Historical overview
Pathological reactions to traumatic experiences have been recognized throughout the centuries by such varied names as shell shock, battle fatigue, irritable heart of soldiers, accident neurosis, traumatic neurosis and post-rape syndrome (Turnbull, 1998; van der Kolk, 2007). These syndromes embodied many, if not all, current PTSD symptoms (van der Kolk, 2007).
PTSD was first recognized as a psychiatric disorder in the third edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Health Disorders (DSM-III) (American Psychiatric Association [APA], 1980). Several authors suggested that PTSD is the result of political climate and anti-war psychiatrists’
campaigns in a post-Vietnam America, caused to some extent by observations of severe distress being manifested by Vietnam War veterans (Bracken, 2001; Summerfield, 1999). Research interest in PTSD has shown almost 10-fold growth since its official definition in the DSM-III in 1980 (Blashfield & Intoccia, 2000). Although initially PTSD was framed to apply only to extremely stressful situations that one would not expect to experience every day, it has increasingly become associated with “low impact” traumas that are fairly common occurrence (e.g. marital disruption, failed adoption plans, mugging, accidents, miscarriage) (Summerfield, 1999). According to some authors, in Western societies pathological response (in the form of PTSD) arising in traumatic circumstances has become the norm (Pupavac, 2001) and the concept of
“trauma” has almost become synonymous with PTSD in both popular and scientific
thought (Pedersen, 2002). Andreasen (1995) commented that it was rare to find a psychiatric disorder that anyone liked to have but posttraumatic stress disorder was one of them. With aetiology placed externally PTSD has avoided the stigma attached to other mental disorders as there can be no reason for blaming a sufferer (Rechtman, 2004).
Classification and current definition of PTSD
Since it was first introduced in DSM-III in 1980, the classification of PTSD has been modified in subsequent editions, the DSM-III-R (American Psychiatric Association [APA], 1987), DSM-IV (American Psychiatric Association [APA], 1994) and its text revision DSM-IV-TR (American Psychiatric Association [APA], 2000).
According to the DSM-IV (American Psychiatric Association [APA], 1994) definition, the diagnosis of PTSD requires: “exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death or injury experienced by a family member or other close associate (Criterion A1). The person’s response to the event must involve intense fear, helplessness, or horror (Criterion A2).” (American Psychiatric Association [APA], 1994, p. 424). The three clusters of symptoms resulting from the exposure to the extreme trauma include: repeated re-experience of the trauma (Criterion B); persistent avoidance of activities and stimuli reminiscent of the trauma and emotional numbing (Criterion C); and persistent symptoms of heightened arousal (Criterion D). The full symptom picture must be present for at least 1 month (Criterion E) and the disturbance
must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F) (American Psychiatric Association [APA], 1994). PTSD is classified as an anxiety disorder.
The DSM-IV also lists a set of associated features, such as guilt and shame feelings, feelings of ineffectiveness, despair, loss of previously sustained beliefs, social withdrawal, hostility, and change from the individual’s previous personality characteristics. These features are most commonly found in the aftermath of prolonged, repeated manmade trauma.
In comparison to the DSM-IV, PTSD was introduced into the psychiatric nomenclature of the International Classification of Diseases (ICD) relatively late, in 1992 (World Health Organization [WHO], 1992). In ICD-10, PTSD is classified among the reactions to severe stress and adjustment disorders that are primarily caused by stressful events.
The underlying concept of PTSD is similar in DSM-IV and ICD-10 i.e., both diagnostic systems agree on the core symptoms of PTSD - re-experiencing, avoidance, emotional numbing, and hyperarousal. However, the key difference between the two systems concerning PTSD diagnosis regards the definition of the traumatic event itself. While DSM-IV places greater emphasis on the subjective experience of the event (Criteria A2 and F), in ICD-10 the emphasis is on the event itself, i.e. the assumption is that certain events, such as being in a war zone, would automatically satisfy the criteria. These differences between DSM-IV and ICD-10 criteria have usually led to a prevalence of PTSD twice as high when ICD-10 criteria are applied as compared to DSM-IV (Peters, Slade, & Andrews, 1999; Rosner & Powell, 2009).
Accordingly, an Australian epidemiological study (Peters, et al., 1999) found the 12-month prevalence of PTSD based on ICD-10 was 7%, compared to 3% based on DSM-IV. Discrepancies between the systems were mainly accounted for by the additional criterion in DSM-IV requiring significant subjective distress or impairment. Similar discrepancy between the two systems was observed by Rosner and Powell (2009) who looked at a comparison of PTSD using data on war exposed civilians in Bosnia and Herzegovina. Prevalence of PTSD was 52% when based on ICD-10 criteria and 30%
when based on DSM-IV criteria. The authors noted that the event criterion contributed most to the difference in prevalence. They concluded that DSM-IV seems more able to portray “the current theoretical constructs of PTSD”.
For the purposes of this thesis, DSM-IV criteria have been therefore adopted.
Traumatic events and situations associated with PTSD
As PTSD is fundamentally related to a traumatic event (criterion A1 in DSM-IV), the question of what constitutes a traumatic event is of obvious importance. The DSM-IV defines a traumatic event as one that involves direct personal experience of an event that involves death, injury or a threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (American Psychiatric Association [APA], 1994). Potentially traumatic events that may lead to pathological reactions in people are various including e.g. torture, rape, sexual abuse, knifing or axing, man-made or natural disaster, murder of a family member or a friend, combat situations, forced evacuation under dangerous conditions, shelling or grenade attacks,
imprisonment, being lost or kidnapped, serious accidents, death of a loved one, serious illness without access to medical care; and witnessing experiences like murder, torture, rape, knifing or axing.
