In the name of PTSD there are two terms whose definition is not simple: stress and trauma . As indicated by the name itself, we are facing a disorder that is manifested by stress responses after a traumatic situation. But what is meant by stress? What does trauma mean? In 1936 Hans Selye published an article in the journal 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.
Definition of stress according to Hans Selye
Originally, Selye defined stress as the “General Adaptation Response” of the organism in the face of a threatening stimulus . That response of the organism can be of two types: of confronting the situation or of flight ( fight or flight) . The preparation of the body for fighting or for flight involves physical changes, such as increased heart rate, respiratory rate, blood pressure, dilation of the pupils, muscle tension, peripheral vasoconstriction, increased blood glucose, release of adrenaline, noradrenaline, glucocorticoids, etc. Once the fight or flight is over, the organism recovers its habitual functioning, recovering from the enormous expenditure of physical and emotional energies. But nevertheless,if the threat persists, the body is kept on permanent alert occurs and what Selye called the ” General Adaptation Syndrome “ . In this condition, the organism does not have the time necessary for its recovery, and its physical and psychic energies begin to deplete.
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 perceived abilities of the individual to be able to satisfy them; and when the failure to achieve it has important consequences perceived by the person.
That is, this concept includes the interaction of 3 factors: the environment, the way in which the person perceives that environment and the way in which he perceives his own resources to face 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 as innocuous 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 the physical integrity of himself or others. The reaction of the individual to this situation is intense fear, horror or panic. Keep in mind that when a person is exposed to situations of this nature, the body reacts with a physiological response, releasing hormones, corticosteroids, etc. , that cause, in some cases, the alteration in the memory, and more specifically, in the storage in the memory of that traumatic event, central aspect, as we will see later.
Regarding the definition of trauma, Vázquez (2005) very graphically points out 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 polemics (Brewin, McNally and Taylor, 2004, McNally, 2003).
Currently this term has been stripped of its psychodynamic nuance and alludes to a situation or highly threatening event.
As we have already indicated, in the DSM-III (APA, 1980) trauma was defined as an event outside the usual framework of human experiences and that would be distressing for practically anyone . This definition, by presupposing 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. . However, very soon it was stated that traumatic situations are not done out of the ordinary, because 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 the DSM IV (APA, 1994) and the accent fell on the reaction of the individual and not on the event, as it happened in the previous editions, that is to say the traumatic event is defined fundamentally by the reaction of the individual: given a given situation, how does each individual react?
Despite these changes, there are still questions 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 (observing the event or having someone tell you about it), it does not offer clear guidelines for evaluating this aspect. The images seen again and again on the TV of 9/11 are an example of this difficulty. As Vázquez (2005) points out, this definition can facilitate the abusive use of the mental disorder label.
On the other hand, the 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 experience are many and varied . While some may have a natural origin (earthquakes, floods, etc.), others are the product of human beings (wars, terrorism, abuses, etc.). While some affect communities, and even whole 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 consequences than natural ones .
On the other hand, there are other stressful situations, although not considered 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 means that they directly attack the feeling of security and self-confidence that people have and that therefore provoke intense reactions of vulnerability and fear towards the environment.
Diagnostic Criteria of the DSM-V for PTSD
A. Exposure to death, serious injury or sexual violence, either actual or threatened, in one (or more) of the following forms:
- 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 close friend. In cases of threat or reality of death of a relative 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 collecting 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):
- Recurrent, involuntary and intrusive distressing memories of the traumatic event (s).
- Recurrent distressing dreams in which the content and / or affect of the dream is related to the traumatic event (s).
- Dissociative reactions (eg, retrospective scenes) in which the subject feels or acts as if the traumatic event (s) were 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 memories, 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 arouse distressing memories, thoughts or feelings about or closely associated with the traumatic event (s).
D. Negative cognitive and mood disturbances 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 to other factors such as brain injury, alcohol or drugs).
- Persistent and exaggerated negative beliefs or expectations about oneself, others or the world (eg, “I am wrong,” “I can not trust anyone,” “The world is very dangerous,” “My nerves are shattered”) .
- 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 loving 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 rage (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 in reconciling or continuing sleep, or restless sleep).
F. The duration of the alteration (Criteria B, C, D and E) is greater than one month.
G. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
H. The disturbance 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 post-traumatic stress disorder and, in addition, in response to the stressor, the individual experiences persistent or recurring symptoms of one of the following characteristics:
- Depersonalization: persistent or recurrent experience of a feeling of detachment and as if one were an external observer of one’s own mental or bodily process (eg, as if one were dreaming, a sense of unreality of oneself or one’s own body, or that time passes slowly).
- Derealization: Persistent or recurrent experience of unreality of the environment (eg, the world around the individual is experienced as unreal, as in a dream, distant or distorted).
Note: To use this subtype, dissociative symptoms can not be attributed to the physiological effects of a substance (eg, fading, behavior during alcohol intoxication) or another medical condition (eg, complex partial epilepsy) ).
With delayed expression: If all of 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 ASD?
The essential characteristic of Acute Stress Disorder or ASD is the development of characteristic symptoms that last from 3 days to a month, and they appear after the exposure of one or more traumatic events .
The clinical presentation of this disorder may vary between individuals, but typically involves an anxiety response, which includes some form of re-experimentation of the event, or reactivity to the traumatic event.
In some individuals, a dissociative or detachment presentation may predominate, although these individuals will typically also exhibit strong emotional or physiological reactivity in response to reminders of the trauma.
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 likelihood of developing this disorder may increase as the intensity of the stressor increases and the physical proximity to it increases.
The 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 a month after the event.
Although this disorder may progress to Posttraumatic Stress Disorder (PTSD) after one month, it may also be a transient response that remits within the first month after the traumatic exposure, and does not result in PTSD.
Approximately 50% of people who eventually develop PTSD initially presented with 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
Diagnostic criteria of the DSM-V 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 been explained one (or more) events characterized by death or threats to their physical integrity or that of others
- the person has responded with intense fear, despair or horror
B. During or after the traumatic event, the individual presents 3 (or more) of the following dissociative symptoms:
- subjective feeling of dullness, detachment or absence of emotional reactivity
- reduced awareness of their environment (eg, being stunned)
- Dissociative amnesia (eg, inability to remember an important aspect of the trauma)
C. The traumatic event is persistently reexperienced in at least one of these forms: images, thoughts, dreams, illusions, recurrent flashback episodes or sensation of reliving the experience, and discomfort when exposed to objects or situations that recall the traumatic event.
D. Acute avoidance of stimuli reminiscent of trauma (eg, thoughts, feelings, conversations, activities, places, people).
E. Acute symptoms of anxiety or increased arousal (eg, difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle responses, motor restlessness).
F. These alterations cause clinically significant discomfort or social, occupational or other deterioration of other important areas of the individual’s activity, or interfere significantly with their capacity to carry out essential tasks, for example, obtaining the help or the necessary human resources explaining the traumatic event to the members of his family.
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 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 reactions to stress that occur in the first month after the traumatic event, and thus identify the people who could develop a PTSD. That is to say, it is hypothesized that those who, immediately after exposure to the traumatic event, develop the symptoms of an ASD, present a greater risk of these symptoms perpetuating themselves in the form of PTSD .
Some empirical studies as well as clinical observations indicate the presence of dissociative experiences as an important predictor of later chronic post-traumatic problems (Spiegel, Koopman, Cardeña and Classen, 1996). In this way, the proposed diagnostic criteria for ASD are similar to those of PTSD, but the accent is placed on dissociative peritraumatic 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.