34.6: Posttraumatic Stress Disorder

With stories of war, natural disasters, and physical and sexual assault dominating the news, it is clear that trauma is a reality for many people. Many individual traumas that occur every day never even make the headlines, such as a car accident, domestic abuse, or the death of a loved one. Yet, while many people face traumatic events, not everyone who faces a trauma develops a disorder. Some, with the help of family and friends, are able to recover and continue on with their lives (Friedman, 2009). For some, however, the months and years following a trauma are filled with intrusive reminders of the event, a sense of intense fear that another traumatic event might occur, or a sense of isolation and emotional numbing. They may engage in a host of behaviors intended to protect themselves from being vulnerable or unsafe, such as constantly scanning their surroundings to look for signs of potential danger, never sitting with their back to the door, or never allowing themselves to be anywhere alone. This lasting reaction to trauma is what characterizes posttraumatic stress disorder (PTSD).

A diagnosis of PTSD begins with the traumatic event itself. An individual must have been exposed to an event that involves actual or threatened death, serious injury, or sexual violence. To receive a diagnosis of PTSD, exposure to the event must include either directly experiencing the event, witness- ing the event happening to someone else, learning that the event occurred to a close relative or friend, or having repeated or extreme exposure to details of the event (such as in the case of first responders). The person subsequently re-experiences the event through both intrusive memories and nightmares. Some memories may come back so vividly that the person feels like they are experiencing the event all over again, what is known as having a flashback. The individual may avoid anything that reminds them of the trauma, including conversations, places, or even specific types of people. They may feel emotionally numb or restricted in their ability to feel, which may interfere in their interpersonal relationships. The person may not be able to remember certain aspects of what happened during the event. They may feel a sense of a foreshortened future, that they will never marry, have a family, or live a long, full life. They may be jumpy or easily startled, hypervigilant to their surroundings, and quick to anger. The prevalence of PTSD among the population as a whole is relatively low, with 6.8% having experienced PTSD at some point in their life (Kessler, Berglund, et al., 2005) (see TABLE 34.2.1). Combat and sexual assault are the most common precipitating traumas (Kessler et al., 1995). Whereas PTSD was previously categorized as an Anxiety Disorder, in the most recent version of the DSM (DSM-5) (APA, 2013) it has been reclassified under the more specific category of Trauma- and Stressor-Related Disorders.

A person with PTSD is particularly sensitive to both internal and external cues that serve as reminders of their traumatic experience. For example, as we saw in PD, the physical sensations of arousal present during the initial trauma can become threatening in and of themselves, becoming a powerful reminder of the event. Someone might avoid watching intense or emotional movies in order to prevent the experience of emotional arousal. Avoidance of conversations, reminders, or even of the experience of emotion itself may also be an attempt to avoid triggering internal cues. External stimuli that were present during the trauma can also become strong triggers. For example, if a woman is raped by a man wearing a red t-shirt, she may develop a strong alarm reaction to the sight of red shirts, or perhaps even more indiscriminately to anything with a similar color red. A combat veteran who experienced a strong smell of gasoline during a road- side bomb attack may have an intense alarm reaction when pumping gas back at home. Individuals with a psychological vulnerability toward viewing the world as uncontrollable and unpredictable may particularly struggle with the possibility of additional future, unpredictable traumatic events, fueling their need for hypervigilance and avoidance and perpetuating the symptoms of PTSD.