In the name of the PTSD there are two terms whose definition is not simple: stress and trauma. As the name itself indicates, we are facing a disorder that is manifested by stress responses following a traumatic situation. But what is meant by stress? What does trauma mean? In 1936 Hans Selye published an article in the magazine Nature in which he introduced the term stress in the field of health. Since then, this term has been blurring as it has become popular and widely used.
- 1 Definition of stress according to Hans Seyle
- 2 What is PTSD?
- 3 DSM-V Diagnostic Criteria for PTSD
- 4 What is ASD?
- 5 DSM-V diagnostic criteria for ASD
Definition of stress according to Hans Seyle
Originally, Selye defined stress as the "General Adaptation Response" of the organism against a threatening stimulus. This response of the organism can be of two types: coping with the situation or escape (fight or flight). The preparation of the organism for fight or flight involves physical changes, such as increased heart rate, respiratory rate, blood pressure, pupil dilation, muscle tension, peripheral vasoconstriction, increased blood glucose, release of adrenaline, norepinephrine, glucocorticoids, etc. Once the fight or flight is over, the body recovers its normal functioning, recovering from the enormous expense of physical and emotional energies. Nevertheless, if the threat persists, the agency remains on permanent alert and what Selye called the "General Adaptation Syndrome." In this condition, the organism does not have the necessary time for its recovery, and its physical and psychic energies begin to run out.
At present, stress is usually defined as a series of physiological and psychological processes that develop when there is a perceived excess of environmental demands on the individual's perceived abilities to satisfy them; and when the failure to achieve it has important consequences perceived by the person.
That is, this concept includes the 3-factor interaction: the environment, the way in which the person perceives that environment and the way in which they perceive their own resources to meet the demands of the environment. Therefore, a very important aspect in the concept of stress is the individual's own perception, so that the same event can be considered harmless or catastrophic by different people.
What is PTSD?
In the case of PTSD, and according to the current definitions of this disorder, the person faces a situation perceived as threatening to life or physical integrity of their own or others. The individual's reaction to this situation is one of intense fear, horror or panic. Keep in mind that when a person is exposed to situations of this nature, The organism reacts with a physiological response, releasing hormones, corticosteroids, etc., which cause, in some cases, the alteration in memory, and more specifically, in the storage in memory of that traumatic event, central aspect, as we will see later.
Regarding the definition of trauma, Vázquez (2005) indicates very graphically that it is a concept “under suspicion”, since Oppenheim proposed in 1892 the term “traumatic neurosis” to refer to intense psychological symptoms produced by traumatic occupational accidents . Since then, the history of this concept is full of controversies (Brewin, McNally and Taylor, 2004; McNally, 2003).
Currently this term has been stripped of its psychodynamic nuance and refers to a highly threatening situation or event.
As we have already indicated, in DSM-III (APA, 1980) trauma was defined as a event outside the usual framework of human experiences and that would be distressing for virtually anyone. This definition, assuming that almost everyone would have that answer if they were in that situation, meant emphasizing the importance of the magnitude of the event and minimizing the role of the victim's personality, that is, giving little importance to psychological vulnerability. . Nevertheless, very soon it was raised that traumatic situations are not made out of the ordinary, since if we analyze the life of any person we will find that it is plagued by traumatic events (deaths, catastrophes, separations, etc.). Therefore, this simplistic conception changed in DSM IV (APA, 1994) and the accent fell on the reaction of the individual and not on the event, as was the case in previous editions, that is, the traumatic event is fundamentally defined by the reaction of the individual: given a given situation, how does each individual react?
Despite these modifications, there are still issues to be clarified, such as what does it mean to have been exposed to a traumatic situation? Although the DSM-V recognizes the possibility of indirect exposure (observe the event or have someone tell you about it), it does not offer clear guidelines to evaluate this aspect. The images seen again and again by the 9/11 TV are an example of this difficulty. As Vázquez (2005) points out, this definition can facilitate an abusive use of the mental disorder label.
On the other hand, diagnostic definitions do not take into account the different types of traumatic situations that exist. As we have already indicated, the highly stressful events that we can live are many and varied. While some may have a natural origin (earthquakes, floods, etc.), others are a product of human beings (wars, terrorism, abuse, etc.). While some affect communities, and even entire countries, others affect a single person or a small group of people. Different types of traumatic events may have different impacts on people. For example, many authors point out that events produced by man's own hand tend to leave more psychological sequels than natural ones.