Various epidemiological studies have demonstrated a high percent of exposure to single or multiple potentially traumatic events in the general population, with lifetime rates of exposure ranging from 60% to 90% (Breslau, Kessler, Chilcoat, Schultz, Davis, &
Andreski, 1998; Darves-Bornoz, et al., 2008; Frans, Rimmo, Aberg, & Fredrikson, 2005; Kessler, et al., 1995; Stein, Walker, Hazen, & Forde, 1997). Presumably, the variability of this exposure depends on the type of traumatic event and socio-demographic characteristics of the population observed. For example, the evidence suggests that men in comparison to women tend to experience higher rates of traumatic events (Breslau, et al., 1998; Kessler, et al., 1995; Stein, et al., 1997). However, certain types of traumatic experiences are more common amongst women (rape, sexual molestation, childhood physical abuse or parental neglect) and certain other types are significantly more common amongst men (non-sexual physical assault, combat experience, being threatened with a weapon, held captive or kidnapped) (Breslau, et al., 1998; Kessler, et al., 1995; Stein, et al., 1997).
Beyond the necessity of the traumatic quality attached to events in predicting a posttraumatic response, research has shown that differentiation among various types of traumatic events, as far as their nature, duration, intentionality and the severity, is relevant to the prediction of PTSD. For example, trauma type was found to independently explain 16.7% of variance of risk of PTSD, while trauma frequency and intensity (irrespective of trauma type) accounted for 23.3% of the variance, indicating the importance of trauma type, frequency and perceived stress in determining PTSD (Frans, et al., 2005). Epidemiological studies report higher rates of PTSD among those
who are exposed to interpersonal violence in comparison to those affected by natural disaster or accidents (Breslau, et al., 1998; Frans, et al., 2005; Kessler, et al., 1995). For example, Kessler, et al. (1995) report that 65% of men and 46% of women who had been raped met PTSD criteria; whereas only 3.7% of men and 5.4% of women exposed to natural disaster with fire met PTSD criteria.
Although many people experience a traumatic event (criterion A1) during their lifetime, not all of them perceive such an event as traumatic or life threatening. To take into account inter-individual variability in response to potentially traumatic events, the authors of DSM-IV included the person’s subjective experience of the event as an additional criterion (Criterion A2), requiring that the person’s response to the event must involve intense fear, helplessness, or horror in adults and disorganized or agitated behaviour in children (American Psychiatric Association [APA], 1994). Studies focusing on concordance between the objective (Criterion A1) and subjective (Criterion A2) components of trauma, and variation in this concordance across types of potentially traumatic events, have reported varying results. Some types of trauma events, such as non-combat interpersonal violence, are generally found to be more likely to meet criterion A2, in comparison to natural disasters and accident. For example, in their meta-analysis, Ozer, Best, Lipsey, and Weiss (2003) found that perceived life threat during trauma was associated with higher levels of PTSD symptoms or higher rates of current PTSD. Perceived life threat during the traumatic event was more strongly associated with PTSD when more time elapsed between the traumatic event and the assessment of PTSD; or when the traumatic experience was non-combat interpersonal violence than when the traumatic experience was an accident.
Previous research indicates that experiencing a greater number of traumas results in a greater vulnerability to pathological reactions, such as PTSD (e.g. Mollica, et al., 1998;
Neuner, Schauer, Karunakara, Klaschik, Robert, & Elbert, 2004; Rasmussen, et al., 2007; Steel, et al., 2002). This dose-effect relationship of trauma to PTSD is essential to the stressor criterion for PTSD, confirming the position that the pathological reactions originate from the trauma event.
Epidemiology of PTSD in Western societies
In the United States, epidemiological studies among general populations have reported lifetime prevalence rates of PTSD between 6.8% and 9.2%, with women being almost two-fold more at risk for developing PTSD than men (Breslau, et al., 1998; Kessler, et al., 1995; Ozer, et al., 2003). In Europe, a large epidemiological study conducted in a random sample of six European countries, reported a considerably lower lifetime PTSD prevalence rate of 1.9% (0.9% for men and 2.9% for women) (ESEMeD/MHEDEA 2000 Investigators, 2004). Similar rates were observed among a young German cohort with PTSD lifetime prevalence of 1.3% and a 12-month prevalence of 0.7% (Perkonigg, Kessler, Storz, & Wittchen, 2000). It has been suggested that this difference between the two continents might be due to lower general level of violence and fewer people participating in recent wars (Perkonigg, et al., 2000).
Although studies on populations at risk indicate substantially variable prevalence rates of PTSD, these rates tend to be higher than those reported for general population.
Epidemiological studies of Vietnam veterans reported lifetime prevalence ranging between 10% and 16.8% and current PTSD rates between 2.2% and 30.9%
(Richardson, Frueh, & Acierno, 2010). The prevalence of PTSD in personnel deployed to the 2003 Iraq War varied between 1.4% and 31% (Sundin, Fear, Iversen, Rona, &
Wessely, 2010). Studies of the course of posttraumatic stress reactions among war prisoners (POW) indicate that PTSD is prevalent and persistent over many years. For example, Engdahl, Dikel, Eberly, and Blank (1997) reported a lifetime PTSD rate of 53% and a current PTSD rate of 29%, even 50 years after the trauma. Bramsen and Van der Ploeg (1999) reported a current PTSD rate of 4.6% among a community sample of WWII survivors, with a statistically significant relationship between exposure to traumatic war events and current PTSD.
1.4.2. Critique of the construct of PTSD and its application to refugee