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CPTAUSRET
08-05-2004, 13:48
Acute and Delayed Posttraumatic Stress Disorders: A History and Some Issues

Nancy C. Andreasen
This issue of the Journal features stress disorders as its theme. The study of the psychological and emotional consequences of stress has become a burgeoning and important field in psychiatric research and treatment. In fact, the diagnoses of posttraumatic stress disorder (PTSD) and acute stress disorder (ASD) are now so frequently made that one wonders how we once got by without them.

The stress syndromes that we refer to as PTSD and ASD have a very long descriptive history. In general, their early history was closely linked to the experiences that soldiers suffered in combat. Before a diagnosis existed, many features of the syndrome were well-described in literary form in The Red Badge of Courage. The terrible carnage of trench warfare during World War I led many young men to return home deeply traumatized, and this led in turn to systematic descriptions of the syndrome under names such as "shell shock" or "combat fatigue." World War II was, however, the catalytic event that led to the creation of a formal diagnostic category to refer to this syndrome: Gross Stress Reaction. World War II for the first time brought together soldiers, psychiatrists, and other medical personnel from all over the country, giving them an opportunity to discover the many things that they had in common and also to recognize the ways that they differed. Socially, our great melting pot received yet another incentive to continue to melt—and to meld together all the diverse components of our society. (The World War II musical, Oklahoma, celebrated this fact—watch it again some time in the context of our current world situation.) On the medical and psychiatric scene people discovered that they did not always share a common vocabulary with which to discuss the syndromes and diagnoses observed in their patients.

After the war ended, the Veterans Administration (VA) developed a diagnostic manual, which provided the incentive for the APA to create its own first manual: DSM-I. The manual was very concise, but it included a diagnosis that covered victims of stress: Gross Stress Reaction. During that post-war era and after, psychiatrists also began systematic investigations of the consequences of exposure to death camps and the POW experience, as well as nonmilitary stressors, such as mass catastrophes—fires, earthquakes, or plane crashes (1). However, for reasons that remain obscure but that perhaps reflect the early links between military combat and the diagnosis of stress disorders, Gross Stress Reaction was somehow dropped from DSM-II. That manual was written when our country was not engaged in any major war. However, the scientific study of the consequences of stress continued. In fact, your editor began her early research career by studying the consequences of severe burn injuries in the pre-DSM-III era—identifying symptoms, risk factors for poor outcome, and the prevalence of severe psychiatric consequences (2–5).

DSM-III was crafted in the post-Vietnam era, a time when our country contained yet another wave of young men who had been exposed to the trauma of combat. VA and military psychiatrists had no official diagnosis to give them, as long as DSM-II was the official diagnostic manual. As a member of the DSM-III Task Force, I was assigned to this problem. An active group of advocates were lobbying for the inclusion of a diagnosis of "Post-Vietnam syndrome." The purpose and the concept were correct, but the name and the specificity were not. I pointed out the long history of the syndrome, as well as the fact that it frequently occurred in traumatized civilians as well. A stress syndrome characterized by reliving, indicators of autonomic overarousal, and other such features was simply a final common pathway with many different sites of entry. We worked together to agree on diagnostic criteria, which were rooted in the extensive literature on stress disorders already available at that time, and christened our 100-year-old offspring Post-traumatic Stress Disorder. I wrote the entire text description of the syndrome, which was based on my experience caring for burn patients and the substantial literature available at the time. My burn patients had almost universally experienced this syndrome immediately after their injuries. So we designated an acute form of PTSD. However, many soldiers do not develop stress symptoms until they return home, since a stress reaction in the midst of combat is not adaptive, and so the impact of their traumatic experiences is delayed. Therefore, we also identified a delayed form.

The concept of PTSD took off like a rocket, and in ways that had not initially been anticipated. 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. The DSM-III formulation emphasized that the stressor should be significant—outside the range of normal human experience. It assumed, but did not explicitly state, that there would be a temporally close juxtaposition between the stressor and the development of symptoms.

