephrine and epinephrine. Cortisol release from the adrenal cortex amplifies the SNS response. Cortisol levels in PTSD patients, especially women, are later reduced by a negative feedback mechanism which contributes to neuroendocrine alterations and promotes structural changes in the brain leading to PTSD. Gender differences in normal HPA responsiveness may be due to an increased vulnerability in women to PTSD. Serotonin and dopamine levels were found to be abnormal in the presence of PTSD. Mechanisms such as the induction of neuroinflammation and alterations of mitochondrial energy processing were also associated with PTSD.

Cultural Context in DSM Diagnosis: An American Indian Case Illustration of Contradictory Trends

Recent revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) increasingly acknowledge the importance of cultural context for the diagnosis of mental illness. However, these same revisions include evolving diagnostic criteria that simultaneously decontextualize particular disorders such as Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). As a result, the DSM reflects a contradictory role for context in psychiatric diagnosis. The case analysis presented here frames the consequences of this contradictory trend for an American Indian woman with a history of DSM-IV MDD and PTSD, whose diagnostic portrait is substantively altered in light of more recent DSM-5 criteria. Specifically, consideration of this respondent's bereavement-related illness experience suggests that a sociocentric cultural frame of reference, which places high value on interdependent personal relationships, is not well-captured by DSM-5's revised MDD or PTSD criteria, or the newly proposed categories of traumatic bereavement or Persistent Complex Bereavement Disorder. The respondent's illness experience argues for greater recognition of this contradictory diagnostic trend, suggesting a need for future resolution of this tension toward more valid diagnosis for culturally diverse populations.

Disrupted functional network connectivity predicts cognitive impairment after acute mild traumatic brain injury

Aims

This study aimed to detect alterations of brain functional connectivity (FC) in acute mild traumatic brain injury (mTBI) and to estimate the extent to which these FC differences predicted the characteristics of posttraumatic cognitive impairment.

Methods

Resting‐state fMRI data were acquired from acute mTBI patients (n = 50) and healthy controls (HCs) (n = 43). Resting‐state networks (RSNs) were established based on independent component analysis (ICA), and functional network connectivity (FNC) analysis was performed. Subsequently, we analyzed the correlations between FNC abnormalities and cognitive impairment outcomes.

Results

Altered FC within the salience network (SN), sensorimotor network (SMN), default mode network (DMN), executive control network (ECN), visual network (VN), and cerebellum network (CN) was found in the mTBI group relative to the HC group. Moreover, different patterns of altered network interactions were found between the mTBI patients and HCs, including the SN‐CN, VN‐SMN, and ECN‐DMN connections. Correlations between functional disconnection and cognitive impairment measurements in acute mTBI patients were also found.

Conclusion

This study indicated that widespread FNC impairment and altered integration existed in mTBI patients at acute stage, suggesting that FNC disruption as a biomarker may be applied for the early diagnosis and prediction of cognitive impairment in mTBI.

A paradigm shift: relationships in trauma-informed mental health services

Trauma-informed approaches emerged partly in response to research demonstrating that trauma is widespread across society, that it is highly correlated with mental health and that this is a costly public health issue. The fundamental shift in providing support using a trauma-informed approach is to move from thinking ‘What is wrong with you?’ to considering ‘What happened to you?’. This article, authored by trauma survivors and service providers, describes trauma-informed approaches to mental healthcare, why they are needed and how barriers can be overcome so that they can be implemented as an organisational change process. It also describes how past trauma can be understood as the cause of mental distress for many service users, how service users can be retraumatised by ‘trauma-uninformed’ staff and how staff can experience vicariously the service user's trauma and can themselves be traumatised by practices such as restraint and seclusion. Trauma-informed mental healthcare offers opportunities to improve service users' experiences, improve working environments for staff, increase job satisfaction and reduce stress levels by improving the relationships between staff and patients through greater understanding, respect and trust.

Examining various subthreshold definitions of PTSD using the Clinician Administered PTSD Scale for DSM-5

BACKGROUND

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association [APA], 2013) includes Other- and Unspecified- Trauma and Stressor-Related Disorders to capture subthreshold Posttraumatic Stress Disorder (PTSD) symptoms. However, the DSM-5 does not specify the number or type of symptoms needed to assign them. The purpose of the current study was to extend our understanding of subthreshold PTSD by comparing four commonly used definitions adapted to the DSM-5 PTSD criteria in an outpatient treatment-seeking sample.

METHODS

Veterans (N = 193) presenting to PTSD clinics were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). Participants reported a criterion A traumatic event, but did not meet criteria for threshold-PTSD. We hypothesized that the number of veterans captured would be highest when fewer specific criterion sets were required by the subthreshold definition.

