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Practice guidelines for the tx of pt with ASD and PTSD

In 1995, a diagnosis criterion of ASD was added to DSM-IV for pt that had PTSD symptoms, but lasted only for 1 month. This was done so that persons who have been exposed to a traumatic event, presenting with early symptoms and those at risk for developing PTSD, could be identified and treated. (American Psychiatric Association. 2004:3)

Some pt with ASD does not develop PTSD and some patients with PTSD didn’t have ASD. (American Psychiatric Association. 2004:3)

Not everyone that is exposed to traumatic events will develop ASD or PTSD. (American Psychiatric Association. 2004:3)

Lifetime prevalence of PTSD higher in woman (American Psychiatric Association. 2004:3)

Definition

“ASD and PTSD are psychiatric disorders consisting of physiological and psychological responses, resulting from exposure to an event or events involving death, serious injury, or a threat to physical integrity. “(American Psychiatric Association. 2004:7)

What is the DSM?

All mental disorders are classified in The Diagnostic and Statistical Manual of Mental Disorders (DSM). There have been five revisions since it was first published in 1952 by the American Psychiatric Association. Over the years, more mental disorders have been added as well as removed from the DSM. (Peele: 2008). Most notably was the removal of homosexuality as a mental disorder with the seventh printing of the DSM-II, in 1974. (Spitzer R.L. 1981:210).

The last major revision was the fourth edition (“DSM-IV”); published in 1994, although a “text revision” (DSM-IV-TR) was produced in 2000. (Peele: 2008) The fifth edition (“DSM-5”) is currently in consultation, planning and preparation, due for publication in May 2013. (DSM-5 Publication Date Moved to May 2013: 2009)

PTSD is listed under Anxiety disorders in the DSM.

Assessment / Diagnosis (DSM-IV)

Initial assessment may occur immediately after event by means of triage before symptoms manifest.

The presence of dissociative symptoms might prevent pt from recalling a feeling of fear, helplessness, or horror, and clinical judgement might be needed to determine if criterion A has been satisfied.

Assessment for symptoms in each of the three symptom groups: re-experiencing, avoidance/numbing and hyperarousal.

In addition, for ASD, the pt has to show dissociative symptoms either during or immediately after the traumatic event. In PTSD, dissociative symptoms are not needed for a dx, but are often observed. (American Psychiatric Association. 2004:23)

Except for the duration of symptoms, the presence of dissociative symptoms is the major distinguishing feature between ASD and PTSD.

The DSM-IV-TR lists additional signs and symptoms associated with PTSD. These include “shame, despair, somatic complaints, hopelessness, social withdrawal, survivor guilt, anger, impulsive and self-destructing behaviour, difficulties in interpersonal relationships, changed beliefs and changed personality.” (American Psychiatric Association. 2004:25)

By definition, “ASD occurs within 4 weeks of the trauma and lasts for a minimum of 2 days. Consequently, it can be diagnosed within 2 days after the trauma exposure continuing to 4 weeks after the traumatic event. If symptoms are present 1 month after the trauma exposure, PTSD is diagnosed.” (American Psychiatric Association. 2004:8)

Difference between ASD & PTSD according to DSM-IV

The diagnosis criteria for ASD & PTSD differ due to the number of symptoms required in the different sections.

According to DSM-IV, the criteria for ASD and PTSD are not identical. Although symptoms for both disorders fall into characteristic symptom sections, the number of symptoms required from each section differs. (American Psychiatric Association. 2000:463)

The dx of ASD requires three or more dissociative symptoms, marked avoidance of stimuli that arouse recollection of the trauma, one reexperiencing symptom as well as “marked” anxiety or increased arousal. (American Psychiatric Association. 2000:463)

For PTSD, there has to be at least one reexperiencing symptom, three avoidance/numbing symptoms and at least two increased arousal symptoms. (American Psychiatric Association. 2000:464)

ASD and PTSD also differ according to the time of onset and duration of symptoms. For ASD, the onset of the symptoms is within 4 weeks of the event and lasts for 2 days to 4 weeks. (American Psychiatric Association. 2000:463)