Many psychiatrists liked the DSM-III formulation and began to use the diagnosis widely. Its application broadened steadily. For example, it was used for victims of childhood sexual abuse who developed traumatic stress symptoms much later. Dissociation, a component of the original definition but not its core, received increasing emphasis. And the requirement that the stressor be outside the range of normal human experience was sometimes reinterpreted to include less severe stressors. In fact, that stringent requirement was dropped in DSM-III-R and DSM-IV, providing a much broader concept than was originally intended. (In my view, this broadening should be reconsidered. Giving the same diagnosis to death camp survivors and someone who has been in a motor vehicle accident diminishes the magnitude of the stressor and the significance of PTSD.) Acute PTSD, dropped from DSM-III-R, was fortunately added back in DSM-IV with a new name: Acute Stress Disorder.

This issue includes several articles on various forms of PTSD. The literature on this diagnosis is now vast. It goes far beyond the descriptive psychopathology upon which the original DSM-III definition was based. We now have a multitude of papers covering topics such as neural mechanisms as revealed in imaging studies, risk factors, prevalence, comorbidity, symptom patterns, and outcome. The study of PTSD has enriched our conceptualization of memory in both its conscious and unconscious forms. The task of summarizing all this literature—and producing a DSM-V description and definition—will be challenging. Not all the studies converge on the same conclusions.

Why?

A clue is provided by the articles in this issue. Although the final common pathway (in the psychological and physical/autonomic sense) is the same, there are many different kinds of stressors. As detailed by Verger et al., experiencing a terrorist bombing in a metro—a man-made and unanticipated disaster that produced concomitant physical injuries, facial deformities, and the psychological terror that was intended—is indeed something outside "the normal human range." A PTSD prevalence rate of 31% was observed approximately 2.6 years after the event. If anything, this seems surprisingly low, but the assessments were done via phone interview and could be an underestimate. A companion paper by Fullerton et al. examines both ASD and PTSD in disaster workers at the site of a plane crash. Their stressors are quite different. A plane crash is an accident, and therefore has a different impact than man-made malevolence. Disaster workers have chosen their occupation with foreknowledge of its risks. To say this is not to diminish the enormous value of their work. But the psychological impact is different. And, not surprisingly, the prevalence of PTSD at a 13-month assessment was lower than in the terrorism victims: 16.7%. The studies examine different predictors of outcome and produce different results. These articles are but two examples of the many difficulties in conceptualizing the essence of PTSD and its consequences. A third article by O’Donnell et al. examines the thorny issue of comorbid depression. (The original concept of Gross Stress Reaction specified that it must occur in an otherwise normal individual—which was probably wrong, since stressors do not preferentially occur in normal individuals, and those with other disorders may have fewer adaptive resources remaining.)

As the psychiatrist who was also midwife at the birth of PTSD, I have followed its growth and maturation with great interest. Others have parented it, and generally well. It is of particular interest in the 21st century, when the entire world is filled with the spectre of terrorism—a stressor of great magnitude that can strike any time and anywhere. This is also a time when we again will have many young soldiers returning from yet another war: the treacherous combat experience in Iraq and Afghanistan. Unfortunately, the present world situation is likely to give us many more opportunities to study ASD and PTSD. For this I have regrets, but I am pleased that I helped create a diagnostic category and conceptual framework for this important syndrome, so that its causes and consequences can be examined both clinically and scientifically.

NousDefionsDoc
08-05-2004, 14:36
I think this needs to be in the med forum?

CPTAUSRET
08-05-2004, 14:41
Sneaky:

OK:

Moving it is fine with me.

Did you get anything worthwhile out of the editorial?

Nancy is the editor in chief of THE AMERICAN JOURNAL OF PSYCHIATRY, and she wrote the PTSD definition for the DSM, years ago:

Terry

CPTAUSRET
08-05-2004, 14:49
NDD:

The reason I asked, if you didn't get anything worthwhile out of it with your background...I doubt few others will.