RESULTS

Our hypothesis was upheld in that the more criteria required by the subthreshold PTSD definition, the lower the number of veterans counted within the group.

LIMITATIONS

The study consisted primarily of trauma treatment-seeking male veterans, with chronic PTSD symptoms. In addition, the sample size was small and was collected as part of routine clinical care.

CONCLUSIONS

These results support previous contentions around careful decision making when defining what constitutes subthreshold PTSD in research and clinical work. It also points to the need for continued research to better understand the diagnostic and treatment implications of subthreshold PTSD.

The Network Structure of Posttraumatic Stress Symptoms in Children and Adolescents Exposed to Disasters

OBJECTIVE

To evaluate current theoretical assumptions about the nature of pediatric posttraumatic stress disorder (PTSD) by examining the network structure of PTSD in a sample of youth exposed to disasters and testing for age differences. Network analysis provides the opportunity to identify "central" symptoms that might hold an outsized influence over others and are important targets for research and treatment. The authors hypothesized that particular symptoms would exhibit greater influence over others. They further hypothesized marked differences in symptom networks across children and adolescents.

METHOD

Participants were 786 youth 8 to 13 years old (children) and 14 to 18 years old (adolescents) exposed to Hurricanes Katrina and Gustav who were assessed for PTSD symptoms using the University of California-Los Angeles PTSD Reaction Index for Children. Network models were computed and constructed using the R-package qgraph, which estimates associations between symptoms and forms graphic network models.

RESULTS

Consistent with the hypotheses, the symptom network demonstrated meaningful variability across age, particularly in the strength of associations, and the relative importance of individual symptoms to the network as a whole. Results further demonstrated that symptoms cluster together in a manner that adds a unique perspective to current model conceptualizations.

CONCLUSION

Network analysis is a potentially important additional conceptualization of psychopathology with related data analytic techniques. Results suggest that PTSD can be characterized as a web of interactions between symptoms. This work illuminates differences in the PTSD symptom network across development, such as the link between numbness of negative affect and amnesia in children, but not in teens, and how the critical symptoms within that network differ across childhood and adolescence. Network analysis could allow the re-envisioning of the nature of this complex disorder with new avenues for research and clinical practice.

Sometimes Less is More: Establishing the Core Symptoms of PTSD

Historically, the symptoms of posttraumatic stress disorder (PTSD) have garnered attention and controversy due to symptom overlap with other disorders. To improve diagnostic specificity, researchers have proposed to reformulate PTSD symptoms into a parsimonious set of core criteria. The core symptoms consisted of recurrent distressing dreams or flashbacks; internal or external avoidance; and hypervigilance or exaggerated startle. The purpose of this study was to examine a previously proposed set of "core" PTSD criteria in identifying cases of PTSD within a veteran sample. Veterans (N = 383) presenting to a Veterans Affairs (VA) Medical Center PTSD clinic for psychological services were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). A logistic regression analysis revealed that the core criteria accurately identified 79% of veterans with PTSD (OR = 11.57). Findings support a parsimonious set of core criteria in the assessment and diagnosis of PTSD. Future studies should replicate these findings in diverse, nonveteran samples.

Concept Analysis of Posttraumatic Stress Disorder

PURPOSE

Mental health nursing is not the same as psychiatry, so it is important for nurses to have an understanding of the defining attributes, antecedents, consequences, model cases, and empirical referents of post-traumatic stress disorder (PTSD).

METHOD

Walker and Avant's (2005) method is used to guide this concept analysis of PTSD.

FINDINGS

Four attributes arise from this concept analysis, which are addressed through both the DSM-IV and DSM-5 (American Psychiatric Association, /): triggering event or events, re-experiencing, fear, and helplessness. Though a majority of the defining attributes are addressed through both versions of the DSM, a key fifth attribute arises through this concept analysis: a disruption of meaning.

CONCLUSIONS

A better understanding of PTSD from a nursing perspective will help inform appropriate nursing interventions and prevention strategies, while expanding the knowledge synthesis and contribution of the nursing profession.

PRACTICE IMPLICATIONS

A model case, borderline case, and contrary case of PTSD are provided. Discussion of the importance of a lack or loss of meaning in PTSD is included, along with exploration of transformative learning theory to inform clinical practice for nurses addressing a disruption of meaning.

Posttraumatic Stress Disorder in the DSM-5: Controversy, Change, and Conceptual Considerations

The criteria for posttraumatic stress disorder PTSD have changed considerably with the newest edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Changes to the diagnostic criteria from the DSM-IV to DSM-5 include: the relocation of PTSD from the anxiety disorders category to a new diagnostic category named “Trauma and Stressor-related Disorders”, the elimination of the subjective component to the definition of trauma, the explication and tightening of the definitions of trauma and exposure to it, the increase and rearrangement of the symptoms criteria, and changes in additional criteria and specifiers. This article will explore the nosology of the current diagnosis of PTSD by reviewing the changes made to the diagnostic criteria for PTSD in the DSM-5 and discuss how these changes influence the conceptualization of PTSD.