If the symptoms last for more than a month, PTSD is dx. Acute PTSD is dx if the symptoms last for less than 3 months and chronic PTSD if the patient presents with symptoms for more than 3 months or longer. (American Psychiatric Association. 2004:24)

Criterion A (List tables)

For ASD and PTSD, the DSM-IV-TR defines criterion A as “exposure to a traumatic event in which both of the following conditions are present:

1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

2. The person’s response involved intense fear, helplessness, or horror.”

These events may be once off or repeated exposure. (American Psychiatric Association. 2004:23)

Screening for acute or remote event exposure is necessary in identifying persons with either ASD or PTSD, considering the individual’s response to the event as well as the nature of the event itself. (American Psychiatric Association. 2004:25)

In some professions i.e. military, police, EMS, exposure to criterion A is unavoidable. (American Psychiatric Association. 2004:25)

References

American Psychiatric Association. 2004. Practice guidelines for the treatment of patients with acute stress disorder and posttraumatic stress disorder. [Online]. Available:http://www.pbhcare.org/Guidelines/Guidelines/Blurb/Tree/Adult%20Mental%20Health/Acute%20Stress%20And%20PTSD/PTSD%20Algorithm.pdf. (Accessed: 10 February 2011).

DSM-5 Publication Date Moved to May 2013. 2009. [Online]. Available: http://www.psych.org/MainMenu/Newsroom/NewsReleases/2009NewsReleases/DSM-5-Publication-Date-Moved-.aspx. (Accessed: 12 February).

Spitzer R.L. 1981. The diagnostic status of homosexuality in DSM-III: a reformulation of the issues”. Am J Psychiatry 138: 210–215.

Peele R. 2008. History and impact of ASA’s leadership in psychiatric diagnosing. [Online].Available:http://www.rogerpeele.com/clinical_topics/history_of_the_dsm.asp. (Accessed 12 Feb. 11).

Posttraumatic stress disorder: An empirical evaluation of core assumptions

The question is asked whether PTSD diagnosis best represents individuals with severe psychological distress or has substantial incremental validity. (Rosen et al, 2008: 838)

PTSD differs from all other psychological diagnosis in the DSM, seeing that it is the only diagnosis where the person has to be exposed to a stressor (Criterion A), which is linked to distinct symptoms (Criterion B-D). (Rosen et al, 2008: 839)

Criterion A

The definition of Criterion A was changed from the DSM-III-TR to the DSM-IV, but the assumption that a person had to be exposed to traumatic event is still evident in both editions. (Rosen et al, 2008: 839)

Research has shown that PTSD is not always caused by a traumatic event, as defined in Criterion A. Events such as money and work stressors (Ravin & Boal: 1989; Scott & Stradling: 1994; Solomon & Canino: 1990); childbirth (Ayers & Pickering: 2001; Czarnocka & Slade: 2000; Olde et al: 2006); divorce and affairs (Burstein:1995; Dattilio: 2004; Dreman: 1991; Helzer et al:1987) and loss of a good friendship (Solomon & Canino: 1990) have all shown symptoms of PTSD.

Studies done by Bodkin et al and Erwin et al concluded that people who are distressed and have not been exposed to a Criterion A event, have shown all the symptoms to be dx with PTSD. (Bodkin et al: 2007, Erwin et al: 2006).

Although the majority of adults will experience a traumatic event, as described in Criterion A, sometime during their lifetime, not all individuals will develop symptoms of PTSD. (Breslau et al: 1991; Breslau et al., 1998; Davidson et al: 1991; Helzer et al., 1987; Kulka et al., 1990; Norris, 1992; Stein et al: 1997)

PTSD results more frequently in individuals that has been exposed to a traumatic event than those who hasn’t. (Rosen et al, 2008: 840)

As shown, the components of a traumatic stressor as defined in Criterion A are not necessary nor sufficient to define PTSD. (Rosen et al, 2008: 842)

Despite this, the Institute of Medicine reported that “the necessary cause of PTSD is by definition a traumatic event” (Posttraumatic Stress Disorder: Diagnosis and Assessment. 2006), not considering the issues surrounding Criterion A.

