The introduction of posttraumatic stress disorder (PTSD) into psychiatric nosology has brought about a great deal of insight as well as controversy. Have complex clinical manifestations of PTSD created a need for further clarification of the disorder?
The introduction of posttraumatic stress disorder (PTSD) into psychiatric nosology has brought new insights as well as controversy. It has deepened our understanding of how severe traumas that exceed ordinary coping mechanisms affect the human mind; however, complex clinical manifestations of PTSD have created serious confusion in diagnostic and therapeutic practice.
The majority of psychiatric disorders are diagnosed according to symptoms, signs and traits. Posttraumatic stress disorder is unique in that etiology is a primary diagnostic factor; and, in patients with PTSD, etiology and symptoms are not always in harmony. Both DSM-IV and ICD-10 are often impractical in regard to PTSD because many patients exhibit multiple symptoms concomitantly or at different times. In addition, the current categorization of PTSD under the umbrella of anxiety disorders is inadequate and misleading, as the PTSD symptom complex overlaps with psychoses, affective disorders, dissociative disorders, personality disorders and numerous other psychiatric disorders.
According to trauma theory, which seems to have been tailor-made for PTSD, acutely painful memories are often buried deeply in the thickets of repression. The strain of trauma invariably seeps through to the surface of consciousness, however, and various seemingly unrelated emotions and behaviors begin to emerge. Trauma may lead to not only PTSD, in the narrowest sense, but to the development of other serious psychiatric disorders.
Therefore, it is impossible to discuss any reclassification of PTSD without discussing trauma, dissociation and coping mechanisms. The nature of the trauma, pre-existing psychiatric disorders, available support systems, age at the time of the traumatic experience and other factors predispose patients to a variety of psychiatric responses (Gladstone et al., 1999; Jung, 2001; Silva et al., 2000).
For instance, it has been my clinical experience that violent, repeated sexual trauma in early life almost invariably leads to severe psychotic features, while nonviolent sexual abuse later in life tends to bring about less severe disorders in psychosexual development, including personality disorders.
In the complex interaction between the nature and severity of trauma and the varying vulnerability of the victim, a spectrum of psychiatric symptoms emerges: acute psychotic, panic, dissociative, depressive features on one extreme, symptoms of narcissistic personality and antisocial personality on the other, and symptoms of multiple personality and borderline personality in between. These multiple clinical features support the idea that PTSD would more accurately be an acronym for posttraumatic spectrum disorder, as opposed to posttraumatic stress disorder.
Given the mounting evidence for the spectrum concept of posttraumatic disorders, a radical revision of PTSD classification is warranted. To address the shortcomings of the current classification system, we must first identify the traumas that precipitate the marked aberration of biopsychosocial functions that are characteristic of PTSD. Second, the vastly different clinical features need to be categorized into a limited number of psychiatric disorders in order to be useful.
The rationale for classifying the different posttraumatic symptoms, signs and traits into one major Axis I diagnostic category has four theoretical cornerstones.
1. Because the psychiatric symptoms that follow trauma frequently coexist and intermingle with one another, it is sensible to make diagnostic distinctions based on one or more predominant clinical manifestations (Jung, 2001; Kolb, 1989).
2. The method of classification of the PTSD spectrum should be based on the current classification system. Psychoses, affective disorders, dissociative disorders, personality disorders, along with other specific psychiatric disorders, should be adopted to represent the complex emotional, cognitive and behavioral manifestations of posttraumatic spectrum disorders.
3. These disorders must be distinguished diagnostically and therapeutically from other psychiatric disorders with similar symptoms, signs and traits unrelated to trauma.
4. Theoretical support must be developed to integrate the etiology, psychopathogenesis, psychopathology and psychotherapeutic relevance of the seemingly unrelated complex of psychiatric disorders.
The classification posttraumatic stress disorder should be replaced with posttraumatic spectrum disorder, using the following subclassifications:
Psychotic Features. Psychotic manifestations following trauma include delusional thinking, various hallucinations, disorganized thought process, confusion, poor reality contact and other formal thought disorders (Beck and van der Kolk, 1987; Kolb, 1989). These characteristics differ from the psychosis indicative of other disorders, however. Posttraumatic psychotic features are often reactive in nature and frequently reflect aspects of the original trauma experience. Conversely, the transient psychotic symptoms in borderline personality disorder may escalate into a full-blown psychosis when stress mounts.