Posttraumatic Stress Disorder and Related Disorders among Female Yazidi Refugees following Islamic State of Iraq and Syria Attacks-A Case Series and Mini-Review

Following the severe attacks by the so-called "Islamic State of Iraq and Syria" on the Yazidi population, which started in summer 2014, the state government of Baden-Württemberg, Germany, funded a Special-Quota Project to bring 1,000 very ill or left-behind women and children who were being held hostage to 22 cities and towns in Baden-Württemberg to receive integrated care. Here, we report for the first time on the cases of four Yazidi women living in Ulm, Germany, focusing on the clinically observed and psychometrically assessed mental phenomena or disorders. Our primary aim was to explore what International Classification of Diseases, 10th Revision diagnoses are present in this population. Although highly traumatized, these women were suffering primarily from adjustment disorder rather than posttraumatic stress disorder according to official classification systems. Despite their symptoms of depression and anxiety, the women's responses to self-assessment questionnaires provided no evidence of compulsion, somatization, or eating disorders. The results suggest that further investigation of the individual-level effects of rape and torture, as well the historic, systemic, and collective effects, e.g., on families and societies, is required.

The Roots of Chronic Posttraumatic Stress Disorder: Childhood Trauma, Information Processing, and Self-protective Strategies

BACKGROUND

Although childhood endangerment often precedes adult posttraumatic stress disorder (PTSD), the mechanism from danger to disorder is unclear. We proposed a developmental process in which unprotected and uncomforted danger in childhood would be associated with "shortcuts" in information processing that, in adulthood, could result in PTSD if the adult experienced additional exposure to danger. Information processing was defined as the basic associative, dissociative, and integrative processes used by all humans. Individual differences in parents' (or primary caregivers') protective and comforting behavior were expected to force unprotected children to use psychological shortcuts that linked early trauma to later vulnerability for PTSD.

METHOD

We compared 22 adults with chronic PTSD to (a) 22 adults with other psychiatric diagnoses and (b) 22 normative adults without any diagnosis, in terms of information processing around childhood danger. The Adult Attachment Interview was used to derive information processing variables, including self-protective strategies, childhood traumas, and depression.

RESULTS

The two patient groups differed from the normative group on all variables. Adults with chronic PTSD differed from other psychiatric patients in having more childhood traumas and using more transformations of associative and dissociative processes. Within the PTSD group, there were three psychologically different subgroups.

CONCLUSION

Our findings suggest that (1) prediction of risk for adult PTSD may be possible, (2) treatment might be facilitated by provision of a protective and supportive therapist, (3) who included a focus on correction of information processing errors and use of more adaptive strategies, and (4) subgroups of adults with PTSD may require different forms of treatment.

Post-traumatic stress disorder moderates the relationship between trauma exposure and chronic pain

Background: Trauma exposure and post-traumatic stress disorder (PTSD) are risk factors for chronic pain. Objective: This study investigated how exposure to intentional and non-intentional traumatic events and PTSD are related to pain severity and outcome of treatment in chronic pain patients. Methods: We assessed exposure to potentially traumatizing events, psychiatric diagnosis with structured clinical interview, and pain severity in 63 patients at a secondary multidisciplinary pain clinic at the beginning of treatment, and assessed level of pain at follow up. Exposure to potentially traumatizing events and PTSD were regressed on pain severity at the initial session and at follow up in a set of multiple regression analysis. Results: The participants reported exposure to an average of four potentially traumatizing events, and 32% had PTSD. Exposure to intentional traumatic events and PTSD were significantly associated with more severe pain, and PTSD significantly moderated the relationship between trauma exposure and pain (all p < .05). The treatment programme reduced pain moderately, an effect that was unrelated to trauma exposure and PTSD. Conclusions: Trauma exposure is related to chronic pain in the same pattern as to mental disorders, with intentional trauma being most strongly related to pain severity. PTSD moderated the relationship between trauma exposure and pain. While pain patients with PTSD initially report more pain, they responded equally to specialist pain treatment as persons without PTSD.

The Mental Disability Military Assessment Tool: A Reliable Tool for Determining Disability in Veterans with Post-traumatic Stress Disorder

PURPOSE

An assessment tool was developed to assess disability in veterans who suffer from post-traumatic stress disorder (PTSD) due to a military mission. The objective of this study was to determine the reliability, intra-rater and inter-rater variation of the Mental Disability Military (MDM) assessment tool.