Criterion A was first defined in the DSM-III as “Existence of a recognizable stressor that would evoke significant symptoms of distress in almost everyone”. (American Psychiatric Association, 1980:238)

DSM-IV' (American Psychiatric Association, 1994:467), made substantial changes in the definition of Criterion A

“The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

(2) the person's response involved intense fear, helplessness, or horror.”

The DSM-IV states that a “confronted” event does not need to be directly experienced or witnessed. (American Psychiatric Association, 1994:464) Technically, a person only need to read about a traumatic event, see it on the television or hear about it to develop PTSD. So, from the DSM-III edition to the DSM-IV edition, the specifications for a traumatic event in Criteria A has gone from direct experiences to confronted events.

Criterion A2 states that the person’s response to a traumatic event involves “fear, helplessness and horror” (American Psychiatric Association, 1994:464). Other symptoms, such as anger and shame have also been documented. (Brewin et al: 2002). The absence of these symptoms can be a good indicator that PTSD may not develop in the individual.

One way of dealing with the controversy surrounding Criterion A, would be to include all stressful events as possible contributing factors to PTSD. Should Criterion A be dismissed in future editions of the DSM, then this disorder will cease to exist as we know it and be diagnosed according to a defining set of symptoms. (Rosen et al, 2008: 843)

Symptoms (fig 1, pg 844)

The symptoms for PTSD have been categorized in different criterions (B-D). Originally, PTSD had 12 symptoms in the DSM-III, which has been extended to 17 in the DSM-III-TR edition. These 17 symptoms remained in the DSM-IV edition, but the descriptions of the symptoms were changed and criterion D6 became D5. The three criterions are now known as reexperiencing symptoms (criterion B), avoidance and numbing (criterion C) and hyperarousal (criterion D). (Rosen et al, 2008: 843)

Even though there are 17 symptoms, a person only has to present with 6 of them to be diagnosed with PTSD. So, two different individuals, presenting with totally different symptoms, can both be diagnosed with PTSD. (Foa et al,1995). For example, one person can present with recurrent and intrusive distressing recollections of the event (criterion B), efforts to avoid thoughts of the trauma, avoiding activities of the trauma, inability to recall an important aspect of the trauma (criterion C), insomnia and irritability (criterion D). Another person can present with reoccurring dreams of the event (criterion B), loss of interest or participation in events, feeling detached from others, restricted affection (criterion C), difficulty in concentrating and startled easily (criterion D).

Comorbidity

Many researchers have asked the question whether PTSD can be distinguished from other psychiatric disorders as well as its ability to be independent, whether it can stand alone and its validity as a diagnosis. (Yehunda & McFarline, 1995, Lilienfeld et al, 1994, King & King, 1991).

Many patients with PTSD are also diagnosed with depression, panic disorder, anxiety disorder, alcoholism and obsessive compulsive disorder. These conditions often share the same symptoms. (Rosen et al, 2008: 845)

“Consider how the DSM-IV defines symptom criteria B-4 for PTSD as “intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event,” while it defines symptom criteria A for Specific Phobia as “marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.” Symptom criteria C-4 for PTSD is defined as “markedly diminished interest or participation in significant activities,” while symptom 2-A for major depression is defined as “markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day.” One of the hallmark symptoms of PTSD concerns the problem of intrusive thoughts (criterion B-1). Yet studies have found that on both quantitative and qualitative measures there are few differences between the intrusive memories of depressed and PTSD patients observed that the phenomenology of

PTSD flashbacks (criteria B-2) meet the DSM-III criteria for panic attacks.” (Rosen et al, 2008: 845)