On the other hand, there are other stressful situations, although not considered as extreme, that can seriously affect people, although they do not usually trigger a post-traumatic stress disorder. We are referring to situations such as job loss, divorce, school failure, etc. In general, it seems that the different investigations suggest that Traumatic events usually have two characteristics: they are unexpected and uncontrollable. This causes them to directly attack the feeling of security and self-confidence that people have and therefore cause intense reactions of vulnerability and fear towards the environment.
DSM-V Diagnostic Criteria for PTSD
A. Exposure to death, serious injury or sexual violence, whether real or threatening, in one (or more) of the following ways:
- Direct experience of the traumatic event (s).
- Direct presence of the event (s) occurred to others.
- Knowledge that the traumatic event (s) has occurred to a close relative or to a close friend. In cases of threat or reality of death of a family member or friend, the event (s) must have been violent or accidental.
- Repeated or extreme exposure to repulsive details of the traumatic event (s) (eg, lifeguards who collect human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies or photographs, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event (s), which begins after the traumatic event (s):
- Recurring, involuntary and intrusive distressing memories of the traumatic event (s).
- Recurring distressing dreams in which the content and / or affect of sleep is related to the traumatic event (s).
- Dissociative reactions (e.g., flashbacks) in which the subject feels or acts as if the traumatic event (s) is repeated. (These reactions can occur continuously, and the most extreme expression is a complete loss of awareness of the present environment.)
- Intense or prolonged psychological discomfort when exposed to internal or external factors that symbolize or resemble an aspect of the traumatic event (s).
- Intense physiological reactions to internal or external factors that symbolize or resemble an aspect of the traumatic event (s).
C. Persistent avoidance of stimuli associated with the traumatic event (s), which begins after the traumatic event (s), as evidenced by one or both of the following characteristics:
- Avoidance or efforts to avoid distressing thoughts, thoughts or feelings about or closely associated with the traumatic event (s).
- Avoidance or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that awaken distressing memories, thoughts or feelings about or closely associated with the traumatic event (s).
D. Negative cognitive and mood alterations associated with the traumatic event (s), which begin or worsen after the traumatic event (s), as evidenced by two (or more) of the characteristics following:
- Inability to remember an important aspect of the traumatic event (s) (typically due to dissociative amnesia and not other factors such as a brain injury, alcohol or drugs).
- Persistent and exaggerated negative beliefs or expectations about oneself, others or the world (eg, "I'm wrong," "I can't trust anyone," "The world is very dangerous," "I have broken nerves") .
- Persistent distorted perception of the cause or consequences of the traumatic event (s) that causes the individual to accuse himself or others.
- Persistent negative emotional state (eg, fear, terror, anger, guilt or shame).
- Significant decrease in interest or participation in significant activities.
- Feeling of detachment or estrangement from others.
- Persistent inability to experience positive emotions (eg, happiness, satisfaction or love feelings).
E. Significant alteration of the alert and reactivity associated with the traumatic event (s), which begins or worsens after the traumatic event (s), as evidenced by two (or more) of the following characteristics :
- Irritable behavior and outbursts of fury (with little or no provocation) that are typically expressed as verbal or physical aggression against people or objects.
- Reckless or self-destructive behavior.
- Exaggerated startle response.
- Concentration problems.
- Sleep disturbance (eg, difficulty falling or continuing to sleep, or restless sleep).
F. The duration of the alteration (Criteria B, C, D and E) is longer than one month.
G. The alteration causes clinically significant discomfort or deterioration in social, labor or other important areas of functioning.
H. The alteration cannot be attributed to the physiological effects of a substance (eg, medication, alcohol) or to another medical condition.
With dissociative symptoms: The symptoms meet the criteria for posttraumatic stress disorder and, in addition, in response to the stress factor, the individual experiences persistent or recurrent symptoms of one of the following characteristics:
- Depersonalization: Persistent or recurring experience of a feeling of detachment and as if oneself were an external observer of one's own mental or bodily process (e.g., as if dreaming; sense of unreality of oneself or one's own body, or that time passes slowly).
- Derealization: Persistent or recurring experience of unreal environment (e.g., the world around the individual is experienced as unreal, as in a dream, distant or distorted).
Note: To use this subtype, dissociative symptoms should not be attributable to the physiological effects of a substance (e.g., fainting, behavior during alcoholic intoxication) or other medical condition (e.g., complex partial epilepsy ).
With delayed expression: If all the diagnostic criteria are not met until at least six months after the event (although the onset and expression of some symptoms may be immediate).
