The stressor criterion, with its historical antecedents to war-related trauma from the Civil War, World War I and especially World War II, clearly infers that the stressor must come from the environment and that the individual must react with fear (acute activation of the sympathetic nervous system).
Diagnosis of PTSD
To test the applicability of the DSM-IV stressor event, the following clinical vignettes have been prepared. After perusing each brief summary, the reader should judge the adequacy of the stressor to initiate PTSD.
- A patient was involved in an accident with several other vehicles, in which one person was killed and several others seriously injured. The patient miraculously did not suffer any physical injury, and his automobile sustained only minor damage. Could the unscathed victim develop PTSD following the accident?
- An individual picks up the telephone and hears an airline official compassionately state that both of her parents have been killed in an airplane crash. Could this event precipitate PTSD?
- You are at the bedside of your elderly mother who is recovering from a myocardial infarct when suddenly she grabs her chest, gasps, closes her eyes and stops breathing. The cardiac monitor triggers an alarm summoning emergency medical personnel. After a valiant effort, the doctor informs you that your mother has died. Can this experience precipitate PTSD?
- If the accounts of sexual harassment brought by Anita Hill against Justice Clarence Thomas and Paula Jones against President Bill Clinton were true, could these incidents precipitate PTSD?
- A middle-aged woman with a diagnosis of colon cancer submits to surgery, radiation and chemotherapy. Later, in the context of a malpractice suit, she claims that these stressors precipitated PTSD. Do you agree?
To assist in the evaluation of these vignettes, clinicians may find the traumatic principle helpful. Simply stated, the traumatic principle is: "Any environmental stimulus which poses a realistic threat to life or limb, if perceived by one or, more likely, a combination of the five sensory pathways to the brain, if cognitively interpreted as dangerous (a serious threat to life or physical integrity to self or others), and followed by intense stimulation of the sympathetic nervous system, whether it produces physical injury or not, can be regarded as a traumatic event which can precipitate PTSD in a vulnerable individual who is in the zone of danger" (Scrignar, 1996). Of course, genetics and developmental factors play a role in predisposition, and it appears that there is a relationship between vulnerability and the intensity of the stressor. Physical injury is not a prerequisite for PTSD; however, physical injury increases the probability that PTSD will develop. When the parameters of the traumatic principle are fulfilled, DSM-IV criteria for PTSD must be met before a diagnosis is finalized.
Discussion of PTSD Diagnosis
Although not physically injured, the man in the first vignette witnessed, experienced and was confronted with a situation that was potentially life-threatening, and he was quite frightened by the accident. One person was killed and several were seriously injured; therefore, the situation did pose a realistic threat to the patient, and he was in the zone of danger. As the accident developed, he thought he was going to die.
The patient clearly met the requirements of the traumatic principle, and the diagnosis of PTSD was substantiated from the history and mental status examination that revealed flashbacks, nightmares, fears about driving, numbing of responsiveness and anxiety symptoms that were not present before the accident. The judgment of some clinicians could have been swayed by the fact that the man was not physically injured and that his car sustained only minimal damage.
Vignettes two and three do not meet the DSM-IV stressor criteria for PTSD or the standard of the traumatic principle. These individuals were never threatened with injury to themselves, and they were not in the zone of danger. Grief, anguish and depression would be appropriate reactions to one's parents' deaths. The cases involving Anita Hill and Paula Jones may, if true, qualify for sexual harassment but certainly do not fulfill DSM-IV criteria for PTSD or the traumatic principle. The alleged actions of Judge Thomas and President Clinton perhaps can best be described as crude attempts at seduction that were magnified and distorted by political opponents. Only when sexual harassment takes the form of physical abuse or verbal threats of force or violence can PTSD be considered.
The final case, involving the woman with cancer, stirs controversy. The descriptive text (not in the diagnostic criteria) of DSM-IV states that "being diagnosed with a life-threatening illness" can precipitate PTSD. One can take issue with this statement since it is true that illnesses are traumatic in the general sense, and some illnesses end in death. However, the historical origins of PTSD stem from an environmental event-such as war or an accident-which may cause sudden death in an otherwise healthy individual. Physical illness caused by a pathological process within the body (internal event) can cause pain, discomfort or death. However, to equate environmental stressors to a disease process within the body does not seem logical. Also, while surgery, radiation and chemotherapy are no doubt traumatic in the general sense, they are therapeutic measures and should not be equated to stressors that can precipitate PTSD. Those who advocate the inclusion of disease or illness as a precipitant for PTSD stretch the definition of trauma. In the aforementioned case, after the woman's malpractice suit was concluded, she returned to work and her cancer was in remission five years after diagnosis.
In personal injury cases involving PTSD, the expert witness will be exhaustively questioned about the stressor criteria during depositions or at trial. Forensic psychiatrists who misinterpret the stressor criteria and underdiagnose PTSD may suffer embarrassment at the hands of a clever inquisitor. Alternatively, psychiatrists who expand the diagnosis of PTSD to include events that are traumatic in the general sense may stumble on the witness stand as a knowledgeable cross-examiner methodically probes into the life-threatening nature of the stressor event.