Clinical features
The criteria for diagnosis of PTSD differ slightly depending upon which disease classification is used. See below for details of ICD 10 (International Classification of Diseases) criteria for PTSD and the DSM IV (The American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders 4th edition) criteria for PTSD.
The symptoms fall into a variable combination of the following three groups, which should have been present for at least a month (not all symptoms are present in every case)-:
1. Intrusions
Repetitive re-experiencing, in one or more ways, of the traumatic event e.g. brief intense, intrusive imagery of the incident (flashbacks) occurring in clear consciousness (and thus to be distinguished from nightmares) outside the person's control; recurrent, distressing dreams of the event; psychological distress or anxiety, which often increases when patient re-experiences or is reminded of the event.
2. Avoidance
Avoidance of stimuli associated with the event, or which arouse recollection of the event; inability or difficulty to recall the incident at will; a feeling of detachment; inability to feel emotion (numbing) and diminished interest in activities.
3. Hyperarousal
Increased arousal and behavioural abnormalities, e.g. persistent anxiety, irritability, hypervigilance, insomnia and poor concentration.
In addition there may be maladaptive coping mechanisms such as aggressive or histrionic behaviour; excess use of alcohol or drugs and deliberate self harm.
Flashbacks do not only occur in PTSD (e.g. they can occur in substance abuse, notably LSD).
Depressive symptoms are common and guilt is often experienced by the survivors of a disaster. After some traumatic events survivors often reconsider their beliefs about the meaning and purpose of life.
PTSD has to be differentiated from the following:
Stress induced exacerbations of an existing anxiety disorder.
Other psychiatric disorders, for example anxiety disorders, obsessive compulsive disorder, depressive disorders, schizophrenia, personality disorders and alcohol/drug abuse.
Acute stress disorder-:
This is an immediate and brief response to sudden intense stressors in a person who does not have another psychiatric disorder at the time. The symptoms may be similar to those of PTSD but acute stress disorder does not last for more than 4 weeks.
Adjustment disorder-:
This is an understandable reaction to stressful events, for example separation, divorce, a change of employment, the birth of a disabled child or bereavement. The symptoms are different from those of PTSD and include anxiety, depression, outbursts of dramatic or aggressive behaviour, deliberate self harm or the abuse of alcohol or drugs. Adjustment disorder may last for several months but usually resolves when the stressor resolves.
PTSD is associated with high rates of alcohol and substance abuse, depressive disorder, other anxiety disorders and personality disorders, especially antisocial personality disorder. Click on the above links to access the relevant guidance.
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Amended June 2008
