“As an undergraduate student in psychology, I was taught that multiple personalities were a very rare and bizarre disorder. That is all that I was taught on ... It soon became apparent that what I had been taught was simply not true. Not only was I meeting people with multiplicity; these individuals entering my life were normal human beings with much to offer. They were simply people who had endured more than their share of pain in this life and were struggling to make sense of it.”
― Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook
Posttraumatic Stress Disorder
Image: "Neglected teen girl sits in her abandoned room with her doll" by Emerson Quinn
The DSM-5 gives the following criteria for a diagnosis of posttraumatic stress disorder (PTSD):
Note: The following criteria apply to adults, adolescents, and children older than 6 years.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains: police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” ‘The world is completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g.,
medication, alcohol) or another medical condition.
Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate) (American Psychiatric Association, 2013)1.
Criterion A specifies that PTSD forms only as a direct response to trauma. This trauma must involve exposure to actual or threatened death, serious injury, or bodily harm. This trauma can be experienced, personally witnessed, known to have occurred to a close family member or friend (though this must involve more than a peaceful death or death from illness), or repeated or extreme exposure to details of trauma through one's line of work. Media exposure does not count as a trauma that can result in PTSD. Events that do count include physical attack, robbery, mugging, childhood abuse, rape, noncontact sexual abuse, human trafficking, being kidnapped, being held hostage, a terrorist attack, torture, being a prisoner of war, natural or human-made disasters, severe motor vehicle accidents, or, for children, developmentally inappropriate sexual experiences. Life threatening medical illnesses on their own may not be traumatic, but medically traumatic experiences can include sudden and catastrophic events such as waking up during a surgery or experiencing anaphylactic shock. Seeing one's child experience a life-threatening medical catastrophe could also cause the disorder.
Criterion B lists intrusion symptoms that can qualify one for a diagnosis of PTSD. These intrusions must relate to the traumatic event and can include: being preoccupied with or being unable to block thoughts related to the trauma; having nightmares related to the trauma; having dissociative flashbacks that range from experiencing sensations, thoughts, or feelings as if one was still being traumatized up to actually reliving the trauma; becoming intensely distressed or being unable to calm down after exposure to reminders of the trauma; experiencing physiological symptoms (a racing heartbeat, difficulty breathing, stomach pains, etc) after exposure to reminders of the trauma. In children, repetitive play that involves traumatic aspects, reenactment of trauma through play, or generally frightening dreams qualify.
Criterion C states that avoidance of memories, thoughts, or feelings about or closely related to the trauma or of people, places, conversations, activities, objects, or situations that are associated with or remind one of the trauma must occur for a diagnosis of PTSD.
Criterion D lists negative alterations in cognition in mood that can follow or worsen after a traumatic event and so qualify one for a diagnosis of PTSD. These can involve: dissociative amnesia regarding the trauma; unreasonable or uncontrollable negative beliefs about oneself, others, or the world; wrongly blaming oneself or others for the trauma; persistent negative emotions such as fear, horror, anger, guilt, or shame; having less interest in previously enjoyed activities; feeling detached or different from others; being unable to feel positive emotions such as happiness, satisfaction, or love.
Criterion E lists symptoms related to increased reactivity and arousal of the nervous system that can follow or worsen after a traumatic event and so qualify one for a diagnosis of PTSD. These can include: unproportionate or unreasonable irritated or angry outbursts that may involve verbal or physical aggression; engaging in reckless or self-destructive behavior; always being on the lookout for harm or danger; having an exaggerated startle response or reacting to sudden and unexpected stimuli with "jumpiness"; being unable to concentrate and having problems remembering daily events or keeping track of conversations; having trouble falling asleep, staying asleep, or sleeping well.
Criterion F specifies that the symptoms must last longer than one month (otherwise, the diagnosis is acute traumatic stress disorder).
Criterion G specifies that the symptoms must cause significant distress or impairment.
Criterion H specifies that the symptoms are not due to a substance or medical condition.
A dissociative subtype of PTSD involves depersonalization or derealization not associated with a substance or medical condition.
PTSD can have delayed expression if some qualifying symptoms arise six or more months after the trauma.
Other possible symptoms of PTSD include developmental regression (reverting to having the skills of an individual of a younger age), auditory pseudo-hallucinations (hearing one's thoughts as being spoken by one or more voices; may be due to structural dissociation), paranoia, or difficulties with emotional regulation and sustaining interpersonal relationships. Reckless behavior can accidently injure the individual or others. In adolescents, PTSD is associated with reluctance to pursue developmentally appropriate opportunities (such as dating or driving), judging oneself as cowardly, being afraid of never being able to fit in with peers, and loss of aspirations for the future. In older individuals, PTSD is associated with crying spells, negative health perceptions, primary care utilization, and suicidal ideation. PTSD from childhood abuse is especially correlated with suicidal ideation, and those with suicidal ideation and PTSD may be more likely to attempt than are those without PTSD. PTSD is associated with disability in impairment in many areas and has high economic costs (American Psychiatric Association, 2013)1.
In the US, lifetime risk using DSM-IV criteria was 8.7%, and 12-month prevalence is 3.5%. Prevalence rates of 0.5-1.0% are more common in other countries. PTSD is more common among veterans and those whose jobs frequently expose them to traumatic situations (firefighters, police, emergency responders). However, the highest rates are found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide. Older adults are less likely to develop PTSD following trauma. Higher rates of PTSD are present among US Latino, African American, and American Indian populations and lower rates among Asian Americans even after adjustment for traumatic exposure demographic variables. PTSD can occur at any age, and though symptoms usually begin within the first three months after the trauma, symptoms can be delayed by years. The duration can stretch from within three months to over half of a century (American Psychiatric Association, 2013)1.
Risk factors include emotional problems and prior mental health disorders, being of a lower socioeconomic class, having less access to education or having a lower intelligence, having been exposed to previous trauma, childhood adversity, belonging to a culture that emphasizes self-blame, being of an ethnic or racial minority, having little social support, being female, having been exposed to the trauma at a younger age, the severity and perceived life threat of the trauma, interpersonal violence, violence by a caregiver, being forced to be a perpetrator (such as military personnel having to kill the enemy), dissociation, inappropriate coping strategies, and repeated exposures to reminders of the trauma (American Psychiatric Association, 2013)1.
Females are more likely to develop PTSD and to have PTSD for longer lengths of time. These differences are negligible within populations of those exposed to trauma, particularly interpersonal violence, suggesting that this accounts for the difference in rates of diagnosis (American Psychiatric Association, 2013)1.
Differential diagnoses include adjustment disorders, anxiety disorders, obsessive compulsive disorder, major depressive disorder, personality disorders, dissociative disorders, conversion disorders, psychotic disorders, and traumatic brain injury. However, it should be kept in mind that those with PTSD are 80% more likely than those without PTSD to meet the diagnostic criteria for at least one other mental disorder (such as depressive, bipolar, or anxiety disorders). Comorbid substance abuse disorders or conduct disorder are more common in males, and oppositional defiant disorder and separation anxiety disorder are more common in children. As well, PTSD often occurs with traumatic brain injury in veterans (American Psychiatric Association, 2013)1.
1 American Psychiatric Association. (2013). Trauma- and Stressor-Related Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). http://dx.doi.org/10.1176/appi.books.9780890425596.dsm07