1. The European Network for Traumatic Stress Training & Practice www.tentsproject.eu

2. The diagnosis of Posttraumatic Stress Disorder (PTSD) Ask Elklit, Denmark 2

3. Glimpses of the history of trauma ‘Railway spine’ (1866) was a diagnosis given after railway accidents to describe emotional and personality impact Pierre Janet (1889) developed a dynamic understanding of trauma that is still valid Various wars gave name to ‘soldiers’ heart’, ‘shell shock’, ‘combat neurosis’, ‘KZ-syndrom’, ‘Vietnam syndrom’ etc. This knowledge disappeared in the years following the wars and was ‘reinvented’ 3

4. Horowitz (1976) In the book, ”Stress Response Syndrom”, Mardi Horowitz described what he saw as the core dynamics after a traumatic experience: A long-lasting oscilliation between intrusive reexperiences and denial/avoidance As Horowitz mainly worked with bereaved people, he paid little attention to arousal symptoms 4

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6. Split Emotions HyperstateParalysed Perceptions Cognitions Actions Model of the consciousness in shock

7. 7 Scenes in a fixed order Amnesia for Intervening details Model of the perceptual condensation (”etching”) after trauma

8. Demogra fis PersonalitySocial groupLife events Traumatic event (situational factors) Original shock / defence reflexes (dissociation) Primary appraisal (cognitive-emotional) Social support (secondary victimization) Defence Coping (action possibilities) Hypervigiilance Avoidance Intrusive recollections Psychiatric syndromes (ASD, PTSD etc.) Personality disorders / dysfunctional traits Psycho-physiological disorders Social changes Attribu- tions Body state *PLEASE ADD AN EXPLANANTION FOR TEACHERS:

9. The DSM-III (a) Before DSM-III, clinicians and scientists met and tried to find common ground in the symptoms of veterans, rape victims, and battered women. In 1980, the APA published the first version of PTSD with the three core symptom clusters Re-experiencing (”intrusive”) Avoidance Hypervigiliance (”arousal”) 9

10. DSM-III (b) The clusters consist of items that are descriptive; so are the clusters and there are no expectations about the inherent dynamics as suggested by Horowitz The Hypervigiliance cluster is a substantial development and addition to the work of Horowitz acknowledging the psychosomatic aspects of experiencing an extreme and threatening situation Confer the Kardiner (1941) concept of trauma as a ”psychoneurosis” 10

11. PTSD today (DSM-IV) The stressor criteria (both A1 and A2): A1 ”a life threatening situation, injury or threat to physical integrity” This can be direct exposure or indirect – witnessing events The subjective experience is what counts A2 The person reacts with fear or help- lessness 11

12. Re-experiencing (1 symptom) 1) Recurrent thoughts or perceptions of the event 2) Recurrent dreams of the event 3) Acting or feeling as if the event were recurring (flashbacks) 4) Intense psychological distress and (5) physiological reactivity when exposed to cues resembling the event 12

13. Avoidance 1 (3/7 symptoms) 1) Avoiding trauma thoughts and feelings 2) Avoiding activities, places, and people that remind of the trauma 3) Inability to recall important parts of trauma 4) Lack of interest in significant activities 13

14. Avoidance 2 5) Feeling of detachment from others 6) Restricted affect (no loving feelings) 7) Sense of a foreshortened future Note: The two first symptoms are conscious efforts; 4-6 are called ’numbness’ (inability to express feelings and plan for a future). Symptoms not present before the trauma 14

15. Hypervigiliance (2/5 symptoms) 1)Difficulties falling or staying asleep 2)Irritability or outburst of anger 3)Difficulty concentrating 4)Hypervigiliance* 5)Exaggerated startle response* Note: Symptoms not present before the trauma. The three first may be considered less specific than the two last symptoms* 15

16. Duration Duration of symptoms more than one month Acute PTSD (less than 3 months) Chronic (3 months or more) Delayed (if onset is at least 6 months after the trauma) 16

17. Functional impairment The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning 17

18. PTSD according to WHO In the ICD-10 diagnostic system, F 43.1 describes PTSD quite differently The stressor criterion is normative ”exposed to an unusual threatening or catastrophe stressor that in almost everyone would result in extensive and very distressing reactions” This downplays the traumas in everyday life 18

19. ICD-10 (cont.) The re-experiencing symptoms corresponds to DSM-IV 2,3, and 4 Avoidance demands one symptom Hypervigiliance is like DSM-IV (2/5 symptoms Amnesia can substitute the hypervigiliance symptoms 19

20. ICD-10 (cont.) Duration: symptoms must be present before 6 months No functional impairment demands. The diagnosis can be given after a few days 20

21. ICD-10 and DSM-IV compared Very little research has used the ICD-10 It is easier to get a PTSD diagnosis from ICD-10 than from DSM-IV There is little (35%) concordance between diagnoses given by the two systems due to fewer demands in the ICD-10 avoidance clusters and lack of impairment criterion Epidemiological studies using ICD-10 reveal very few cases of PTSD 21

22. Empirical analyses of PTSD No study has replicated the PTSD structure with the three symptom clusters Many have suggested that the avoidance group should be divided in conscious avoidance and numbing. Numbing seems to be closely associated with hypervigiliance where conscious avoidance is associated with re- experiencing 22

23. Empirical analyses of PTSD - 2 Recently, several have suggested that numbing symptoms together the non- specific hypervigiliance symptoms constitute a dysphoria factor not specific to PTSD 23

24. Subclinical PTSD A large number of clients miss one symptom to get the full diagnosis They typically miss one avoidance symptom They are often described as having ’sub- syndromal’, ’partial’, or ’subclinical’ PTSD 24

25. Subclinical PTSD - 2 This group often requires clinical attention It is important to distinguish between those who once had PTSD and are now in partial remission and those never exceeded the full PTSD threshold For this group is important to consider the functional impairment criterion 25

26. PTSD remission PTSD symptoms often decrease in the weeks and months following a trauma After three to six months a stabilisation (= little or no change) often comes about One third will recover fully One third will have a number of symptoms One third will become chronic cases 26

27. PTSD and other disorders Having PTSD means that 4 out of 5 will have comorbid (= at the same time) disorders; the most common being: Anxiety (and phobias) Depression Somatoform disorders Alcohol and drug abuse Some also develop a personality disorder 27