METHODS

Twenty-four assessment interviews of veterans with an insurance physician were videotaped. Each videotaped interview was assessed by a group of five independent raters on limitations of the veterans using the MDM assessment tool. After 2 months the raters repeated this procedure. Next the intra-rater and inter-rater variation was assessed with an adjusted version of AG09 computing weighted percentage agreement.

RESULTS

The results of this study showed that both the intra-rater variation and inter-rater variation on the ten subcategories of the MDM assessment tool were small, with an agreement of 84-100% within raters and 93-100% between raters.

CONCLUSIONS

The MDM assessment tool proves to be a reliable instrument to measure PTSD limitations in functioning in Dutch military veterans who apply for disability compensation. Further research is needed to assess the validity of this instrument.

AS VÍTIMAS DA VIOLÊNCIA: ENTRE DISCURSOS CIENTÍFICOS E BIOPOLÍTICAS DO CONTEMPORÂNEO

Este artigo apresenta reflexões em torno do papel social da vítima da violência na produção do medo e da insegurança, e sua influência no aumento dos mecanismos repressivos do estado penal brasileiro. Foi realizada uma pesquisa bibliográfica não sistemática buscando proposições acerca da criação de uma psicopatologia relacionada à vitimização, nesse caso o Transtorno de Estresse Pós-Traumático (TEPT). Indo além de uma proposta de caracterização do transtorno em si, o presente trabalho teve como objetivo entender as práticas que o engendram, quais contingências históricas o fizeram emergir em um determinado momento e quais efeitos têm produzido na medicalização da vida e nas atuais políticas públicas de segurança de nossa sociedade.

Posttraumatic stress in survivors 1 month to 19 years after an airliner emergency landing

Posttraumatic stress (PTS) is common in survivors from life-threatening events. Little is known, however, about the course of PTS after life threat in the absence of collateral stressors (e.g., bereavement, social stigma, property loss) and there is a scarcity of studies about PTS in the long term. This study assessed the short- and long-term course of PTS, and the influence of gender, education and age on the level and course of PTS, in survivors from a non-fatal airliner emergency landing caused by engine failure at an altitude of 1 km. There were 129 persons on board. A survey including the Impact of Event Scale was distributed to 106 subjects after 1 month, 4 months, 14 months, and 25 months, and to 95 subjects after 19 years (response rates 64-83%). There were initially high levels of PTS. The majority of changes in PTS occurred from 1 to 4 months after the event. There were small changes from 4 to 25 months but further decrease in PTS thereafter. Female gender was associated with higher levels of PTS whereas gender was unrelated to the slope of the short- and long-term trajectories. Higher education was related to a quicker recovery although not to initial or long-term PTS. Age was not associated with PTS. The present findings suggest that a life-threatening experience without collateral stressors may produce high levels of acute posttraumatic stress, yet with a benign prognosis. The findings further implicate that gender is unrelated to trajectories of recovery in the context of highly similar exposure and few collateral stressors.

Combat-related PTSD in military court: a diagnosis in search of a defense

As more veterans return from Iraq and Afghanistan, Posttraumatic Stress Disorder (PTSD) often returns with them. As a result, PTSD has quickly become the most prevalent mental disorder diagnosis among active duty United States (U.S.) military. Although numerous studies have not only validated PTSD but have chronicled its negative behavioral impact, it remains a controversial diagnosis. It is widely diagnosed by all types of mental health professionals for even minimal trauma, and DSM-IV PTSD criteria have wide overlap with other mood and anxiety disorders. This, however, has not stopped PTSD from being used in civilian courts in the U.S. as a mental disorder to establish grounds for mental status defenses, such as insanity, diminished capacity, and self-defense, or as a basis for sentencing mitigation. Not surprisingly, PTSD has recently found its way into military courts, where some defense attorneys are eager to draw upon its understandable and linear etiology to craft some type of mental incapacity defense for their clients. As in the civilian sphere, this has met with mixed success due to relevance considerations. A recent court-martial, U.S. v. Lawrence Hutchins III, has effectively combined all the elemental nuances of PTSD in military court.

The underlying dimensionality of PTSD in the diagnostic and statistical manual of mental disorders: where are we going?

There has been a substantial body of literature devoted to answering one question: Which latent model of posttraumatic stress disorder (PTSD) best represents PTSD's underlying dimensionality? This research summary will, therefore, focus on the literature pertaining to PTSD's latent structure as represented in the fourth (DSM-IV, 1994) to the fifth (DSM-5, 2013) edition of the DSM. This article will begin by providing a clear rationale as to why this is a pertinent research area, then the body of literature pertaining to the DSM-IV and DSM-IV-TR will be summarised, and this will be followed by a summary of the literature pertaining to the recently published DSM-5. To conclude, there will be a discussion with recommendations for future research directions, namely that researchers must investigate the applicability of the new DSM-5 criteria and the newly created DSM-5 symptom sets to trauma survivors. In addition, researchers must continue to endeavour to identify the "correct" constellations of symptoms within symptom sets to ensure that diagnostic algorithms are appropriate and aid in the development of targeted treatment approaches and interventions. In particular, the newly proposed DSM-5 anhedonia model, externalising behaviours model, and hybrid models must be further investigated. It is also important that researchers follow up on the idea that a more parsimonious latent structure of PTSD may exist.

