Posttraumatic Stress Disorder in All Its Manifestations

June 1, 2007

In 1980 DSM-III created a new diagnostic entity-posttraumatic stress disorder (PTSD). Although this condition had been described for centuries, it was always within the context of a particular stressor, most often war. The term shell shock was applied to World War I soldiers who seemed to have been struck senseless in the heat of battle. The horrors of World War II produced not only robust psychiatric morbidity in its combatants but also devastating emotional symptoms in the civilian victims of concentration camps and atomic bombs.

In 1980 DSM-III created a new diagnostic entity-posttraumatic stress disorder (PTSD). Although this condition had been described for centuries, it was always within the context of a particular stressor, most often war. The term shell shock was applied to World War I soldiers who seemed to have been struck senseless in the heat of battle. The horrors of World War II produced not only robust psychiatric morbidity in its combatants but also devastating emotional symptoms in the civilian victims of concentration camps and atomic bombs.

During the past 60 years there has been an endless series of wars, large and small, in Southeast Asia, Central America, Africa, Europe, and elsewhere, each with its own set of traumatized survivors. PTSD has been seen as a multinational, multicultural, and multireligious affliction. In addition, it has become increasingly clear that in people directly exposed to criminal violence, natural disasters, and even mundane motor vehicle accidents, the same constellation of symptoms that constitute DSM-III criteria of reexperiencing, numbing, and arousal can and do develop. With minor modifications, these 3 clusters were preserved in DSM-III-R and DSM-IV and were extended to explicitly include children and adolescents.

With PTSD having been firmly established as a reliably diagnosed and valid mental disorder, there ensued a parade of scientific publications reporting research and offering informed opinions about its epidemiology, neurobiology, and treatment. Indeed, in November 2004, PTSD received its own American Psychiatric Association Practice Guideline, a compendium filled with evidence-based interventions. A current trend of inquiry has employed a strategy of dismantling the unitary concept of PTSD to further examine some of its specific elements. The articles in this Special Report section reflect this approach by focusing on clinically salient and narrower topics.

We begin with an article by Kim Mueser and colleagues that reminds us that patients with severe and persistent mental illness are at higher risk for PTSD, which then becomes a comorbidity necessitating separate but integrated treatment. The article describes the complicating effects of PTSD on schizophrenia and bipolar disorder, which can be misunderstood by patient and clinician alike. Fortunately, there are methods for assessing PTSD in these patients, and both individual and group treatment programs have been shown to be effective. Astute clinicians will be alert to the vulnerability of their severely ill patients, have available evaluation tools to confirm the presence of traumatic symptoms, and provide therapies with the best record of effectiveness for this population.

Even in the absence of another diagnosable mental illness, the natural history of PTSD predicts that perhaps one third of cases will become chronic, thereby inflicting years of distress and disability. As time passes, the disorder becomes increasingly treatment-resistant. Mark Hamner presents data on the therapeutic strategies that may confer hope for patients experiencing the long-term consequences of trauma.

Phebe Tucker and Elizabeth Foote explore an aspect of psychosomatic medicine, the physical manifestations of mental illness. Many psychiatric conditions present with somatic symptoms, and there is a category, somatoform disorders, in which physical symptoms are especially prominent. Although it is formally an anxiety disorder, patients with PTSD frequently complain of somatic symptoms and commonly have comorbid medical illness. These mind-body relationships are challenging and deserving of special care.

Another group in whom traumatic syndromes commonly develop are patients with major medical and surgical illnesses and their caregivers. With psychosomatic medicine having recently been recognized as a psychiatric subspecialty, closer scrutiny will be given to the manifestations of emotional difficulty in medical and surgical patients. Both the illness itself and its treatment can be experienced as overwhelming and, therefore, induce posttraumatic stress symptoms. Eyal Shemesh guides our understanding of these traumatic effects, so that the consulting and treating psychiatrist can be equipped to assist in the comprehensive medical treatment of the patient and family.

It is ironic that older persons are more acutely afraid of violence, when the perpetrators and victims of violence in America are predominantly the young. Whether the event is child abuse in the home or criminal violence in the community, the psychological consequences are profound and enduring throughout the person's life span and into subsequent generations. Dwain Fehon details the cycle of youth violence and reminds us of the opportunities to interrupt or at least minimize its dreadful traumatic effects.

Rape is an extraordinarily harmful attack on the body and mind that is often shrouded in secrecy and shame. Yet, the actual lifetime prevalence of rape for women in the United States may exceed 15%. The prevalence of rape among our patients is even greater. Every psychiatrist should be knowledgeable about the demographics, screening, assessment, and treatment of rape victims. The article by Dean Kilpatrick and colleagues is an essential guide to these issues.

Whatever the specific trauma underlying PTSD, it is a distressing and damaging condition that affects all facets of its victims' lives. Taken together, the articles in this special section will permit us to refresh and refocus our skills in recognizing the consequences of trauma in our patients and helping them recover from it-something that is especially timely in the aftermath of the recent tragedy in Virginia.