Terry

NousDefionsDoc
08-05-2004, 15:27
Originally posted by CPTAUSRET
Sneaky:

OK:

Moving it is fine with me.

Did you get anything worthwhile out of the editorial?

Nancy is the editor in chief of THE AMERICAN JOURNAL OF PSYCHIATRY, and she wrote the PTSD definition for the DSM, years ago:

Terry

But of course.

Sacamuelas
08-05-2004, 15:55
Great article Terry. :cool:

I deal with patients almost DAILY that have PTSD as a diagnosis. I really need to learn how to better accomodate them.

I need to do some research on Nancy's work.

CPTAUSRET
08-05-2004, 16:07
The editorial was too long, so I chopped off the references, here they are.

References


Adler A: Neuropsychiatric complications in victims of Boston"s Coconut Grove disaster. JAMA 1943; 123:1098–1101
Andreasen NJ, Noyes R Jr, Hartford CE, Brodland G, Proctor S: Management of emotional reactions in seriously burned adults. N Engl J Med 1972; 286:65–69[Medline]
Andreasen NJ: Neuropsychiatric complications in burn patients. Int J Psychiatry Med 1974; 5:161–171[Medline]
Andreasen NJ, Noyes R Jr, Hartford CE: Factors influencing adjustment of burn patients during hospitalization. Psychosom Med 1972; 34:517–525[Medline]
Andreasen NJ, Norris AS, Hartford CE: Incidence of long-term psychiatric complications in severely burned adults. Ann Surg 1971; 174:785–793[Medline]



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Posttraumatic Stress Disorder

CPTAUSRET
08-05-2004, 16:08
Originally posted by NousDefionsDoc
But of course.

Just checking.

Thanks.

Terry

CPTAUSRET
08-05-2004, 16:09
Originally posted by Sacamuelas
Great article Terry. :cool:

I deal with patients almost DAILY that have PTSD as a diagnosis. I really need to learn how to better accomodate them.

I need to do some research on Nancy's work.

Sacamuelas:

Glad you liked it, hope it helped.

Terry

pulque
08-05-2004, 16:15
Thank you sir. I remain with utmost respect for this work. I hope there were lessons which will reduce the number of cases of PTSD, and dissociation, in the coming years.

Bill Harsey
08-05-2004, 18:46
Thanks for posting that. Well done.

CPTAUSRET
08-05-2004, 19:22
Originally posted by pulque
Thank you sir. I remain with utmost respect for this work. I hope there were lessons which will reduce the number of cases of PTSD, and dissociation, in the coming years.

pulque:

The last time we PM'd one another you were all set to read Nancy's latest book "BROKEN BRAIN"...Got it done yet?

Terry

CPTAUSRET
08-05-2004, 23:29
Originally posted by Bill Harsey
Thanks for posting that. Well done.

Bill:

Glad you liked it...Still haven't forgotten about the books.

Terry

Solid
08-06-2004, 04:29
I had to study the DSM IV on PTSD for psych... I never even realised it was Dr. Andreasen's work!
Small world.

Solid

CPTAUSRET
08-06-2004, 09:03
Originally posted by Solid
I had to study the DSM IV on PTSD for psych... I never even realised it was Dr. Andreasen's work!
Small world.

Solid
Solid:

She gets around, she is now (perhaps) the worlds leading expert on Schizophrenia. She was awarded the NMS for her research in biological sciences.

Terry

Blackjack78
08-06-2004, 09:15
Originally posted by CPTAUSRET
Solid:

She gets around, she is now (perhaps) the worlds leading expert on Schizophrenia. She was awarded the NMS for her research in biological sciences.

Terry

Terry,

She can only have that title if she evaulated me ! lol Great article. Thanks for sharing.

Bill Harsey
08-06-2004, 09:51
Originally posted by CPTAUSRET
Bill:

Glad you liked it...Still haven't forgotten about the books.

Terry Thanks! At your leisure Sir.

