Traumatic Stress Disorders


By Jane Matthews and Dan DeMento. Reviewed and edited by M. Williams, Ph.D.

Symptoms of Traumatic Stress Disorders

Traumatic stress disorders occur when a person experiences an event that is life-threatening or involves possible death or injury to others, and the person's feels intense fear, helplessness, or horror. Following the event, the traumatized person may experience nightmares, sleep problems, flashbacks, and ongoing distress. They may also have dissociative symptoms, depression, avoid all of reminders of the trauma, and difficulties at work and in social roles.

If the symptoms occur within four weeks of the traumatic event, and last from two days to four weeks, it is classified as Acute Stress Disorder (ASD). For individuals with the symptoms of ASD whose symptoms last for more than 4 weeks, the diagnosis becomes Posttraumatic Stress Disorder (PTSD).

History of Traumatic Stress Disorders

Historically, both PTSD and ASD are closely linked to the experience of soldiers in combat. The terrifying trench warfare typical of World War I sent many soldiers home with a condition that became known as "shell shock." World War II led to the creation of a formal diagnostic categorization of this syndrome, and called it "Gross Stress Reaction."

After World War II, the Veterans Administration developed a diagnostic manual, which provided the incentive for the American Psychiatric Association to create its own first manual, the DSM-I, which also included Gross Stress Reaction. The DSM-II was published when the U.S. was not engaged in a major war, and Gross Stress Reaction was dropped from the manual. However, the disorder resurfaced after Vietnam, appearing in the DSM-III as Posttraumatic Stress Disorder, alongside a variation called Acute Posttraumatic Stress Disorder. In the DSM-IV-TR, the disorder formerly called Acute PTSD became Acute Stress Disorder, the name by which it is called today. Initially, due to its correlation with military combat, the disorder was thought to occur exclusively in males. With time, however, perspective and understanding of the disorder have broadened.

Gender Differences with Traumatic Stress Disorders

Gender differences play a significant role in the incidence and manifestation of PTSD and
ASD. Women — more than men — experience dissociation after a traumatic event. Feelings such as derealization can cause the sufferer to feel "frozen" in a post-trauma response, unable to process the event in a productive manner. Women tend to internalize their emotional responses to trauma, avoiding reminders of the trauma, which can lead to dissociation and depression, while men tend to externalize their experiences, resulting in increased irritability and substance abuse. A study performed at the University of New South Wales assessed survivors of motor vehicle accidents for ASD one month after their accident, and then for PTSD six months after their accident. The incidence of ASD in women was 23% but only 8% in men. Among these, the incidence of PTSD in women was 92% and 57% in men. The women displayed higher dissociative symptoms than the men. This study highlights the elevated incidence of ASD in women following a traumatic event, and illustrates the strong predictive powers of ASD for PTSD, particularly in women.

Large-scale studies of people suffering from ASD have found that women are especially likely to develop ASD and subsequent PTSD as a result of rape. This is particularly true if the victim is injured, thinks that her life is in danger, or if the rape is completed. Sixty percent of rape victims will experience PTSD. Men are especially likely to develop ASD and subsequent PTSD as a result of combat exposure, particularly if wounded, involved in the death of innocent civilians, or witness to atrocities. Both men and women have a poor prognosis for recovery if they lack a strong network of social support. People who still have symptoms a year after their trauma are unlikely to get better without professional intervention.

Cross-Cultural Differences

While there is a marked difference between the rates of traumatic stress disorders in men and women, there is not a significant predominance of one race over the other in the incidence overall. People experience similar distress symptoms cross-culturally, with the severity of the trauma, proximity to the trauma, and pattern of response influencing the development of ASD. Resource loss as the result of a natural disaster (such as a hurricane) is a trauma that is felt universally, but lower income people in developing countries may bear an inordinate amount of loss compared to their wealthier counterparts. Similarly, people with a lower socioeconomic status in the United States are more likely to experience trauma and subsequent ASD because of the elevated levels of danger in their environment. The DSM-IV-TR notes that recent immigrants to the United States from areas of conflict may be more likely to suffer from stress disorders because of their past experiences, and may be less likely to seek help due to their uncertain immigrant status. This reluctance limits their social support, increasing their chances of suffering from serious ASD and subsequent PTSD. Some symptoms of trauma, such as dissociation, may be found in one culture more than another, depending on the societal norms of that culture.

Causes of Traumatic Stress Disorders

By definition, traumatic stressors cause ASD and PTSD. However, not every person that is exposed to traumatic stress develops these disorders. There are also social, biological, and psychological factors that play a role in the manifestation of the disorder. In the social domain, as mentioned previously, the availability and quality of emotional support following the trauma are very important. From a biological perspective, studies in PTSD have shown alterations in the functioning, and perhaps the structure, of the amygdala and hippocampus. There is also evidence of increased levels of circulating norepinephrine and general arousal (elevated resting heart rate) in people with ASD. Finally, the psychological domain suggests the two-factor theory, in which classical conditioning creates fears in the victim, while operant conditioning maintains these fears.

Early Intervention in Traumatic Stress Disorders

Early intervention with a person suffering from ASD is the first line of defense against the development of PTSD. ASD's classification as a separate disorder in 1994 was in large part a preventative measure. Psychologists hoped that by diagnosing and treating ASD, they could prevent PTSD.
Research into treatment for this relatively new disorder is limited. Anti-depressants are not usually prescribed until a diagnosis of PTSD has been made. The most empirically-backed treatment for ASD is cognitive behavioral therapy. A study done on trauma survivors compared the long-term benefits of cognitive behavioral therapy (CBT) and supportive counseling. Eighty people with ASD were randomly assigned to either CBT or supportive counseling. Six months post-trauma 17% of the group who had received CBT met the criteria for PTSD, and 67% of the group who had received supportive counseling met the criteria for PTSD. These findings suggest that early intervention with CBT holds great benefit for people suffering from ASD.

A cognitive behavioral therapist who is treating a person with a recent trauma must first establish a trusting therapeutic relationship. They will typically provide education about reactions to trauma and work with the patient to reduce avoidance behaviors. Stress management training is often part of the treatment and involves breathing retraining, progressive muscle relaxation, and self-talk exercises. The most important (and often the most painful) part of therapy for sufferers is the purposeful revisiting of their trauma. This is achieved through Prolonged Exposure Therapy which involves confronting fears in vivo and in the imagination over extended periods of time. Finally, the therapist and the patient must work together to help integrate the trauma into the individual's life by extracting meaning and a sense of purpose from the experience.

Learn more about prolonged exposure for the treatment of PTSD.

Outcomes of Traumatic Stress Disorders

The prognosis for traumatic stress disorders is dependent on a variety of factors: the severity of pre-existing conditions, comorbid disorders (such as depression and substance abuse), the severity of the trauma, personality characteristics (such as flexibility or avoidance), emotional processing after the event, and social support.

Understanding of traumatic stress disorders has come a long way, but much research can still be done to further our comprehension of these disorders. For example, studies should be done to better assess ASD's prevalence and to expand the understanding of factors (besides the trauma) that play a role in causing the disorder. The higher prevalence rates in woman beg further research, and could lead to interesting discoveries that extend well beyond this particular disorder. ASD and PTSD can heal with time as long as the right steps are taken to ensure that the individual has the coping strategies required to overcome the legacy of their traumatic experience. Treatment can still be improved however, and will become increasingly important in a world stricken with war and terrorism.

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