PTSD can both resemble and commonly co-occur with a broad range of other psychiatric conditions. Mindpath Health’s Shannon LeMaster, MD, explains how clinicians catch PTSD using the DSM-5 in this Psychiatric Times article.
Many confident psychiatrists have quipped, “I can recognize post-traumatic stress disorder (PTSD) as it walks down the hall.” It may be an exaggeration, but it does belie a surprising truth about the disorder. Even without knowing that someone has been traumatized, PTSD is recognizable.
PTSD is a constellation of maladaptive changes that can occur after an extreme stressor, though it does not happen to everyone who is traumatized. When it occurs, it involves disturbing experiences, such as flashbacks to the trauma and potentially long-term alterations to patterns of thinking, behavior, and biology.
While these changes have long been described, our current conceptualization of PTSD was identified as shell shock in 1915 by World War I soldiers. It described the experience of fatigue, tremor, confusion, nightmares, and impaired sight and hearing among soldiers recovering from battle. The definition of shell shock has changed over the years to include different categories of traumas, such as sexual trauma and indirect trauma. And while PTSD used to be considered an anxiety disorder, it is now just one among a separate group of trauma- and stressor-related disorders in the DSM-5.
Walking through PTSD
Not every patient with PTSD will experience every symptom of the disorder. In fact, it is not atypical for patients to display the opposite of some symptoms. What is typical of PTSD is that there is no middle ground. There is an all-or-nothing quality to these changes. As a model of nonrecovery after trauma, each may be conceptualized as either an over- or under-compensation.
DSM-5 lists five criteria for diagnosing PTSD, but the order in which they are presented is almost precisely backward from how they will present during a session. Unless you happen to work in a PTSD clinic, where every patient is presumed to have experienced a trauma, you will not necessarily know this from the start. So, let us review the criteria in reverse order.
Criterion E: Alterations in arousal and reactivity
In particularly severe cases of heightened arousal or hypervigilance, the patient may refuse to walk down the hall ahead of you. They simply cannot abide anyone walking behind them. You may gesture for them to go ahead of you, and they will instead gesture for you to go ahead of them. It creates an unmistakably awkward moment. Others may handle the hallways just fine but then refuse to go into the office before you.
A patient with PTSD may point out flaws that exist in your paperwork, scheduling, or front-office operations. While most patients try to make a good impression, a patient with PTSD may put you on the defensive. Or they might not show up at all.
Criterion D: Negative alterations in cognitions and mood
There are two themes at work with this criterion: extremes in thinking and numbing or avoidance. Though the biology of these changes is still not well understood, numbing symptoms can be thought of as being on a continuum with dissociation, a more severe form of detachment from reality. In these criteria, numbing is distinct from avoidance, which is discussed further in Criterion C.
In extreme cases of dissociation, symptoms may be chronic or may include depersonalization or derealization. Depersonalization is when patients feel they are detached from their body, such as an out-of-body experience. Derealization is the sense that they are not in the real world, as if this world is a fake.
Criterion C: Persistent avoidance of stimuli associated with the traumatic event
Patients with PTSD avoid talking about, remembering, or even feeling the feelings associated with the trauma for good reason: it may trigger a flashback.
Avoidance, whether through willpower or dissociative amnesia, and how it is accomplished is quite varied in style and intensity. In talking with the clinician, some patients may simply pretend the event did not happen or convince themselves their experience was normal.
When asked to identify when symptoms started, some patients will openly reveal their trauma. Others will deflect. Let them. This avoidance protects them, as well as the interview, from being waylaid by flashbacks. Instead, invite the patient to start at the beginning and collect their history longitudinally. This has many benefits. For one, it is easier to open up to someone who knows you, and learning about someone’s childhood helps them feel known. This also has the benefit of redirecting the narrative toward a potentially pre-trauma part of their life.
Criterion B: The presence of intrusion symptoms associated with the traumatic event
Classic intrusion symptoms, known as flashbacks, are essentially raw memories that have not been processed normally into long-term memories. The amygdala is the part of the brain believed to be responsible for the formation of fear memories and their retrieval as flashbacks. It works in close association with the hippocampus.
During a flashback, a patient with PTSD experiences their traumatic memory as if it were happening right at that moment. These unprocessed memories remain linked with all the sensory and physiological data that was encoded by the hippocampus during the original trauma.
Intrusion symptoms do not just bother patients, they haunt them. Flashbacks refer to the complete sensory phenomenon of reliving the experience. Nightmares replay the trauma. Intrusive memories are partially processed memories that pop up randomly, but do not bring the full sensory experience.
Criterion A: Exposure to actual or threatened death, serious injury, or sexual violence
In 2013, the criteria for diagnosing PTSD were updated with the publication of the DSM-5. It both expanded (by including sexual violence) and narrowed the definition of a qualifying event for Criteria A (by excluding threats to “physical integrity.”) These changes succeeded in clarifying the diagnosis, which was hailed as beneficial to research efforts. Yet, they are not as helpful for clinicians who are treating patients in the field. Furthermore, the question of whether a global pandemic can be a Criterion A event—and under what circumstances—is yet to be clarified.
Read the full Psychiatric Times article with sources.