CPTAUSRET
08-06-2004, 10:56
Originally posted by Blackjack78
Terry,

She can only have that title if she evaulated me ! lol Great article. Thanks for sharing.

Jim:

Glad you liked the article, she may yet get a chance to evaluate you...We are in NYC fairly often.:D

Terry

Blackjack78
08-06-2004, 11:49
Originally posted by CPTAUSRET
Jim:

Glad you liked the article, she may yet get a chance to evaluate you...We are in NYC fairly often.:D

Terry

Terry,

Better yet, maybe she should evaulate Natalie lol. Have a good one.

Jim

pulque
08-06-2004, 12:11
Originally posted by CPTAUSRET
pulque:

The last time we PM'd one another you were all set to read Nancy's latest book "BROKEN BRAIN"...Got it done yet?

Terry

Terry, I read Brave New Brain. I spent a large amount of time in the „mapping the genome“ chapter, as I am a grunt in that area (looking for those on-off switches for genes). I enjoyed Dr. Andreasens explaination for why the promise of the human genome is yet to be realized for complex illnesses. She is VERY effective in telling the story, and its clear how much work went into it. Overall, I have to say that BNB is one of the most well written science books I have ever read (any science book that mentions the Malleus Maleficarum, William Blake, and Hebbian plasticity is GTG with me!). I was grateful that she included both the historical science (anatomy, early brain-mapping, inheritance stuff), and a perspective on diagnosing mental illness within society.. distinguishing between „the bad and the mad“. She even listed some of the politicians who had mood disorders (Teddy Roosevelt, Abraham Lincoln).

Perhaps most of all though, I am grateful that she got PTSD back in the manual, that she named it the way she did, and that she has the interest of the soldier at heart. [[I know SF dudes are supposed to be „more adaptive“ and less prone to PTSD, but its good the diagnosis is there for those in need (soldier or not)]].

CPTAUSRET
08-06-2004, 13:01
Originally posted by Blackjack78
Terry,

Better yet, maybe she should evaulate Natalie lol. Have a good one.

Jim

Cute...Yeah she is way to cool to be hanging with your sorry ass!:D

Terry

CPTAUSRET
08-07-2004, 21:26
pulque:

Good...I am glad that you read BNB, I will pass your comments on to Nancy.

Sounds like you got a lot out of it, she'll appreciate that.

Terry



Originally posted by pulque
Terry, I read Brave New Brain. I spent a large amount of time in the „mapping the genome“ chapter, as I am a grunt in that area (looking for those on-off switches for genes). I enjoyed Dr. Andreasens explaination for why the promise of the human genome is yet to be realized for complex illnesses. She is VERY effective in telling the story, and its clear how much work went into it. Overall, I have to say that BNB is one of the most well written science books I have ever read (any science book that mentions the Malleus Maleficarum, William Blake, and Hebbian plasticity is GTG with me!). I was grateful that she included both the historical science (anatomy, early brain-mapping, inheritance stuff), and a perspective on diagnosing mental illness within society.. distinguishing between „the bad and the mad“. She even listed some of the politicians who had mood disorders (Teddy Roosevelt, Abraham Lincoln).

Perhaps most of all though, I am grateful that she got PTSD back in the manual, that she named it the way she did, and that she has the interest of the soldier at heart. [[I know SF dudes are supposed to be „more adaptive“ and less prone to PTSD, but its good the diagnosis is there for those in need (soldier or not)]].

Guy
08-08-2004, 11:53
Great article!

I was telling some one else. "Wait until the number of civilian contractors begin returning from overseas contract work."

I've seen men, out run women to get to the bomb shelters.:eek:

CPTAUSRET
01-12-2005, 10:52
Great article!

I was telling some one else. "Wait until the number of civilian contractors begin returning from overseas contract work."

I've seen men, out run women to get to the bomb shelters.:eek:

Guy:

I think we are starting to see some of this already...and it will only get worse.

On the other hand, I personally feel that some (primarily military) will use this as a crutch, and that's a shame!!

Terry