Keane et al did a study to determine whether doctors could differentiate between PTSD, major depression and generalized anxiety disorder. (Keane et al, 1997), Doctors were asked to rate how 90 different symptoms relate to the three disorders. The results showed that the participants could differentiate between the symptoms, but because the theory was never tested on patients, the study had severe limitations. Despite this, the Institute of Medicine only used Keane’s study to report that PTSD could be differentiated from other disorders with similar symptoms. (Posttraumatic Stress Disorder: Diagnosis and Assessment. 2006), ignoring other studies stating that PTSD, depression and generalized anxiety disorder can not be described as individual conditions. (Breslau et al, 2000; O'Donnell et al, 2004; Brown et al,1998; Clark & Watson, 1991; Krueger, 1999; Forbes et al, 2005; Ruscio et al, 2002, Broman-Fulks et al., 2007; Bogenschutz & Nurnberg, 2000; Brown, 2001)

Emotional numbing

“Emotional numbing may be specific to PTSD and has been proven to be distinct from depression, contributes to the prediction of PTSD after depression has been statistically controlled and may relate to PTSD severity and low cortisol levels.” (Rosen et al, 2008: 846) It has been recommended that people who are exposed to a traumatic event and do not show symptoms of emotional numbing, be diagnosed with PTSD and not another psychiatric disorder. These recommendations, however, need to be supported by further research.

Pathophysiology PTSD

Because of overlapping symptoms and the comorbidity of PTSD and other psychiatric disorders, researchers have tried to identify pathophysiological markers to distinguish PTSD from other disorders. (Rosen et al, 2008: 847)

Neuroendocrine (Cortisol)

General stress studies have shown that the elevation of cortisol levels in stressed individuals is an indication of the activation of the hypothalamic-pituitary-adrenal (HPA) axis. (Rosen et al, 2008: 848)

Research has reported many contradicting findings, Mason et al, Yehunda et al and Boscarino found that patients that have been diagnosed with PTSD had lower levels of cortisol in their urine (Mason et al, 1986, Yehunda et al, 1990, Boscarino, 1996), some did not find decreased urine cortisol levels, (Liberzon et al, 1999, Pitman & Orr, 1990, Yehunda et al, 1991) where others reported higher urine cortisol levels in PTSD patients. (Liberzon et al, 1999, Pitman & Orr, 1990)

Low cortisol levels have also been found in adults with fibromyalgia, chronic fatigue syndrome as well as children with conduct syndrome. Higher cortisone levels have also been found in patients suffering from major depression. (Rosen et al, 2008: 848)

These contradictory findings bring into question the validity of cortisol levels as pathology for PTSD.

Neuroanatomy

Several studies conducted by Bremner found reduced hippocampus volumes in animals, combat veterans and abused children that had been exposed to stress, concluding PTSD can be caused by traumatic stressors damaging the brain. (Bremner, 1999, Bremner et al, 1995, 1997). These findings were supported by several others. (Stein et al, 1997a ,Bremner et al, 2003,Villareal et al, 2002, Kitayama et al, 2005, Gilbertson et al, 2002). Other studies however, challenge Bremner’s hypothesis (Stein et al, 1997 a,b; Pitman, 2001; Fennema-Notestine et al, 2002; Pederson et al., 2004; DeBellis et al, 2001; Golier, et al., 2005; Schuff et al., 2001; Bonne et al., 2001;).

Rothbaum et al, Shalev, North and Bonne et al observed individuals that presented with PTSD symptoms shortly after being exposed to a traumatic event. In none of these cases was a reduced volume of the hippocampus noted. (Rothbaum et al, 1992; Shalev, 2002; North, 2001 and Bonne et al, 2001).

This anatomy has also been observed in patients suffering from depression, a condition often diagnosed alongside PTSD. (Rosen et al, 2008: 849)

The Institute of medicine reported that “No biomarkers are clinically useful or specific in diagnosing PTSD, assessing the risk of developing it, or charting its progression” (Posttraumatic Stress Disorder: Diagnosis and Assessment. 2006:46).

Conclusion

Based on ample negative evidence, Rosen et al concluded that research has not supported the assumptions surrounding the diagnosis of PTSD. The difference in symptoms, the controversy around Criterion A, failure to identify a specific pathophysiology and etiology, brings the validity of PTSD into question. (Rosen et al, 2008: 853)

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