Comparison of DSM-IV and proposed ICD-11 formulations of PTSD among civilian survivors of war and war veterans

The World Health Organization recently proposed a reformulation of posttraumatic stress disorder (PTSD) for the 11(th) edition of the International Classification of Diseases (ICD-11), employing only 6 symptoms. The aim of this study was to investigate the impact of this reformulation of PTSD as compared to criteria according to Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association, 1994) on the prevalence of current PTSD as well as comorbid major depressive episode and anxiety disorders other than PTSD. Study 1 involved previously collected interviews with 560 Kosovar civilian war survivors; Study 2 employed a previously collected sample of 142 British war veterans. Results revealed no change in the diagnostic status under the criteria proposed for ICD-11 in 87.5% of civilian war survivors and 91.5% of war veterans. Participants who only met the newly proposed criteria showed lower rates of comorbid major depressive episode than participants who only met DSM-IV criteria (13.6% vs. 43.8% respectively). Rates of comorbid anxiety disorders did not significantly differ between participants who lost or gained a PTSD diagnosis under the proposed criteria.

Properties of Swedish posttraumatic stress measures after a disaster

This study evaluated the properties of Swedish versions of self-report measures of posttraumatic stress disorder (PTSD), with emphasis on the Impact of Event Scale-Revised (IES-R). Survey data from adult survivors 1, 3, and 6 years after the 2004 Indian Ocean tsunami (n=1506) included the IES-R (from which the IES-6 was derived) and the 12-item General Health Questionnaire (GHQ-12). The PTSD Checklist (PCL) was included in one survey. A structured clinical interview was performed after 6 years (n=142). Factor analyses of the IES-R and PCL indicated that a dysphoric-arousal model provided good fit invariant across assessments. Both measures were accurate in excluding PTSD while all measures provided poorer positive predictive values. The IES-R, but not the IES-6 and GHQ-12, evidenced stability across assessments. In conclusion, the Swedish IES-R and PCL are sound measures of chronic PTSD, and the findings illustrate important temporal aspects of PTSD assessment.

Posttraumatic stress disorder: a theoretical model of the hyperarousal subtype

Posttraumatic stress disorder (PTSD) is a frequent and distressing mental disorder, about which much remains to be learned. It is a heterogeneous disorder; the hyperarousal subtype (about 70% of occurrences and simply termed PTSD in this paper) is the topic of this article, but the dissociative subtype (about 30% of occurrences and likely involving quite different brain mechanisms) is outside its scope. A theoretical model is presented that integrates neuroscience data on diverse brain regions known to be involved in PTSD, and extensive psychiatric findings on the disorder. Specifically, the amygdala is a multifunctional brain region that is crucial to PTSD, and processes peritraumatic hyperarousal on grounded cognition principles to produce hyperarousal symptoms. Amygdala activity also modulates hippocampal function, which is supported by a large body of evidence, and likewise amygdala activity modulates several brainstem regions, visual cortex, rostral anterior cingulate cortex (rACC), and medial orbitofrontal cortex (mOFC), to produce diverse startle, visual, memory, numbing, anger, and recklessness symptoms. Additional brain regions process other aspects of peritraumatic responses to produce further symptoms. These contentions are supported by neuroimaging, neuropsychological, neuroanatomical, physiological, cognitive, and behavioral evidence. Collectively, the model offers an account of how responses at the time of trauma are transformed into an extensive array of the 20 PTSD symptoms that are specified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition. It elucidates the neural mechanisms of a specific form of psychopathology, and accords with the Research Domain Criteria framework.

The Evolving Construct of Posttraumatic Stress Disorder (PTSD): DSM-5 Criteria Changes and Legal Implications

In the DSM-5, the diagnosis of posttraumatic stress disorder (PTSD) has undergone multiple, albeit minor, changes. These changes include shifting PTSD placement from within the anxiety disorders into a new category of traumatic and stressor-related disorders, alterations in the definition of a traumatic event, shifting of the symptom cluster structure from three to four clusters, the addition of new symptoms including persistent negative beliefs and expectations about oneself or the world, persistent distorted blame of self or others, persistent negative trauma-related emotions, and risky or reckless behaviors, and the addition of a dissociative specifier. The evidence or lack thereof behind each of these changes is briefly reviewed. These changes, although not likely to change overall prevalence, have the potential to increase the heterogeneity of individuals receiving a PTSD diagnosis both by altering what qualifies as a traumatic event and by adding symptoms commonly occurring in other disorders such as depression, borderline personality disorder, and dissociative disorders. Legal implications of these changes include continued confusion regarding what constitutes a traumatic stressor, difficulties with differential diagnosis, increased ease in malingering, and improper linking of symptoms to causes of behavior. These PTSD changes are discussed within the broader context of DSM reliability and validity concerns.

