That Traumatic Events

Introduction

It is no surprise that traumatic events can negatively impact an individual, yet many do not fully understand some of the repercussions that can follow them. While some events may happen suddenly and occur briefly, the aftermath can often be devastating and in some cases cause symptoms to delay or linger. The DSM-IV-TR classifies post-traumatic stress disorder (PTSD) as a disturbance, regardless of its trigger, that causes clinically significant distress or impairment in an individual's social interactions, capacity to work or other important areas of functioning (American Psychiatric Association, 2013).

Any individual who undergoes a traumatic event is susceptible to developing symptoms of PTSD, yet several studies have found a significantly higher rate of the disorder among veterans who have served in the military. Furthermore, there are several risk factors that may attribute to the higher likelihood of developing the disorder. This paper will examine the history of PTSD according to DSM classification, range of risk factors and symptoms, as well as diagnosis and forms of treatment for the disorder.

Historical Significance of PTSD

Although traumatic experiences have long been a part of the human experience, mental or psychological effects of such events have not always been easy to identify. It was not until 1952 where the American Psychological Association began to piece together risk factors and symptoms that would one day be known as post-traumatic stress disorder. Friedman (2018) has asserted that the first development of PTSD spanned from the early DSM-I model and was originally known as gross stress reaction. Of this diagnosis, people were perceived as relatively normal, but had symptoms from traumatic events such as disaster or combat, and also assumed that reactions to trauma would resolve relatively quickly (Friedman, 2018).

As years passed, descriptions of the disorder were modified or taken out of later revisions of the DSM model entirely. It was not until 1980 where PTSD was officially established and added to the DSM-III, which stemmed from research involving returning Vietnam War Veterans, Holocaust survivors, sexual trauma victims, and others (Friedman, 2018). It was at this point where researchers began to finally piece together the trauma of war and post-military life.

It is important to also understand the complexity behind establishing mental illnesses and disorders. This is evident in the several DSM editions and continuous research of conditions that are not necessarily visible to the naked eye. For years, the reality of mental illness has often been overlooked and plagued with stigmas. Wide ranges of symptoms that are often found to be a result of other underlying conditions have often added to the intricacy and difficulty of understanding certain mental disorders and their origin. In other words, it has been common for individuals to be diagnosed with some form of a mental disorder due to presented symptoms that could have easily accounted for a different disorder.

This was most likely more of a possibility in earlier stages of a disorder's establishment.
In earlier days, many people had conflicting ideas on what PTSD actually was and assumed that only war veterans were susceptible to developing a condition following a traumatic event. Goldman and Keegan (2018) stated the term shell shock came from World War I and was used to describe soldiers experiencing PTSD symptoms after being exposed to explosions of artillery shells. Before an official establishment of PTSD occurred in 1980, people did not understand that experiencing or fighting a war was only one piece of the puzzle, or did not realize many of the risk factors involved that attributed to the development of PTSD.
Fast forward to today, the DSM-IV has outlined a more detailed and clearer line in terms of what constitutes a traumatic event and the criterion that must be established before diagnosing an individual with PTSD (American Psychiatric Association, 2013).

Risk Factors

Although the development of PTSD can manifest on its own simply from the trauma itself, there are often times at least one or several risk factors that lead to the increased likelihood of developing a specific disease or disorder. Xue et al. (2015) attributed various risk factors to the development of PTSD in veterans or military personnel to include female gender, ethnic minority status, low education, non-officer ranks, army service, combat specialization, high numbers of deployments, longer cumulative length of deployments, more adverse life events, prior trauma exposure, and prior psychological problems.

Although the development of PTSD can be the result of other underlying factors in an individual, such as factors not associated with military combat or other service experiences, studies have suggested that these are some of the primary factors found. Furthermore, studies found the most common risk factors among veterans to be being younger at the time of the trauma, being female, being of a racial minority, being of a lower socioeconomic status (SES), and lack of social support (Xue et al., 2015).

Furthermore, risk factors can also be divided into different categories. Gates et al. (2012) has asserted that three primary categories exist in terms of PTSD risk factors, to include individual-level (pre-trauma) factors, characteristics of the trauma, and post-trauma factors. Individual level factors may include earlier traumatic experiences in an individual's life and may often lead to a higher likelihood of an individual developing PTSD after experiencing later traumatic events. Peri-trauma factors or characteristics of a trauma include combat exposure, the severity of the trauma, and acute reactions to deployment-related adverse events, while post-trauma factors include individual comorbid psychological problems, social support, and subsequent stressful life events (Xue et al., 2015).