Depressive features. Depression is a common posttraumatic response (Helzer et al., 1987; Levitan et al., 1998). Helplessness, hopelessness, poor concentration, lack of interest, insomnia, suicidal feeling, and other symptoms and vegetative signs are common in both types of depression. However, posttraumatic depression is directed more externally (e.g., war, society, other people) and less internally (e.g., self blame). Anger toward others and feeling that "somebody has to pay" is one of the common features of posttraumatic depression. Although many patients experience substantial mood changes -- such as mood swings or mild elation -- in the aftermath of trauma, these are often not clinically significant enough to justify classification as a distinct affective disorder.
Anxiety and panic features. Anxiety and panic episodes are other symptoms commonly associated with trauma (Helzer et al., 1987; Winfield et al., 1990). Many individuals suffer from panic reactions at the time of initial trauma. Subsequent panic episodes are a reflection of the original trauma and may be responsible for the psychopathogenesis of other posttraumatic symptoms, such as terror, paralyzing fear, palpitation, breathlessness and dizziness, as well as a feeling of impending doom, that are common to posttraumatic patients. In this aspect, panic is a core symptom of the posttraumatic spectrum, setting in motion a vicious circle of retraumatization (Jung, 2001; Shea et al., 2000; Silva et al., 2000).
Dissociative features. Dissociative disorders are primarily associated with trauma (Blake-White and Kline, 1985; Goodwin et al., 1979), and almost 80% of patients with multiple personality disorder have a sexual abuse history (Ross et al., 1989). Since dissociation seems to be one of the core defense mechanisms against the severe pain of sexual or nonsexual traumas, it is imperative for future research to determine whether dissociative disorders are exclusively related to trauma. I believe dissociative disorders are more appropriately classified as a subgroup of the posttraumatic spectrum than as a unique Axis I category. It is important to note that dissociation does not occur in generalized anxiety disorder or obsessive-compulsive disorder (Blake-White and Kline, 1985). In multiple personality disorder, the patient's repression is grossly inadequate to deal with the trauma. The numbing, detachment and denial cannot be sustained. The thinly disguised, barely repressed trauma explodes through the inadequate adoption of a change in personality.
Borderline features. The correlation between borderline personality disorder and sexual trauma has been well-documented (Barnard and Hirsch, 1985; Gelinas, 1983; Goodwin et al., 1990). Other personality disorders as well have been attributed to trauma (Goodwin et al., 1990; Shea et al., 2000; Zanarini et al., 1998). In borderline personality disorder, the repression is more successful and the coping character becomes more sustainable.
Other clinical features. Other psychiatric manifestations, including self-mutilation, pyromania, substance abuse, and sexual dysfunction and/or sexual identity disorders, are often seen among the victims of sexual trauma and require special diagnostic and therapeutic attention (Liskow et al., 1986; Winfield et al., 1990; Wonderlich et al., 2000).
The original concept of PTSD was born out of battle trauma or other physical trauma, and these manifestations closely match the current diagnostic criteria of DSM-IV. Psychiatric symptoms following sexual trauma are increasingly appearing, however, and the diagnostic significance of this shift needs to be investigated (Kendler et al., 2000). Battle trauma frequently occurs during early adulthood when the victim is more mature and presumably better equipped to handle the trauma inflicted by an identified offender. Sexual abuse more often occurs during the vulnerable period of childhood, and the perpetrator is often a close relative. Sexual trauma is therefore unique in that it affects the child's basic trust and subsequent psychosexual development.
The term posttraumatic stress disorder was introduced in an attempt to classify psychiatric sequelae that arise from the experience of severe trauma. However, the magnitude and complexity of the psychiatric disorders caused by trauma are such that current classification systems (including DSM-III, DSM-III-R, DSM-IV and ICD-10) are grossly inadequate to be of use scientifically. My hope is that the reorganization suggested here will lead to further research, more accurate diagnosis and more appropriate treatment for our traumatized patients.