Post-traumatic stress disorder and urban violence: an anthropological study

The study aimed to understand how "distress" is experienced by patients with Post-Traumatic Stress Disorder (PTSD) in the social-cultural context of São Paulo, Brazil, an urban environment marked by social inequality and high levels of violence. A qualitative study was conducted between 2008 and 2010 with PTSD patients (F43.1, ICD-10, 1997) who had been victims of robberies and kidnappings in São Paulo. Dense ethnographic observations were carried out, as well as in-depth semi-structured interviews with ten adult patients. The analysis method used was based on anthropology. The results show that it is particularly important to distinguish between perceptions of different forms of the experience of social suffering and perceptions of health and illness held by victims and biomedical experts. The cause of PTSD is more often associated with the personal problems of the victim than with the specific traumatic event. The distress described in terms of what is considered a "normal" reaction to violence and what is considered a symptom of PTSD. The findings indicate that the diagnostic of PTSD can be understood in relation to the different contexts within a culture. The ethnographic approach serves not only to illuminate individual suffering but also the social suffering experienced by the residents of São Paulo.

Performance on the Green Word Memory Test following Operation Enduring Freedom/Operation Iraqi Freedom-era military service: Test failure is related to evaluation context

This study investigates prior reports of high neuropsychological symptom validity test (SVT) failure rates in post-deployed Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) active and veteran military personnel, using a large, multi-site sample (N = 214) drawn from three levels of the Department of Defense/Department of Veterans Affairs (VA) Polytrauma System of Care. The sample failure rate and its relationship to research versus dual research/clinical context of evaluation were examined, in addition to secondary variables explored in prior studies. Results yielded an overall failure rate of 25%, lower than prior reports describing OEF/OIF active-duty and veteran military personnel. Findings also supported the hypothesis that SVT failure rates would differ by context (dual > research). Participants with traumatic brain injury (TBI) failed more frequently than those without TBI in the dual context but not in the research context. Secondary analyses revealed that failure rates increased in the presence of depression, posttraumatic stress disorder, and male sex but were unrelated to active versus veteran military status, service connection (SC) or percentage of SC, age, education, or ethnicity. Further research is required to elucidate the underpinnings of these findings in light of the limited literature and variability between OEF/OIF-related SVT studies, as well as the substantial diagnostic and treatment implications for VA.

Posttraumatic reactions to an earthquake: multidimensional scaling profile analysis of adolescent survivors

The current study examined the prototypical profiles of posttraumatic stress reactions among a sample of 282 adolescent survivors of the 2008 Wenchuan earthquake in China. Based on a dimensional perspective, the results of profile analysis via multidimensional scaling (PAMS) model revealed a two-dimensional solution corresponding to four profiles: intrusion, avoidance/arousal, partial avoidance, and hyperarousal. These profiles of posttraumatic stress symptoms equally manifested across gender. In addition, the Intrusion Profile was found to be associated with more elevated psychological distress symptoms. Results are discussed with respect to the typical posttraumatic stress symptoms following the earthquake.

Lessons from the 2004 Asian tsunami: epidemiological and nosological debates in the diagnosis of post-traumatic stress disorder in non-Western post-disaster communities

BACKGROUND

The nosological validity of post-traumatic stress disorder (PTSD) remains controversial in non-Western communities. After natural disasters, epidemiological studies often overlook these conceptual debates and assess post-traumatic stress symptoms (PTSS) by short screening instruments. Such PTSS estimates are reported as inflated prevalence rates of PTSD in post-disaster settings.

AIMS

To discuss the prevalence and determinants of PTSS within the context of pertinent epidemiological and nosological debates.

METHODS

We assessed PTSS and grief symptoms of 643 survivors from five Indian villages struck by the Asian tsunami using the Impact of Events Scale - Revised and Complicated Grief Assessment Scale. We adopted a case control design and employed complex sample multiple logistic regression statistics to study the determinants of PTSS.

RESULTS

The prevalence of PTSS was 15.1% (95% CI 12.3%-17.9%). PTSS was significantly associated with traumatic grief, female gender, physical injury, death of children and financial losses, but not with functional disability (p = .91).