Pre-trauma Factors

Overall, any veteran or military personnel who experiences or witnesses a traumatic event can be more likely to develop PTSD. Yet, several studies have indicated a higher presence of the disorder among female veterans. For instance, one such study found that women generally have lower levels of combat exposure than men, but significantly higher rates of military sexual trauma, which is strongly associated with development of PTSD (Gates et al., 2012). Although this discovery may be the result of any number of things, many have developed stereotypes or unfounded opinions that this particular risk factor is the result of a female's higher level of sensitivity or emotionality.
Furthermore, several studies have identified an individual's ethnic status as a significant risk factor in developing PTSD. A major study consisting of both male and female veterans at a local VA facility concluded that PTSD was 20.6% among black veterans and 27.9% among Hispanic veterans, compared with 13.7% among white veterans (Gates et al., 2012). Ethnic status as a risk origin may also possibly be attributed to an individual's social or economic class, including level of education and

Peri-trauma Factors

Apart from pre-trauma factors, much of the actual trauma itself and an individual's environment at the time can significantly affect whether or not an individual develops symptoms of PTSD. In many cases, the environment where the trauma occurs can bring forth an increased likelihood of developing PTSD symptoms, such as level of fear or perceived risk of loss of life.
Boden et al. (2015) has asserted that several studies exist that have shown elevated rates of PTSD symptomatology among individuals exposed to natural disasters, with those exposed to higher levels of potentially life-threatening events being at the greatest risk for developing PTSD symptomatology. While veterans may not have experienced actual natural disasters, similar environmental factors of them may exist such as the fear for one's life. Keane, Marshall and Taft (2006) have discussed further studies that found a small to medium weighted effect size (r = 0.26) for the strength of the relationship between perceived life threat and PTSD. In other words, there has been known correlation between an individual's perceived life threat and the likelihood that they will develop symptoms related to PTSD.

Post-trauma Factors

Another significant factor regarding the development of PTSD involves the period of time following a traumatic event. Depending on whether or not the fear or worry decreases post-trauma, importance also depends on the level of support that is available to the veteran. This may include family units, supportive friends or counseling availability. The sad reality is that many veterans do not have sufficient support to help carry them through the painful process of reliving traumatic events. Moreover, some veterans may also choose to turn down support or deny a problem exists, which may lead to worsening symptoms.

On the contrary, individuals who exhibit symptoms of PTSD sometimes run the risk of destroying existing support systems or burning bridges between them. Further findings have supported the idea that interpersonal problems associated with PTSD negatively in?uence one's support resource (Keane et al., 2006). As a result, individuals who destroy links between social support sources may cause symptoms to worsen or in some cases remain left untreated. Mental illnesses in general typically require the existence of strong support systems in order for a patient to improve or reach some form of management of the disorder.

Symptoms

In addition to risk factors, veterans or military personnel often exhibit a number of symptoms that help counselors or physicians confirm an actual PTSD diagnosis. Some of the common symptoms of the disorder include intrusive thoughts, recurrent dreams, flashbacks, distress, avoidance, sleep difficulties, irritability and anger, concentration problems and hyper-vigilance (Gates et al., 2012). While an individual will typically report or show more than one symptom, even a single symptom such as difficulty sleeping can often be a major sign that they are experiencing PTSD.

Furthermore, symptoms may occur at any number of times following a traumatic event. In some cases, symptoms appear immediately following the event, while other times signs and symptoms are delayed or do not present themselves until much later. More specifically, veterans who experience PSTD-like symptoms long after a traumatic event are more than likely experiencing what is known as delayed-onset post-traumatic stress. Andrews et al. (2009) has stated that earlier revisions of the DSM classify delayed-onset PTSD as occurring when onset is more than 6 months after a traumatic event that fulfills the stressor criterion. In other words, these individuals move on after the traumatic event, but do not feel its impact until much later.

Diagnosis

According the DSM-IV, there are several criterion groups comprised of various symptoms that must be met in order for an individual to be clinically diagnosed with PTSD. National Center for PTSD (2018) has asserted that there are a total of eight criterion groups ranging from alphabetical categories A to H. Certain symptoms within each group are required in order for a patient to qualify of having the disorder (National Center for PTSD, 2018):

Criterion A- Stressor: Involves direct exposure or witness of the trauma, or even indirect exposure to significant details of the trauma.
Criterion B- Intrusive Symptoms: The traumatic event is constantly relived or revisited in one or more of the following ways: unwanted memories, nightmares, flashbacks, emotional distress following exposure to traumatic reminders.
Criterion C- Avoidance: Individual attempts to avoid trauma-related stimuli, such as traumatic feelings or external reminders of the trauma.
Criterion D- Negative Altercations in Cognitions and Mood: Individual experiences negative thoughts or feelings following the trauma, such as inability to recall key aspects of the trauma, blame towards self or others involved in the trauma, decreased interest in activities, feelings of isolation, or difficulty experiencing positive emotions.

