1. “What is’t that takes from thee
Thy stomach, pleasure, and thy
golden sleep? ...And thus hath so
bestirr’d thee in thy sleep, That
beads of sweat have stood upon thy
brow...”
- Henry IV, Part 1

6. widely diagnosed
among returning soldiers.

7. “Survivors”
No doubt they'll soon get well; the shock and strain
Have caused their stammering, disconnected talk.
Of course they're "longing to go out again,"--
These boys with old, scared faces, learning to walk,
They'll soon forget their haunted nights; their cowed
Subjection to the ghosts of friends who died,--
Their dreams that drip with murder; and they'll be
proud
Of glorious war that shatter'd all their pride ...
Men who went out to battle, grim and glad;
Children, with eyes that hate you, broken and mad.
Sigfried Sassoon
Oct. 1917.

8. After World War I, "shell shock" was
entirely banned as a diagnosis in the British
Army, and mentions of it were censored,
even in medical journals.
Meanwhile, Alexandra Adler published seminal
papers on the psychological effects of stress on
civilian populations, working with the survivors
of the Cocoanut Grove Fire, the second most
deadly building fire in U.S. History
And then came World War II…

11. “gross stress reaction.”
response to “exceptional physical or mental stress”
-- patient is “otherwise normal”
-- must subside in days to weeks

12. Two Early Conceptual Frameworks for Understanding
How Stress Relates to Mental Illness
The “Biological School” The “Psychological School”
Hans Selye: Father of Stress --rooted in psychodynamic
--stress mediated by the tradition
hypothalmic-pituitary-adrenal --stress caused by repressed
(HPA) axis memories and childhood
--emphasized role of physical traumata
mechanisms
--led to descriptions of
--”traumatic neuroses” defense mechanisms and
consequence of chronic or
role in
severe stress
producing/preventing
disease

13. DSM-II was published in 1968.
With no explanation, GSR was
omitted from this version, and
not replaced with any similar
diagnosis.
And then came the Tet Offensive…

16. After 22 years of absence of a diagnostic category
for stress syndromes, DSM III (1980) adds
Post-Traumatic Stress Disorder to its diagnoses.
But first, three things had to be defined:

17. So severe that it would produce symptoms in almost
anyone
Could be physical, psychological or both
No pre-condition of “normality” necessary
Divided into 3 general categories:
Re-experiencing (including dissociative-like states)
Numbing of responsiveness
Cognitive/Autonomic
Onset could be acute or delayed

18. DSM III-TR (1987) Changes to Diagnostic Criteria:
Stressor no longer defined as “so severe that it would produce
symptoms in almost anyone”
Psychological rather than physical nature of stressor emphasized
Stronger emphasis on dissociative symptoms
Eliminated the acute form of the disorder
DSM IV (1994) Changes to Diagnostic Criteria:
Stressor no longer limited to that experienced by patient (“a threat
to physical integrity of self or others”)
Acute Stress Disorder added as a diagnosis, with emphasis on
dissociative symptoms

21. Criterion A: stressor
The person has been exposed to a traumatic event in which both of the following have been present:
The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a
threat to the physical integrity of oneself or others.
The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated
behavior.
Criterion B: intrusive recollection
The traumatic event is persistently re-experienced in at least one of the following ways:
Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play
may occur in which themes or aspects of the trauma are expressed.
Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content
Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative
flashback episodes, including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur.
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Criterion C: avoidant/numbing
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by
at least three of the following:
Efforts to avoid thoughts, feelings, or conversations associated with the trauma
Efforts to avoid activities, places, or people that arouse recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted range of affect (e.g., unable to have loving feelings)
Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
Criterion D: hyper-arousal
Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hyper-vigilance
Exaggerated startle response
Criterion E: duration
Duration of the disturbance (symptoms in B, C, and D) is more than one month.
Criterion F: functional significance
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if: Acute: if duration of symptoms is less than three months
Chronic: if duration of symptoms is three months or more
Specify if: With or Without delay onset: Onset of symptoms at least six months after the stressor

22. Co-morbidity with Other Disorders
In one large study of individuals with PTSD, 92% met
criteria for another Axis I disorder (Brown et al., 2001);
more specifically, the following disorders were present at
the following rates:
1. Major depression 77%
2. Generalized anxiety disorder 38%
3. Alcohol abuse/dependence 31%

23. Women and PTSD
(some statistics)
Most of the preliminary research on PTSD was done on male
veterans
Half of all women will be exposed to a traumatic event in
their lifetime
Studies suggest that women experience rates of PTSD that are
twice those of men
Sexual assault is a high risk factor for development of PTSD
A recent study found that 78% of women in the military have
been sexually harassed and 6% have been raped

25. Proposed changes to PTSD diagnosis in
DSM-V
--Wording changes to criterion A
--PTSD in preschool children proposed
as subtype instead of separate diagnosis
--Proposed dissociative symptom
subtype
--Change of name of Disorder to “Post-
Traumatic Stress Injury” under
consideration

26. “Combat stress reactions are normal,
predictable responses to abnormal,
psychologically traumatic,
sometimes terrifying and horrible
experiences.”
--U.S. Military
Report
http://www.youtube.com/watch?v=NkWwZ9ZtPEI