Page 72 - Journal of Special Operations Medicine - Winter 2015

Unfortunately, gaps exist in the diagnostic criteria. TBIs, circles is on the role of brain injuries and how they affect
especially those that lead to chronic conditions, are dif- PTSD or, if they are TBIs, cause a type of PTSD. 13–15
ficult to diagnose and can be mistaken for other condi-
tions, but the DSM-V now comes with a warning to Diagnostic criteria for PTSD, as defined by DSM-V, in-
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clinicians and mental health professionals: “Posttrau- clude a history of exposure to a traumatic event meeting
matic stress disorder (PTSD) can occur with the NCD two of the five criteria (A–E) listed below and symptoms
[neurocognitive disorder due to TBI] and have overlap- from each of three symptom clusters: intrusive recollec-
ping symptoms (e.g., difficulty concentrating, depressed tions, avoidant/numbing symptoms, and hyperarousal
mood, aggressive behavioral disinhibition).” Slowly, symptoms. A fifth criterion (F) concerns duration of
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the medical community has improved its identification symptoms and a sixth (H) cautions the diagnosing cli-
and analysis of the symptoms, applying correct diagnos- nician to make sure that drugs (prescription or other-
tic tests and prescribing treatments. As we have learned, wise) or other disease process are not involved. DSM-IV
some treatments are standard and accepted, while oth- has fewer criteria, but DSM-IV was used to diagnose
ers are not, but should be. PTSD in Servicemembers active during the War on Ter-
ror (which started in 2002) and has been used to diag-
nose the majority of Servicemembers now suffering with
Posttraumatic Stress Disorder
PTSD and/or TBI. A Servicemember who was diagnosed
Shell shock, battle fatigue, combat exhaustion, nostal- with DSM-IV will definitely need to be re-evaluated.
gia—these are just a few of the names that have been used The list of eight criteria in the DSM-V is as follows:
to describe the mental state of fighting men and women
over the ages (Figure 1). Although PTSD is associated A. Stressor: The person has been exposed to a traumatic
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with individuals exposed to the trauma of war, it occurs event that could have resulted in death to others or
in the civilian population after a single horrific event (e.g., wounds/injury to themselves or others, coupled with
surviving the 9/11 attacks on the World Trade Center or intense emotions (e.g., fear, helplessness, or horror).
the Pentagon) or after sustained events (e.g., Hurricane B. Intrusive recollection: The traumatic event is persis-
Katrina), as well. The concept of psychological or “in- tently reexperienced (must include at least one reex-
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visible wounds” associated with the experience of war or periencing condition).
trauma (including accidents, domestic violence, sexual 1. Recurrent and intrusive distressing recollections of
assaults, and so forth) has been part of recorded human the event, including images, thoughts, or perceptions
experience since 490 bc and earlier. Over the years, the 2. Recurrent distressing dreams (i.e., nightmares) of
medical and psychological fields have circled around a the event
core set of symptoms and criteria to diagnose this condi- 3. Acting or feeling as if the traumatic event were re-
tion. The majority of patients with PTSD routinely work curring in the present (includes a sense of reliving
through their symptoms in about 1–3 months without the experience, illusions, hallucinations, and dis-
the need for psychoactive drugs, although counseling is sociative flashback episodes, including those that
a great help; but a proportion of patients develop longer- occur upon awakening or when intoxicated)
term symptoms. The current debate within psychological 4. Intense psychological distress at exposure to inter-
nal or external cues that symbolize or resemble an
Figure 1 A grief stricken American infantryman whose aspect of the traumatic event
buddy has been killed in action (Korea, circa 1950). 5. Physiologic reactivity upon exposure to internal
or external cues that symbolize or resemble the
incident
C. Avoidant/numbing: Persistent avoidance of stimuli
associated with the trauma and numbing of gen-
eral responsiveness (must not be present before the
trauma; at least three symptoms must be present)
D. Efforts to avoid thoughts, feelings, or conversations
associated with the trauma
1. Efforts to avoid activities, places, or people that
Photo courtesy of Sfc. Al Chang, U.S. Army 2. Negative changes in thinking and mood associ-
arouse recollections of the trauma
ated with the traumatic event
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in
significant activities
5. Feeling of detachment or estrangement from others

60 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015