Criterion E- Alterations in Arousal or Reactivity: Individual experiences trauma-related arousal or reactivity in the form of irritability, aggression, destructive behavior, hypervigilance, increased startling reactions, difficulty concentrating or sleeping.
Criterion F- Duration: Individual has experienced symptoms that have lasted for a period of more than 1 month.
Criterion G- Functional Significance: Trauma-related symptoms have cause significant distress or functional impairment.
Criterion H- Exclusion: Symptoms are not a result of medication, substance use, or any other illness (National Center for PTSD, 2018).
It is important to note that an individual only needs to exhibit at least one of the symptoms above for each category, yet they must have experienced a symptom from each category or subgroup of criteria (National Center for PTSD, 2018). In other words, it is enough for a patient to only exhibit a few symptoms in only a few categories or they will not receive an official PTSD diagnosis. Furthermore,

Treatment

As is generally the case with any disorder or illness, treatment will vary depending on the individual in question. Of mental disorders, the saddening reality is that many individuals have a difficult time seeking help or even noticing the signs that they have a problem. It is often family members, friends or other life acquaintances who notice symptoms first. Unfortunately, societal stigmas have also played a major role in whether or not an individual decides to seek treatment for a mental illness.

Furthermore, treatment for PTSD may also be dependent upon what resources are available to the veteran or at what point they decide to seek treatment, which can be impacted by the length of time the individual was suffering from symptoms. Depending on the severity of the symptoms, some veterans may benefit from one form of treatment, such as counseling services, whereas another individual may require several forms of treatment such as exposure therapy. For instance, exposure therapy for PTSD, the patient is guided through a vivid remembering of the trauma until extinction occurs, and is applied using in vivo and imaginal forms of exposure (Keane 2006). While exposure therapy is one of the more common forms of treatment for PTSD, other patients may benefit from other forms such as support groups or through the active management of anxiety or depression.

Overall, treatment for any mental illness should not be perceived as a one-size-fits-all' approach. What may work for one individual, might not be the case for another. For example, a veteran who had pre-existing risk factors may need more specialized treatment than someone who developed PTSD simply as a result of the trauma itself.

Limitations

Despite updated research involving PTSD as seen in later revisions of the DSM, various limitations still exist in terms of fully understanding the disorder. One primary limitation is the very complexity of being able to understand such mental illnesses, as psychological disorders can sometimes be tricky in terms of how they present themselves. Although symptoms are usually easy to categorize and are almost always helpful in reaching a definitive diagnosis, symptoms may still occur for any number of reasons and may sometimes be the result of something else entirely. For instance, a major limitation of available literature is the dearth of studies comparing the clinical presentation and etiology of delayed and more immediate forms of the disorder (Andrews et al., 2009). This is a prime example of complexity behind mental disorders and the many variations of specific conditions such as PTSD.

Furthermore, another possible limitation concerning PTSD among veterans is the level of research that can be conducted within military environments, such as deployment zones or restricted areas. Considering the impact that these areas may have and how they are generally where actual traumas occur, there may be valuable information missing that could help researchers to better understand how these environments affect the likelihood of a veteran or military personnel developing PTSD.

Additionally, further limitations may include the difficulties at the time of seeking treatment. Concerns about the potential implications of positive (or negative) screening results may lead to over- or underreporting of symptoms, depending on the individual and circumstances of testing (Gates et al., 2012). This could potentially be the result of an individual feeling guilt or shame and not wanting to admit known symptoms, or being so overwhelmed that they over-present their symptoms in order to get help. Furthermore, reliance on a single measure or assessment methodology may lead to inaccurate diagnosis in many cases and a large number of false positives and negatives (Gates, 2012). For this purpose, several measures may be necessary in order to reach a definitive diagnosis. As is the case with most mental illnesses, reliance on a single measure, such as a patient questionnaire, may not be enough to accurately diagnose the patient.

Conclusion

Overall, the diagnosis of PTSD and many other mental illnesses can prove to be very complex. There are several risk factors that attribute to the development of PTSD. Although any individual who experiences or witnesses a traumatic is susceptible to developing the disorder, several studies have found that veterans or military personnel are more likely in developing PTSD at some point, given the stressful and demanding nature of the military. Studies also presented several risk factors, yet gender, ethnic status, and social support were found to be the most common in terms of developing the disorder.

Combined with unfortunate societal stigmas surrounding mental illness, many veterans feel that asking for help is a sign of weakness. In other cases, some individuals fail to see the warning signs or remain in denial that they have any such symptoms. This is where support may be come into play, and be often be the turning point for an individual experiencing PTSD.
Although great strides have been made in better understanding PTSD, some limitations still exist such as the study of military environments (I.e. deployment zones or military base conditions). In order to better understand how veterans or military personnel are specifically affected by traumatic events, it may be useful to conduct further research on military environments and how they may impact the likelihood of developing PTSD, and whether or not it is these environments that play a major role in the PTSD diagnoses, or if more truth lies behind underlying risk factors.

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