CONCLUSIONS

Although PTSS were common in this population, elevating them to a psychiatric construct of PTSD is questionable, when functional impairment and avoidance behaviours were absent. Grief reactions, socio-economic burden, and poor support systems contribute towards PTSS. We highlight the important issues regarding the nosological validity and epidemiology of PTSD in non-Western communities.

Personality and Major Depression among Directly Exposed Survivors of the Oklahoma City Bombing

Background. Few disaster studies have specifically examined personality and resilience in association with disaster exposure, posttraumatic stress disorder (PTSD), and major depression. Methods. 151 directly-exposed survivors of the Oklahoma City bombing randomly selected from a bombing survivor registry completed PTSD, major depression, and personality assessments using the Diagnostic Interview Schedule for DSM-IV and the Temperament and Character Inventory, respectively. Results. The most prevalent postdisaster psychiatric disorder was bombing-related PTSD (32%); major depression was second in prevalence (21%). Bombing-related PTSD was associated with the combination of low self-directedness and low cooperativeness and also with high self-transcendence and high harm avoidance in most configurations. Postdisaster major depression was significantly more prevalent among those with (56%) than without (5%) bombing-related PTSD (P < .001) and those with (72%) than without (14%) predisaster major depression (P < .001). Incident major depression was not associated with the combination of low self-directedness and low cooperativeness. Conclusions. Personality features can distinguish resilience to a specific life-threatening stressor from general indicators of well-being. Unlike bombing-related PTSD, major depression was not a robust marker of low resilience. Development and validation of measures of resilience should utilize well-defined diagnoses whenever possible, rather than relying on nonspecific measures of psychological distress.

Rehabilitation of the concept of neurosis

The use of the term “neurosis” has been gradually pushed out form the medical literature and from the everyday practice since the eighties of the last century. Instead, the categories of DSM-III, and its new versions, and those of the ICD-10 have become commonly used. The author analyses the advantages and drawbacks of this radical change. He points out that it is not merely the problem of the medical profession. Transformation of the way of diagnostic thinking has been put into a broader social and cultural context. The expression “deconstruction” describes appropriately the process when comprehensive, entire categories resign to small sliced parts of reality. The deconstruction recalls the “Universalia-dispute” of the Middle Ages, namely the question whether the general concepts have real existence, and to what extent. The term “neurosis” as a comprehensive category, which is characteristic of many patients, it has a heuristic value if it is filled up with new contents (anthropology, ontology). Orv. Hetil., 2012, 153, 1327–1333.

Comparing the stability of diagnosis in full vs. partial posttraumatic stress disorder

We studied differences in diagnostic stability between patients with full and patients with partial posttraumatic stress disorder (PTSD). We collected self-reported symptoms of PTSD, anxiety, depression, and functioning at a Veterans Affairs mental health clinic (n = 1962). We classified patients as meeting full or partial PTSD based upon their initial assessment. We performed Kaplan-Meier survival analysis to compare stability of diagnosis over time and Cox proportional hazards models to understand how comorbid symptoms and level of functioning confounded the relationship. We performed a chart review to examine differences in treatment received by the two groups. Patients in the partial PTSD group lost their diagnosis significantly faster and at significantly higher rates than did patients with full PTSD. Comorbid symptoms contributed significantly to this difference. Mental health treatments delivered to the two groups were similar. These diagnoses appear to be different, suggesting that people with partial PTSD may benefit from a different clinical approach.

Anthropological discourses on the globalization of posttraumatic stress disorder (PTSD) in post-conflict societies

Posttraumatic stress disorder (PTSD) is a construct that has moved far beyond its origins in Veterans Administration hospitals after the Vietnam War. It is now commonly used in post-conflict societies by humanitarian agencies and researchers. This article looks at the ever-growing expansion of PTSD and reviews medical anthropologists' critiques of this cross-cultural dissemination of Western psychiatric knowledge. The article also reviews post-conflict ethnographies and their results, which often highlight a mismatch between local priorities and the psycho-social services being provided by outside agencies. Finally, the author highlights interventions that are currently being undertaken by humanitarian agencies in an attempt to bridge psychiatric expertise and local forms of healing. Although PTSD is a useful construct for conceptualizing the experience of those who have suffered traumatic events, it does not lend itself to universal cross-cultural application and should be cautiously applied in post-conflict societies.