What is the ASD?
The essential feature of Acute Stress Disorder or ASD is the development of characteristic symptoms that last from 3 days to a month, and appear after exposure to one or more traumatic events.
The clinical presentation of this disorder may vary among individuals, but typically involves an anxiety response, which includes some form of re-experimentation of the event, or of reactivity towards the traumatic event.
In some individuals, a dissociative or detachment presentation may predominate, although these people will typically also exhibit strong emotional or physiological reactivity in response to trauma reminders.
In other people, a strong anger response may occur, whose reactivity is characterized by irritable or aggressive responses. This disorder can be especially severe when the stressor is interpersonal and intentional., such as rape or torture. The probability of developing this disorder may increase as the intensity of the stressor and the physical proximity to it increases.
Symptoms must be present for at least 3 days after the traumatic event, and this disorder can only be diagnosed after those 3 days and up to one month after the event.
Although this disorder may progress to Post-traumatic Stress Disorder (PTSD) After one month, it may also be a transient response that remits within the first month after traumatic exposure, and does not result in PTSD.
Approximately 50% of people who eventually develop PTSD initially had Acute Stress Disorder (ASD).
The worsening of symptoms may occur during the first month, often as a result of ongoing life stressors or more traumatic events.
DSM-V diagnostic criteria for ASD
A. The person has been exposed to a traumatic event in which 1 and 2 have existed:
- the person has experienced, witnessed or explained one (or more) events characterized by deaths or threats to their physical integrity or that of others
- the person has responded with intense fear, hopelessness or horror
B. During or after the traumatic event, the individual has 3 (or more) of the following dissociative symptoms:
- subjective feeling of dullness, detachment or absence of emotional reactivity
- reduced awareness of your surroundings (e.g., being stunned)
- dissociative amnesia (e.g., inability to remember an important aspect of trauma)
C. The traumatic event is persistently reexperienced in at least one of these ways: images, thoughts, dreams, illusions, recurring flashback episodes or a sensation of reliving the experience, and discomfort when exposed to objects or situations that recall the traumatic event.
D. Avoidance accused of stimuli that recall trauma (eg, thoughts, feelings, conversations, activities, places, people).
E. Symptoms accused of anxiety or increased activation (arousal) (eg, difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle responses, motor restlessness).
F. These alterations cause clinically significant discomfort or social, labor or other important areas of activity of the individual, or significantly interfere with their ability to carry out essential tasks, for example, obtaining the necessary help or human resources explaining the traumatic event to his family members.
G. These alterations last a minimum of 2 days and a maximum of 4 weeks, and appear in the first month following the traumatic event.
H. These alterations are not due to the direct physiological effects of a substance (eg, drugs, drugs) or to a medical illness, they are not better explained by the presence of a brief psychotic disorder.
The need and importance of identifying as soon as possible those people who can develop a PTSD after exposure to a traumatic event have been emphasized from various instances. The DSM-IV (APA. 1994) introduced for the first time the category of "Acute Stress Disorder" (ASD), aimed precisely at the diagnosis of stress reactions that occur in the first month after the traumatic event, and thus identify people who could develop a PTSD. That is, it is hypothesized that who immediately after exposure to the traumatic event develops the symptoms of an ASD, presents a greater risk that these symptoms are perpetuated in the form of a PTSD.
Some empirical studies as well as clinical observations indicate the presence of dissociative experiences as an important predictor of subsequent chronic post-traumatic problems (Spiegel, Koopman, Cardeña and Classen, 1996). Thus, the diagnostic criteria proposed for ASD are similar to those of PTSD, but the emphasis is placed on peritraumatic dissociative symptoms (dissociative amnesia, depersonalization, derealization, etc.). This is one of the differences between both disorders; the other difference lies in the temporality of the appearance of the symptomatology with respect to the traumatic event.
Signs and symptoms of posttraumatic stress disorder. Mardi J. Horowitz, MD; Nancy Wilner; Nancy Kaltreider, MD; and others. Arc Gene Psychiatry. 1980; 37 (1): 85-92. doi: 10.1001 / archpsyc.1980.01780140087010
Stress response syndromes. Horowitz, MJ (1976). Syndromes of stress response. Oxford, England: Jason Aronson
Trauma-related disorders in children. Baubet T, Rezzoug D. Rev Prat. 2018 Mar; 68 (3): 307-311.
- Depression test
- Goldberg depression test
- Self-knowledge test
- how do others see you?
- Sensitivity test (PAS)
- Character test