In the post-Vietnam period, it became clear that many soldiers were suffering severe psychological consequences as a result of their traumatic exposure, yet psychiatrists were left without a diagnosis in the DSM-II. Chaim Shatan, a psychiatrist and advocate for Vietnam veterans, raised awareness about the absence of a combat-stress diagnosis in the DSM-II. In 1972, he wrote an Op-Ed piece for the New York Times regarding what he termed, “post-Vietnam syndrome,” an affliction which occurred nine to 30 months after Vietnam combat (Scott, 1990). Shatan “described the syndrome as ‘delayed massive trauma’ and identified its themes: guilt, rage, the feeling of being scapegoated, psychic numbing, and alienation” (Scott, 1990, p. 301). Shatan expanded upon Freud’s conceptualization of grief thusly:
“Freud elucidated the role grief plays in helping the mourner let go of a missing part of life and acknowledging that it exists only in the memory. The so-called Post-Vietnam Syndrome confronts us with the unconsummated grief of soldiers—impacted grief, in which an encapsulated, never-ending past deprives the present of meaning. Their sorrow is unspent, the grief of their wounds is untold, their guilt unexpiated. Much of what passes for cynicism is really the veterans’ numbed apathy from a surfeit of bereavement and death” (Shatan, 1973, as quoted in Scott, 1990, p. 301).
Shatan’s piece in the New York Times garnered a great deal of support for legitimizing post-Vietnam syndrome in the DSM (Scott, 1990).
Soon thereafter, a DSM-III Task Force, called the Committee on Reactive Disorders, was assigned to scour the existing research on stress and inquire into the possibility of adding a diagnosis to the DSM-III (Scott, 1990). The committee accumulated evidence from hundreds of cases of what they termed, “catastrophic stress disorder.” The task force acknowledged that catastrophic stress disorder could arise from non-combat traumas, and symptoms could develop immediately after exposure (i.e., “acute” PTSD), or much later (i.e., “delayed” PTSD; Andreasen, 2004). Nancy Andreasen, a psychiatrist who was head of the committee and who wrote the text description of PTSD for the DSM-III, describes some of the challenges in the DSM-III criteria thusly:
“The DSM-III text struggled with many issues: how severe should the trauma be? What types of trauma could be considered causative? Does it make a difference if the trauma is inflicted by another human being, by an accident, or by a natural disaster? What impact does duration of the stressor have? What impact does premorbid psychiatric status have? And so on. PTSD is a complex concept” (Andreasen, 2004, p. 1322).
Ultimately, the APA accepted the committee’s findings, but changed the term to “posttraumatic stress disorder” (Scott, 1990). The DSM-III was published in 1980.
PTSD has remained a diagnosis in the DSM throughout subsequent iterations of the manual, but the criteria were changed over the years. For example, the criteria were broadened in the DSM-III-R (APA, 1987), as the requirement that the stressor be outside the range of normal human experience was dropped (Andreasen, 2004). In the most recent edition of the DSM-IV-TR (APA, 2000), the criteria are defined as follows:
“Criterion A: Stressor
The person has been exposed to a traumatic event in which both of the following have been present:
- The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.
- The person’s response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior.
Criterion B: Intrusive recollection
The traumatic event is persistently re-experienced in at least one of the following ways:
- Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed
- Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content
- Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes,including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur
- Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
- Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Criterion C: Avoidance/Numbing
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
- Efforts to avoid thoughts, feelings, or conversations associated with the trauma
- Efforts to avoid activities, places, or people that arouse recollections of the trauma
- Inability to recall an important aspect of the trauma
- Markedly diminished interest or participation in significant activities
- Feeling of detachment or estrangement from others
- Restricted range of affect (e.g., unable to have loving feelings)
- Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
Criterion D: Hyperarousal
Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:
- Difficulty falling or staying asleep
- Irritability or outbursts of anger
- Difficulty concentrating
- Exaggerated startle response
Criterion E: Duration
Duration of the disturbance (symptoms in B, C, and D) is more than one month.
Criterion F: Functional significance
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Acute: if duration of symptoms is less than three months
Chronic: if duration of symptoms is three months or more
With or Without delay onset: Onset of symptoms at least six months after the stressor” (APA, 2000, as quoted in Department of Veteran Affairs, 2007).
In sum, our current understanding of PTSD is that intrusion, avoidance, and arousal symptoms are all present for at least one month, and cause significant problems in functioning. The introduction of these criteria was a great step forward in our understanding of PTSD, as the criteria indicate that the cause of the trauma is outside of the individual, rather than the result of a weakness inherent in the individual (Friedman, 2007). Additionally, the current criteria acknowledge both psychological and biological components of the disorder.
Notably, the DSM-IV-TR criteria indicate that PTSD can arise even as a result of threat to the physical integrity of another, leaving room for “vicarious traumatization” or “secondary traumatic stress.” That is, even individuals, such as family members or helping professionals who are exposed to the traumatic experiences of others, can be susceptible to developing PTSD symptoms themselves (Bride, Robinson, Yegidis, & Figley, 2004).
Fortunately, as our understanding of PTSD has evolved, so too has the treatment for this disorder. No longer are patients prescribed rest alone; rather, several empirically-based treatments are available. VAs primarily use two treatments known as Cognitive Processing Therapy and Prolonged Exposure Therapy. Cognitive Processing Therapy involves educating patients about PTSD symptoms and cognitive changes in the areas of safety, trust, control, intimacy, and esteem. Patients are also helped to identify their negative, irrational thoughts and learn skills for challenging and countering these beliefs (Department of Veteran Affairs, 2009). Prolonged exposure therapy also begins with education about PTSD, but focuses on helping patients to relive their trauma in their imagination, while simultaneously practicing calming breathing exercises they have learned, in order to reduce the emotional distress they feel in response to traumatic memories (Department of Veteran Affairs, 2009). Both treatments have been studied with randomized controlled trials, with favorable results (Department of Veteran Affairs, 2010).
Additionally, some psychotropic medications, such as Zoloft (sertraline) and Paxil (paroxetine), have been approved by the FDA for the treatment of PTSD, but are primarily used when therapy alone is ineffective (Friedman, 2007).
Andreasen, N. C. (2001). Acute and delayed posttraumatic stress disorder: A history and some issues. The American Journal of Psychiatry, 161, 1321-1323. Retrieved from http://ajp.psychiatryonline.org/article.aspx?Volume=161&page=1321&journalID=13
Bride, B. E., Robinson, M. M., Yegidis, B., & Figley, C. R. (2004). Development and validation of the secondary traumatic stress scale. Research on Social Work Practice, 14(1), 27-35. Retrieved from http://rsw.sagepub.com/content/14/1/27.abstract
Department of Veteran Affairs (2007-2010). National center for PTSD. Retrieved from http://www.ptsd.va.gov/index.asp
Friedman, M. J. (2007). Posttraumatic stress disorder: An overview. Retrieved from http://www.ptsd.va.gov/professional/pages/ptsd-overview.asp
Scott, W. J. (1990). PTSD in DSM-III: A case in the politics of diagnosis and disease. Social Problems, 37(3), 294-310. Retrieved from http://www.jstor.org/stable/800744?seq=1