Posttraumatic stress disorder in DSM-5: estimates of prevalence and symptom structure in a nonclinical sample of college students

We empirically investigated recent proposed changes to the posttraumatic stress disorder (PTSD) diagnosis for DSM-5 using a non-clinical sample. A web survey was administered to 585 college students using the Stressful Life Events Screening Questionnaire to assess for trauma exposure but with additions for the proposed traumatic stressor changes in DSM-5 PTSD. For the 216 subjects endorsing previous trauma exposure and nominating a worst traumatic event, we administered the original PTSD Symptom Scale based on DSM-IV PTSD symptom criteria and an adapted version for DSM-5 symptoms, and the Center for Epidemiological Studies-Depression Scale. While 67% of participants endorsed at least one traumatic event based on DSM-IV PTSD's trauma classification, 59% of participants would meet DSM-5 PTSD's proposed trauma classification. Estimates of current PTSD prevalence were .4-1.8% points higher for the DSM-5 (vs. the DSM-IV) diagnostic algorithm. The DSM-5 symptom set fit the data very well based on confirmatory factor analysis, and neither symptom set's factors were more correlated with depression.

The factor structure of posttraumatic stress disorder: a literature update, critique of methodology, and agenda for future research

We present an update of recent literature (since 2007) exploring the factor structure of posttraumatic stress disorder (PTSD) symptom measures. Research supporting a four-factor emotional numbing model and a four-factor dysphoria model is presented, with these models fitting better than all other models examined. Variables accounting for factor structure differences are reviewed, including PTSD query instructions, type of PTSD measure, extent of trauma exposure, ethnicity, and timing of administration. Methodological and statistical limitations with recent studies are presented. Finally, a research agenda and recommendations are offered to push this research area forward, including suggestions to validate PTSD’s factors against external measures of psychopathology, test moderators of factor structure, and examine heterogeneity of symptom presentations based on factor structure examination.

Testing whether posttraumatic stress disorder and major depressive disorder are similar or unique constructs

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) co-occur frequently, are highly correlated, and share three symptoms in common. In the present paper, the authors tested whether PTSD and MDD are similar or unique constructs by examining their symptoms using Rasch modeling. Data were used from the 766 trauma-exposed subjects in the National Comorbidity Survey-Replication (conducted in the early 2000s) with PTSD and MDD symptom ratings. Results demonstrate that MDD symptoms were less frequently endorsed than PTSD symptoms-even for the three symptoms shared between the disorders. PTSD and MDD items represented a single, underlying dimension, although modest support was found for a secondary sub-factor. Removing their shared symptoms, and additional depression-related dysphoria symptoms, continued to result in a single underlying PTSD-MDD symptom dimension. Results raise further questions about PTSD's distinctiveness from MDD, and the causes of their comorbidity.

Anxiety disorders diagnosis: some history and controversies

Treatment of and research on anxiety disorders depends on the adequate conceptualization and measurement of these conditions. We review the history of the nosology of anxiety disorders and note that divisions of "neurosis" have inadvertently taken attention away from what is shared among conditions now classified separately. We note the changes in the definition of agoraphobia over time and the striking differences between DSM-IV and ICD-10 definitions. We mention ongoing controversies in the diagnoses of posttraumatic stress disorder, acute stress disorder, and generalized anxiety disorder. Finally, we discuss controversies surrounding the proper placement of obsessive-compulsive disorder and putatively related conditions in future diagnostic classifications. We hope that reviewing controversial aspects of diagnosis is useful to clinicians and researchers interested in the neurobiology of anxiety disorders.

Adjustment disorders: the state of the art

Adjustment disorders are common, yet under-researched mental disorders. The present classifications fail to provide specific diagnostic criteria and relegate them to sub-syndromal status. They also fail to provide guidance on distinguishing them from normal adaptive reactions to stress or from recognized mental disorders such as depressive episode or post-traumatic stress disorder. These gaps run the risk of pathologizing normal emotional reactions to stressful events on the one hand and on the other of overdiagnosing depressive disorder with the consequent unnecessary prescription of antidepressant treatments. Few of the structured interview schedules used in epidemiological studies incorporate adjustment disorders. They are generally regarded as mild, notwithstanding their prominence as a diagnosis in those dying by suicide and their poor prognosis when diagnosed in adolescents. There are very few intervention studies.

A Good War? Exploring British veterans' moral evaluation of deployment

Historically, war trauma research has concentrated on the relationship between level of exposure and development of post-traumatic symptoms. More recently, it has been recognized that intra- and interpersonal differences can mediate how service personnel are affected by their experiences. This paper is a qualitative study exploring moral evaluations of 30 British male veterans towards their deployment in conflicts from WWII to the most recent Iraq War (2003-2009). Retrospective thematic analysis is used to explore moral evaluation and societal support. Four categories emerged based on veterans' moral evaluation of deployment: justifiable, implicitly justifiable, unclear, and unjustifiable. Analysis revealed broad differences between these groups. Veterans able to justify their experiences reported more positive aspects of both deployment and societal support than those unable to justify their deployment. These findings make clear the importance of future research exploring the interactions between civilians and service personnel, and the impact this has on mental health.